Page 1 of 34 Emotion-focused Emotion-Focused Therapy and Children with Problematic Sexual Behaviors Jane F. Gilgun University of Minnesota, Twin Cities Kay Rice Danette Jones St. Paul, MN 8500 words Chapter to appear in Martin C. Calder (Ed.), Children and young people who sexually abuse: New theory, research, and practice developments. Dorset, England: Russell House. Jane F. Gilgun, Ph.D., LICSW, is professor, School of Social Work, University of Minnesota, Twin Cities, 1404 Gortner Avenue, St. Paul, MN 55108 USA. Phone: 612/925-3569; Fax: 612/624-3744; e-mail: email@example.com. Kay Rice, LICSW, ACSW, and Danette Jones, AAMFT, LICSW, are in private practice in St. Paul MN. 2375 University Avenue W., Suite 160, St. Paul, MN 55114 USA. Phone: 651/642-1709; fax: 651/642-0150 Emotion-focused Page 2 of 34 Emotion-Focused Therapy and Children with Problematic Sexual Behaviors When Alan1, 8, and his family entered treatment because of Alan’s inappropriate sexual behaviors, the primary emotion he expressed was anger. He did not want to talk about his sexual behaviors. Parents in the neighborhood warned their children to stay away from him. Children at school either avoided him or taunted him. Alan’s parents also were angry. They were quick to blame others for their son’s behaviors, reluctant to look at their personal issues that affected Alan, and were unable to deal with their son’s sexual behaviors, emotional states, and difficulties in school and with peers. Frustrated, ashamed, and confused, they wanted therapists to fix their son. At the end of treatment, Alan’s parents had begun to manage the difficulties in their relationship and had gained new parenting skills. Alan had developed capacities for appropriate emotional expressiveness, had learned to recognize his emotional states that meant he was at risk to act out sexually, and had demonstrated that he knew what to do when he was at risk to be sexually inappropriate or abusive. In general, he had learned to manage his sexual behaviors through becoming aware of his emotions and through learning how to express his emotions in appropriate ways. He and his parents accepted that Alan was at risk to act out sexually in the future and might require additional interventions as time went on. Alan’s parents were key in how well Alan did after treatment ended. They learned to talk easily and openly about issues related to his sexual acting out. When he needed emotional support, they were there for him. In the years following the end of therapy, Alan and his parents returned periodically to see the therapists. Alan would say, “It’s time for a tune-up,” meaning he needed extra help in managing his sexual behaviors. Usually these return visits were one to two Emotion-focused Page 3 of 34 sessions, taking place when Alan was at a transitional point and experiencing emotional turmoil, such as going to a new school and entering puberty. The purpose of this chapter is to demonstrate the centrality of emotional expressiveness in the treatment of children ages five to 10 with problematic sexual behaviors. To do so, we pieced together clinical experience, findings from research on the development of sexually abusive behaviors, research and theory on emotional development and expression, and research and theory on resilience. Though there is a vast literature on topics that can shed light on children’s emotional development, there is little on the emotional expressiveness of children with issues related to their sexual behaviors. The second and third authors of this paper originated the emotion-focused therapy program we discuss in this chapter. This paper represents an initial attempt to put to paper ideas that we think are important in child and family therapy when children have sexually inappropriate behaviors. Sexually Inappropriate Behaviors In our view, behaviors are sexually inappropriate when children are pre-occupied with sexual topics to the point where other aspects of their development suffer, when children’s sexual behaviors are intrusive, unwanted, and ignore the wishes of others, and when children trick, manipulate, and force others into sexual contact. Like abuse perpetrated by older persons, sexual abuse perpetrated by children often involves an abuse of power where older, stronger, more cognitively developed children takes advantage of younger children. We believe the sexual abuse that children and young people perpetrate is as damaging as abuse that adults perpetrate. The younger the children are when sexually inappropriate behaviors begin, the more likely the children were sexually abused themselves. Some childhood sexual behaviors are normative. Sexual contacts between age peers that are mutually wanted, are of short duration, and where privacy is respected are not inappropriate. Emotion-focused Page 4 of 34 A useful guideline that helps to assess for inappropriate sexual behaviors is whether a child stops the behavior when someone in authority makes the request. For example, a child who masturbates during nap time in preschool is likely doing what comes naturally. If teachers ask the child not to masturbate in public, and he complies, then there is nothing to worry about. If the child persists, then the child and family require professional assessment. Children who engage in sexual activity, even when mutual, but who persist after parents and others ask them to stop would benefit if their parents or others in authority obtain consultation with competent professionals. An Overview of Child and Family Issues When they began treatment, Alan and his family were typical of families in the early stages of learning to manage children’s sexually inappropriate behaviors. In the beginning of treatment, family members typically express a restricted range of emotions, primarily displaying defensive anger, possibly covering up their hurt and confusion. Their emotional responses may be under-reactions (flat) or over-reactions (highly emotive), usually with emotions disconnected from conscious thought. The language they use to express emotions lack concreteness, specificity, imagery, and clarity. These qualities are associated with positive change in therapy (Watson, 1996). Most parents are like Alan’s. They come to treatment angry. Their children’s behaviors are everyone else’s failure. It’s hard for them to get beyond their own guilt to their other emotions. Parents usually have their own therapeutic issues. Those who engage in their own therapy are most likely going to “make it.” For example, when parents had been sexually abused and haven’t dealt with the effects, they are unlikely to be effective with children who may have been sexually abused and who have sexually problematic behaviors. Dealing with their own issues clears the way for them to be more emotionally available to their children. Since the Emotion-focused Page 5 of 34 pioneering research of social worker Selma Fraiberg (Fraiberg, Adelson, & Shapiro, 1975) on infant mental health, researchers and practitioners have recognized the importance of parents’ working through their own issues in order to become more effective with their children. Sometimes parents are willing to examine themselves and their relationships for the sake of their children. They might not have done so without this motivation. When the parents are engaged in their own therapy, this takes the pressure off the children. Not only may parents function better as a result of therapy, but from children’s point of view, everyone in the family is in therapy, not just the children identified with the acting out problems. Clinically and through research, we have developed a typology of how children display their emotions at the beginning of treatment for sexual behavior problems. The categories are angry, anxious, hollow, disorganized, blaming, denying, and emotionally expressive. Children typically move back and forth between emotion states, but some display a predominant style. There are likely to be other types of displays of emotions and our list may be incomplete. These styles of presentation sometimes, but not always, mirror how one or both parents and other family member initially display their emotions. Angry. Typically, when boys begin treatment, they channel their emotions through anger. If they are hurt, they express anger. If they don’t get their own way, they are angry. They may express feelings of affection through physically aggressive behaviors such as headlocks or through verbal aggression such as name-calling and put-downs. The impression they give is a desire to show mastery and dominance over others, perhaps in reaction to their own perceived lack of control or their sense of how they are “supposed” to act, or a combination. To show their vulnerability may be impossible. Many of the boys also have fears of being called gay, especially if they have acted out sexually with other boys or been sexually abused by males. Some boys worry that they may be girls, since they believe that men victimize only girls Emotion-focused Page 6 of 34 sexually. Girls, too, may be angry, possibly as a defense against and as a means of managing fear, embarrassment, and shame. Anxious. Some children display a great deal of anxiety. These children often begin therapy as if they are “snakes in a can,” but when treatment works, they let go of their anxiety, and their personally appealing qualities emerge. Hollow. Other children appear hollow and disassociated. These children are challenging because therapists find it difficult to connect emotionally with them. Their affect may be flat. Sometimes the term withdrawn fits them. They simply do not want to or cannot discuss their sexual behaviors and usually almost any other emotion-laden topic. Disorganized. Another typical child presents a picture of emotional disorganization, often carrying multiple diagnoses including attention deficit hyperactivity disorder, conduct disorder, and oppositional disorder. It is likely that these children have underlying physiological features that are implicated in their emotional disorganization. They often have experienced multiple adversities, but if parents are willing to engage in therapy and to secure resources needed to facilitate children’s development, there is reason to hope that children can learn to manage sexual impulses and develop good peer relationships, do well in school, and look forward to a fulfilling future. Blaming. Some children appear unable to take responsibility for their behaviors. Typically they blame others, with statements such as “It’s his fault. If he hadn’t this, I wouldn’t have done what I did.” Underlying shame and fear of consequences are associated with blaming responses. Still other children may be unable to see that they have any responsibility for their own behaviors. Denying. Some children outright deny their inappropriate sexual behaviors, even when presented with clear evidence. Like children who engage in blaming, they may be full of shame Emotion-focused Page 7 of 34 and fear of consequences that they don’t want anyone to think they could act in sexually inappropriate or abusive ways. Emotionally expressive. Not all children and families begin treatment displaying their emotions in these ways, but some do. Some children and families can express a range of emotions, their affect and cognitions are interconnected and in balance, and they are accepting of a need for help. This type of family will probably require a less intense form of intervention, perhaps a course of psychosocial education that involves the whole family as well as peer group work for the child with sexual issues. An Overview of Emotion-Focused Therapy Emotion-focused therapy is based on ideas derived from clinical experience and relevant research and theory. Emotions are a big part of who we are as human beings. They affect what we perceive, how we perceive, and what we do in response to our perceptions (Isen, 1984; Izard et al, 2002). They influence thoughts and activate internal representations of self, others, and how to behave in particular situations. Children who are emotionally competent can identify and name their own feelings and those of others. They can talk about their negative emotions such as anger, envy, and anxiety, have the presence of mind to consider possible courses of actions, and take into considerations the effects of their behaviors on others (Raver, 2002). They have good peer relationships. Adults find them appealing and engaging. They comply with adult requests, while they also are assertive and express their own wants. Children with these qualities have positive emotional connections with others. These connections are based on capacities for empathy where children accurately imagine how others are feeling through sensitive interpretations of often subtle clues. Children modify their behaviors in response to these perceptions. Such contingent responsiveness is possible when children identify and understand their own inner states. Emotion-focused Page 8 of 34 Families and Emotional Expressiveness Children can’t do what their parents can’t. Children’s emotional development stems from qualities of their attachment relationships to primary caregivers. Sensitive, responsive, reciprocal caregiving fosters emotional expressiveness, responsiveness, and empathy in children. When children enter treatment for sexually inappropriate behaviors, therapists obviously cannot observe the quality of attachments that occurred earlier. They can, however, observe parents’ interactions with their children as clues to the family’s emotion systems. Children internalize parental behaviors as guidelines for their own. When parents model empathy, consideration for others, and emotional expressiveness that shows integration of thoughts and feelings, children are likely to have similar qualities. For example, when parents take responsibility for their own mistakes, this provides children with important lessons in how to handle emotion-charged situations. An illustration comes from the authors’ clinical experience. A mother took responsibility for her inaction when her children first told her their father was molesting them. With no prompting from the therapists, she said in front of the children, You told me Daddy was touching you sexually. I thought you were imagining it. I was wrong. I’m so sorry. This mother showed balance between powerful emotions of guilt, shame, and regret and her cognitive awareness of the impact of her mistake on her children. In this situation, she neither under-reacted nor over-reacted but provided a balanced and articulate response based on an integration of thoughts and feelings. Children Must Feel Safe Another principle in emotion-focused therapy is that children have to feel safe to express their emotions. Sometimes these emotions are unpleasant and may be displayed in ways that Emotion-focused Page 9 of 34 trigger in parents automatic responses of guilt, shame, and rage. In such situations parents respond to children’s emotion dysregulation with their own. Parents require coaching to rein back their own emotions to give children the space they need to express themselves. Parents’ primary job in these situations is to ensure that the children do not harm themselves and others and to provide guidance in constructive management of these powerful inner states. Gendered Emotion Expression and Display Parents also may have been socialized to believe gender stereotypes about girls’ and boys’ display of emotion, where they shame boys for showing “feminine” emotions such as sadness, shame, compassion, and fear, while they reward boys for being aggressive, stoic emotionally, and in charge. Ironically, the emotions that stereotypic notions stigmatize in boys are those whose expression is important for emotional health. Effective parenting takes teamwork. In families where there are two parents, the quality of parenting styles reflects the quality of parental relationships. When parents are not getting along, they have difficulty parenting effectively. Children with sexual issues are likely to tax them beyond what they can manage. Children also may misinterpret parents’ preoccupation and distraction over their relationship difficulties and think that the parents don’t love them or they are to blame for parental difficulties. Therefore, if parents take care of themselves and take care of their own needs, this will help their children. When parents are single, effective parenting requires the help of others: friends, family members, and neighbors. Child care, respite, and organized recreation are integral to providing support to parents. Family Assessments At intake, therapists assess family members’ capacities for the integration of affect and cognitions, whether their emotions are not minimized or overblown, and whether their parents want to come to therapy and genuinely want help. We want to know if they are willing to do Emotion-focused Page 10 of 34 what it takes to help their children. Blame typically is present. We are most hopeful if the parents blame themselves and not the children or the system. Self-blame is not a huge issue when parents are willing to engage in therapy. Multi-Modal Approaches Typically, children and their families require a multi-modal approach that entails child individual therapy, group psychoeducation for the children, family therapy, and couples therapy for two-parent families. We offer this spectrum of services in our emotion-focused therapy program. Providing individual therapy before entering peer group has important benefits. In emotion-focused therapy, therapists communicate empathy and understanding while at the same time are clear that the sexual behaviors are inappropriate. Therapists speak directly about the children’s sexually inappropriate behaviors. Surprising to some, children and young people often are relieved when therapists speak frankly about sex and expect them to do the same. Far too often, children and young people with sexual issues are raised in families and communities where sexual topics are approached with strain and reluctance, as if there is something naughty, dangerous, and taboo about sexuality. Many adults buy into the myth that children are not sexual beings until some time in adolescence. Thus, individual therapy can communicate acceptance of young people where they are. When children act out sexually, rarely do adults respond appropriately, this is, directly, empathically, and with clear setting of boundaries. Not only do children gain personally from individual therapy, such work is preparation for group work. The psychoeducation groups are 12 weeks long and are small (five to six children) with two therapists required because the children often have attention difficulties and hyperactivity. Group psychoeducation provides a place for children to be with other children with similar issues and thus provides opportunities for them to see that they are not the only ones Emotion-focused Page 11 of 34 with sexual issues. In peer groups, children learn to manage their sexual behaviors through a series of learning modules that include information and practice in the management of emotion and sexual behaviors. They can learn from other group members. Peers are a primary socializing group for children and adolescents, often as important and sometimes more important to young people than their families of origin. Family therapy provides opportunities for therapists to assess family processes that contribute to the children’s sexual issues. Rarely is the family atmosphere characterized by emotional balance, where parents model the expression of a range of emotions in appropriate ways, where emotions and cognitions are connected, and where parents coach their children in emotion expression that is balanced and considerate of others. The range of emotions expressed may be restricted and out of balance. Emotions are often suppressed. When expressed, they may be disconnected from conscious thought and thus can be hurtful and counterproductive. Parents may be dismissive of children’s attempts at emotion expression. Teasing and taunting about displays of emotion are common. Older siblings may be part of an ineffective family emotional system. Gender stereotypes may play out in families where fathers are alternatively distant and harsh and mothers are emotive or distracted and thus emotionally unavailable. Families in treatment for children’s sexually inappropriate behaviors rarely view sexuality as a natural topic of conversation. Few parents provide direct instruction about healthy sexual expression. Rather parents convey information through innuendo and cryptic remarks. Displays of affection may be restrained and awkward. On the other hand, some families have sexualized family atmospheres where ordinary conversation is infused with sexual content, sexual boundaries are routinely violated, and older children and adults in the family perform sexual acts in the presence of children. Children internalize these sexual processes and draw on them as they develop inner representations of usual and appropriate ways to express sexuality. Emotion-focused Page 12 of 34 Thus, families typically are out of balance in terms of sexuality. On the one hand, they may restrict sexual discussions and appropriate expressions or they may go far in the other direct and creative a highly sexualized family atmosphere. Children learn what is normal and usual from their families and they bring these assumptions into their relationships with persons outside of the family. Multiple family therapy and parent groups are beneficial when they are available. Children benefit when they see how other parents interact with their own children. Parents benefit when they have opportunities to interact with other parents in similar situations. In the authors’ program, this type of therapy happens informally, as parents spend time together waiting for the children who are participating in peer group. At the end of each peer, group parents are invited in so that their children can show them what they learned during that day’s session. A more formal multiple-family and couples group would be desirable but the costs and time commitment for families are often prohibitive. Significance of Emotional Expressiveness In the first author’s long-term research on how persons cope with, adapt to, or overcome adversities, Jane found that the single most important factor distinguishing persons who were resilient from those who harmed others was emotional expressiveness during childhood and adolescence (Gilgun, 1990; 1991, 1992; 1996, 1999c). Aspects of emotional expressiveness include experiencing, naming, and expressing a range of emotions and not just a few; experiencing continuity in emotional states and not switching abruptly from one state to another, such as appearing joyful and an instant later conveying rage; dealing directly with emotions without suppressing them or attempting to relieve them through self-destructive or anti-social means; and Emotion-focused Page 13 of 34 responding with empathy to the emotional states of others without taking advantage of their vulnerabilities. Behaviors and activities associated with the acquisition of emotional expressiveness included confiding to others about personal, painful events and experiencing affirmation; writing out emotions in journals; having outlets for tender feelings, such as caring for younger children and tending to pets; seeking comfort and solace through artistic expression, music, dance, and sports; and doing something kind for someone else. In short, in Jane’s research, persons who had capacities for coping with, adapting to, or overcome risks for harmful behaviors knew what they were feeling, experienced a range of feelings, and managed their feelings so that neither others nor themselves were harmed. When they chose to express their feelings they did so in pro-social ways, certainly not all the time, but they refrained from seriously harmful behaviors to others such as sexual abuse, rape, and physical violence and to themselves such as cutting, chemical abuse, and recklessness. These harmful behaviors appear to stem from a desire to manage overwhelming negative emotions. Persons who had experienced adversities but who also had capacities for emotional expressiveness had at least one long-term close relationship in childhood and adolescence with pro-social persons in whom they confided; with whom they identified; whom they admired; whom they emulated because they wanted to be like the persons they admired; and whose positive values they internalized and wanted as guidelines for their own lives. Emotion-focused Page 14 of 34 Persons with adversities and who turned out well also had relationship with persons who actively coached them on appropriate expression of emotion and modeled it themselves. In childhood and adolescence, these young people consciously studied the behaviors of persons they admired and emulated them. In short, emotional expressiveness develops from positive, long-term relationships during childhood and adolescence. The young people model their own behaviors on persons they admire and work hard at being like them. These relationships typically are with family members, both nuclear and extended, and with peers and families of peers. Appendix 1 lists qualities associated with these positive capacities. Persons who develop these capacities display resilience. Persons who had experienced adversities and harmed others typically were out of touch with their feelings and the feelings of others; or, if they did have capacities for emotional expressiveness, they also easily disconnected from the emotions and interests of others. They did not confide their personal, painful experiences to others, often because they could not find anyone who they thought was trustworthy. The persons with whom they identified and wanted to emulate typically modeled negative values and behaviors, such as justifications for vengeance when they perceived that others had harmed them. Persons in their environments applauded them when they behaved in ways that lived up to gender stereotypes. In addition, when they thought about acting out in harmful ways or were in the midst of harming someone, they often felt a tremendous release of strong negative emotions. So powerful was their desire to alleviate this emotional pressure that they disconnected from the humanity of their victims. This release is highly pleasurable. Thus, the act of being sexually abusive can be so strongly pleasurable that young people experience tunnel vision and disconnect from negative consequences for others and for themselves. Emotion-focused Page 15 of 34 Emotional Expressiveness and Emotion Display Emotional expressiveness is not the same as emotion display. Emotional display is how people chose to show their emotions, through facial expressions, words, tone of voice, and body language (Brody, 2000, 1999; Zeman & Garber, 1996). Persons can express their emotions appropriately without making an obvious display. Some people have muted displays of emotion, often based on cultural practices that enforce limits on emotion displays and encourage stoicism. Many boys and men believe overt display of emotions is not appropriate in some social situations, but if anyone asked them how they were feeling they could say so. The key idea, then, is awareness and identification of emotions and pro-social expression. Gender and Emotional Expression Most of the persons who acted out against others were male, leading Jane to search for explanations, which can be summarized as related to how males are socialized. All males are exposed to cultural themes and practices that encourage them to be aggressive, in charge, to be stoic and repress displays of most emotions except anger, and to be sexually aggressive (Brody, 1999c; 2000; Gilgun & McLeod, 1999). Males who cope successfully with adversities associated with sexually harmful behaviors somehow bypass these gender-based themes and practices. When pressure builds because of unexpressed emotions, they find release in a range of possible activities, not by harming others. Cultural themes and practices related to being male and that enforce suppression of most emotions, that punish men for emotions associated with being female such as feelings of vulnerability, loneliness, and loss, and that lead men to believe that they can be aggressive and take what they want are strongly implicated in male sexual aggression, apparently even boys and adolescent young men. In Western cultures, girls and women are less likely to harm others when they have risks to do so because they are socialized to value relationships, to nurture and take care of others, and Emotion-focused Page 16 of 34 to express their emotions. In short, being female appears to be a protective factor against sexual acting out while being male is a risk. It’s important to state that some girls and women are sexually abusive and most boys and men are emotionally expressive. Connections Between Therapy and Research While Jane was developing her understandings of the centrality of emotional expressiveness and gender in how persons cope with adversities, Kay and Danette were developing treatment programs for children and adolescents with sexual behavior problems. Like Jane in her research on resilience, Danette and Kay found that boys were much more likely than girls to be their clients and that the boys typically had a great deal of difficulty naming, articulating, managing, and expressing their emotions appropriately. They tended to overregulate their emotions to the point of suppressing them, sometimes out of fear of appearing unmanly and sometimes because of assumptions about how boys are supposed to handle their emotions. Their sexual acting act, when it involved the safety and well-being of others, is a clear indicator of insensitivity to the emotions and wants of others. Kay and Danette found that when girls acted out sexually, they usually were flooded with many conflicted emotions and had enormous difficulties managing and regulating their emotions. In brief, boys tended to have a restricted range of emotions and girls tended to be flooded. Though we arrived at our understanding of emotional expressiveness from different places, there is a great deal of overlap. The three of us view emotional expressiveness in children as developing from a complex web of relationships that have taken place over time. These relationships include those with parents, siblings, peers, extended family, teachers, neighbors, and youth leaders. In addition, children’s emotional development, expression, and repression also are influenced by a range of other factors, such as cartoons, films, sports, internet, Emotion-focused Page 17 of 34 video and computer games. These various sources provide guidance, rewards, and punishments for how emotions are expressed, with different rules for females and males. Children absorb messages about appropriate emotional expression for girls and for boys at young ages. Typically by age three, children understand qualities and roles associated with each gender. They emulate those that match their gender and avoid those of the other gender. For boys, to be called a girl or a sissy is an ultimate insult. Appendix 2 is an instrument for the assessment of emotional expressiveness that we developed for use with children and their families where the children had sexual behavior problems. Appendix 3 is a tool that assesses for healthy child sexuality. These instruments are part of the CASPARS, a set of five assessment tools for children and their families (Gilgun, 1999a, 1999b; Gilgun, Keskinen, Marti, & Rice, 1999) and are available at http://ssw.che.umn.edu/faculty/jgilgun.htm. Applications In the final pages of this chapter, we address two questions: What fosters therapeutic gains? What are the indictors that children are making gains in capacities for managing sexual behaviors? Getting There: Fostering Change The following are strategies and treatment guidelines the second and third authors use in their emotion-focused work with children and families. This, unfortunately, is a partial list, but it is suggestive of directions for treatment professionals to take in emotion-focused work. Build relationships with each family member. This will help the children get to the point where the children can manage their sexual behaviors; Help children identify and label their feelings. Some kids get angry in therapy and dump on the therapists. When this happens, help them label their feelings. “I can see you are very angry.” Sometimes children have such powerful fears of abandonment Emotion-focused Page 18 of 34 that they do not express their anger. The therapeutic task is to provide a sense of safety in therapy and then in the family so that the children can identify, label, and learn to express these feelings appropriately. Provide parents with opportunities to become more emotionally available to their children. As discussed, individual and couples therapy can do this, as well as instruction and information about appropriate ways of dealing with their children’s sexuality and other behaviors that are stressing family members and others in the children’s environments. See the therapist role as multi-faceted including o a facilitator of emotional development for the children and other family members; o as role model for parents on how to set limits on children’s behaviors including sexual behaviors while at the same time creating a sense of safety where no topic is taboo in families; as role models for children and parents in how to talk directly and respectfully about sexuality; o as sex educator for the parents and the children, including preparing parents and children for the kinds of behaviors to expect in the future. In a sense, the toothpaste is out of the tube. The children know what sexual pleasure is, and it is unlikely that they will stop being sexual. Masturbation will probably be an important sexual outlet, even for younger children who have not reached puberty; o as advocate for services children need, from insurance companies, social service agencies, and schools. Be prepared to participate in school Emotion-focused Page 19 of 34 conferences to plan how to deal with the children’s sexual behaviors in school settings; o as honest appraisers of risks to reoffend. When children do not make progress in their emotional development, treatment professionals typically are required to tell any referral sources and the parents. Red flags for reoffending include having a restricted range of feelings, flat affect when discussing emotioncharged events such as apology and empathy letters, and on-going incapacities for believe there was nothing wrong with their sexual behaviors when there is clear evidence that they violated the rights of others, abused their power, and perpetrated harm. Assume that children have capacities in the following areas: o for dealing forthrightly with their sexual behaviors and the circumstances under which their sexual behaviors take place; o for taking responsibility for their behaviors; o for engaging in therapy and becoming competent emotionally including developing empathy for the people they’ve harmed; o for managing their sexuality and the emotions that are associated with their sexual acting out; and o have capacities for letting go of gender-based ideologies that stigmatize emotional sensitivity and encourage bravado, aggression, and entitlement. Specific structured activities build children’s capacities for emotional expressiveness. These activities take place in the psychoeducation group. The children show their parents their accomplishments at the end of group. The activities include Emotion-focused Page 20 of 34 o Reading the book Feelings by Aliki (1987) with the children. The book is a great help to children who have difficulties identifying and labeling feelings. o Presenting children with cartoons where the children state what the story is about and identify what the characters might be feeling; o Reading Jan Hindman’s (1998) A very touching book...for little people and big people with the children The humour in this book helps children and adults relax about sexual issues and helps then see that sexuality is part of being human from birth to old age; o Viewing a video about sexual abuse. Then the children draw a feeling they saw in the video and discuss a time in their lives when they had that feeling. They also ask questions about how the child victim might have felt before, during, and after the abuse. This approach gives the children some distance from there own experiences but they are still focusing on a specific person from the video. Feelings charts. In this exercise, the therapists provide a list of feelings to the children. They ask the children to pick a feeling and pick a color that stands for the feeling. Then they draw a picture of something that represents the feeling. The children then explain the pictures to other group members. One child drew a black tornado to represent anger. Another child drew a yellow light bulb that shined so hard it exposed everything. The therapists engage children in discussions about the times in the past that they have felt this way, the pros and cons of the various ways to deal with these feelings, and positive ways to deal with these feelings now. In group discussion of the feelings charts, the children present their charts to their parents at the end of group. Emotion-focused Page 21 of 34 o Anger pyramid. The therapists draw a three-foot pyramid with the apex designated as anger. They explain that anger is like the tip of the iceberg that appears above the water line. Underneath the water are all the other feelings that anger covers up such as shame, fear, sadness, loneliness, and rejection. The therapists hope to help the children identify, label, discuss, and identify strategies for the feelings that make them feel vulnerable. o Feelings charades. The therapists present the children with a list of feelings. The children silently chose a feeling and the act out the feeling. The other children yell out their guesses until they guess correctly. o Collages. The therapists provides the children with a list of terms for feelings, magazines, child-safe scissors, glue, and paper and ask the children to pick a feeling and then find a picture in the magazines that represents the feeling. o Empathy letters. When the therapists have evidence that the children have developed emotional competence, they show them how to write an empathy letter to the persons they’ve acted out on sexually. The children share their letters in group to get the opinions of other group members. o Apology letters. Once the therapists have evidence that the children have developed empathy for the persons they’ve harmed and can take responsibility for their behaviors, then they provide guidelines on how to write a letter of apology. o Reconciliation sessions. In these face-to-face meetings, the persons the children harmed tell the children who perpetrated sexual abuse what the abuse meant. The child victims typically go through a period of preparation that is supported by the victim’s family. The children who perpetrated go through a Emotion-focused Page 22 of 34 long preparation as well, to ensure that they have capacities for empathy and will not even subtly place the blame on victims. Often these reconciliation sessions are between siblings, where an older child sexually abused one or more younger children. Jan Burton and colleagues (1998) have an extensive set of exercises for children with sexual issues. Each of these strategies requires parental involvement. For example, under the supervision of therapists in family therapy, parents can be helpful in composing and rehearsing empathy letters under the supervision of therapists in family therapy. This, of course, assumes that the parents have also made gains in their own therapy. For each of the structured activities, parents are involved. They participate in the last ten minutes of every peer group session when the children show them what they did that day in group. Indicators of Change Indicators that suggest the children are at lower risk to act out in the future come from both the children and their parents. Usually, when the parents make progress in their own therapy, the children’s progress is parallel. If the parents don’t make progress, any gains the children make are likely to be short-term. The following are some indicators of change. There are many more, but this brief discussion provides Children show assertiveness. This quality is complex, but most therapy situations are. The following example will illustrate. Two school age girls were acting out sexually with each other in school. They were unable to stop their behaviors when the teachers told them to. Both girls were referred to treatment and both had single mothers. One mother and daughter engaged in treatment. The other mother refused treatment and did not allow her daughter to do. The untreated mother told her Emotion-focused Page 23 of 34 daughter, other family members, and friends that the other girl and not her daughter is a perpetrator and should be charged with a crime. The girl in treatment wrote a letter to the mother stating, “Dear ___, I’m not a bad kid.” She expressed regret at what had happened between her and the mother’s daughter and apologized. In therapy, she took responsibility for her behaviors, became emotionally expressive, and assertive without being aggressive. The child also began doing well in school and behaved appropriately. Her mother showed many therapeutic gains. Thus, with responsiveness to treatment and a mother who also engaged in treatment, this child took the initiative and wrote an assertive and not aggressive letter to the mother of the child with whom she had been inappropriately sexual. Previous taboo topics are on the table. A family who had completed treatment a few years earlier came back for a tune-up session. The boy who had been the “target” client in the program wanted to talk about puberty and masturbation. For almost the entire session, family members told puberty stories and stories about masturbation with humor and respect for boundaries. Children can ask questions that they were too ashamed to ask in the past. . One boy who was approaching puberty asked during group time if it was okay if white stuff came out when he masturbated last week. The therapists said, “Congratulations. You are growing up.” Children tell on themselves. Children talk about topics that might have been too painful for them in the past. One boy said he was masturbating in his room and his sister peeked in on him. She told her mother he was masturbating. He was angry at his sister and was embarrassed. Another kid said, “You got caught white-handed.” Emotion-focused Page 24 of 34 The humor allowed the boy to admit that he got in trouble not because he was masturbating because when he saw his sister spying on him, he chased her with semen on his hand. Humor. As this story shows, humor often accompanies the development of emotional competence, as well as fostering it. Signs of attachment to others. Some children feel are lonely and isolated and have minimal emotional attachments to others. These children are at high risk to act out sexually if they have been exposed to inappropriate sexual behaviors. One boy, in foster care, formed an attachment to his foster father. He considers the foster father his father. He said, “He’s the only one I have.” He’s also attached to his therapist and to his psychoeducation group. He is not attached to his foster brothers and he’s doing everything he can to keep everyone else away. Thus, though he’s made some progress, he still has more work to do. Affect becomes more animated. Another child, who is developmentally delayed, really likes his foster mother and is attached to her. His affect is less flat than it used to be, and he smiles at jokes, even makes jokes himself. He is neater, cleaner, and looks like a different kid. Connection to others is a protective factor. Separateness from others is a risk for sexual acting out in children with these histories. Emotions and cognitions are connected. When kids are preparing to apologize for their behaviors and express fears and doubts about the apology, this is a more hopeful sign than if they read it by rote. Takes responsibility for their behaviors; empathy for victims. These two qualities go hand-in-hand. In a reconciliation session, a boy stated that he had had no idea what Emotion-focused Page 25 of 34 his sister, whom he had sexually abused, had gone through. He cried for her. He said, “I took advantage of you.” He admitted that he had exploited her. Parents set limits. The following is an example. A single-parent family had been in and out of treatment for several years. The son in the family had been molested in pre-school and soon after began grabbing and fondling other children. His mother refused for years to deal with her own childhood abuse. Finally, she agreed to some help with how she was parenting her son. Once she began to manage her own issues, she could start setting limits. She could say to her son, “Knock it off. I don’t want you to behave this way.” The child responded to her limited setting and started showing other signs of making treatment gains, such as handling teasing by age peers with humor. He was in special education and waited at the same bus stop as other children but took a different bus. The other kids picked on him for this. He said, “I have my own limo to take me to school.” The teasing stopped. He also has become an excellent skate boarder, and when he showed up, the other kids shouted greetings. Discussion This chapter pieced together the authors’ research and clinical experience as well as some research on children’s emotional development. Our purpose was to show the significance of emotional expressiveness in the treatment of children and their families where children have sexually inappropriate behaviors. The therapy program is emotion-focused. Treatment professionals are just beginning to formulate programs. Rigorous evaluations will take place some time in the future. The approaches we described and the indicators of progress in treatment have not been submitted to randomized clinical trials where children and families are randomly assigned to treatment and control groups. We do not have quantified indicators of treatment effectiveness. Emotion-focused Page 26 of 34 Rather, what we have presented are a set of good ideas, grounded in clinical experience and research and theory. We have recommendations as to how treatment professionals can use this information. We want other professionals to use these ideas to help them think about and identify issues that their own clients might have. We want others to test these ideas for their fit with clients after they have done a thorough assessment of clients’ strengths and vulnerabilities. If our ideas don’t fit, then modify our ideas. Do not force information from clients into any of the categories that we have offered. For any of the interventions we’ve discussed, such as the feelings chart or charades, make sure the children understand what professionals are asking them to do and be sure that how professionals present these exercises is developmentally appropriate. Even children who are about the same age may vary a great deal in terms of their levels of cognitive and emotional development. If professionals want to do reconciliation sessions and apology and empathy letters, they must have the skills to do so. These are not simple procedures. They require a great deal of skill, experience, and sensitivity to the multiple issues at stake. Be sure to learn from the experiences of other professionals who have expertise in these approaches. We believe that children’s behaviors are adaptations to their life circumstances, filtered through cognitive schemas that shape what they perceive, how they perceive, and what actions they take. The work of Toth and colleagues (2002) provides an in-depth discussion of cognitive schemas and how they affect behaviors. In the long run, effective treatment leads to modification of these adaptive inner representations of self, others, and how the world works. These are not trivial pursuits, nor are they easily accomplished. To do this work, professionals must have highly developed emotional competencies themselves and respect for their own limits. References Emotion-focused Page 27 of 34 Aliki (1987). Feelings. New York: Morrow. Bargh, John A. (1997). The automaticity of everyday life. In Robert S. Wyer, Jr. (Ed.), Advances in social cognition, Vol. X (pp. 1-61). Ahwah, NJ: Erlbaum. Brody, Leslie R. (2000). The socialization of gender differences in emotional expression: Display rules, infant temperament, and differentiation. In Agneta H. Fischer (Ed) Gender and emotions (pp.24-47). New York: Cambridge University Press. Brody, Leslie R (1999). Gender, emotion, and the family. Cambridge, MA: Harvard University Press. Burton, Jan Ellen et al (1998). Treating children with sexually abusive behavior problems: Guidelines for child and parent. New York: Haworth. Fraiberg, Selma, E. Adelson, & V. Shapiro (1975). Ghosts in the nursery: A psychoanalytic approach to impaired mother-child relationships. Journal of the American Academy of Child Psychiatry, 14, 387-421. Gilgun, Jane F. (1999a). CASPARS: Clinical assessment instruments that measure strengths and risks in children and families. In Martin C. Calder (Ed.), Working with young people who sexually abuse: New pieces of the jigsaw puzzle. Dorset, England: Russell House. Gilgun, Jane F. (1999b). CASPARS: New tools for assessing client risks and strengths. Families in Society, 80, 450-459. Tools available at http://ssw.che.umn.edu/faculty/jgilgun.htm Gilgun, Jane F. (1999c). Mapping resilience as process among adults maltreated in childhood. In Hamilton I. McCubbin, Elizabeth A. Thompson, Anne I. Thompson, & Jo A. Futrell (Eds.), The dynamics of resilient families. (pp. 41-70). Thousand Oaks, CA: Sage. Gilgun, Jane F. (1996). Human development and adversity in ecological perspective: Part 1: A conceptual framework. Families in Society, 77, 395-402. Emotion-focused Page 28 of 34 Gilgun, Jane F. (1992). Hypothesis generation in social work research. Journal of Social Service Research, 15, 113-135. Gilgun, Jane F. (1991). Resilience and the intergenerational transmission of child sexual abuse. In Michael Q. Patton (Ed.), Family sexual abuse: Frontline research and evaluation (pp. 93-105). Newbury Park, CA: Sage. Gilgun, Jane F. (l990). Factors mediating the effects of childhood maltreatment. In Mic Hunter (Ed.), The sexually abused male: Prevalence, impact, and treatment (pp. 177-190). Lexington, MA: Lexington Books. Gilgun, Jane F., & Laura McLeod (1999). Gendering violence. Studies in Symbolic Interactionism, 22, 167-193. Gilgun, Jane F., Susan Keskinen, Danette Jones Marti, & Kay Rice. (1999). Clinical applications of the CASPARS instruments: Boys who act out sexually. Families in Society, 80, 629641. Hindman, Jan (1998). A very touching book...for little people and big people (rev. ed.) Baker City, OR: Alexandria Associates. Isen, Alice M. (198). Toward understanding the role of affect in cognition. In Robert S. Wyer, Jr. & Thomas K. Srull (Eds.), Handbook of social cognition, Vol. 3 (pp. 179-236). Hillsdale, NJ: Erlbaum. Izard, Carroll E.,Sarah Fine, Allison Mostow, Christopher Trentacosta, & Jan Campbell (2002). Emotion process in normal and abnormal development and preventive intervention. Development and Psychopathology, 14, 761-787. Raver, C. Cybele (2002). Emotions matter: Making the case for the role of young children’s emotional development for early school readiness. Social Policy Report, XVI (3), 318). Emotion-focused Page 29 of 34 Toth, Sheree, Angeline Maughan, Judy Todd Manly, Mary Spagnola, & Dante Cicchetti (2002). The relative efficacy of two interventions in altering maltreated preschool children’s representational models: Implications for attachment theory. Development and Psychopathology, 14, 877-908. Watson, Jeanne C. (1996). The relationship between vivid descriptions, emotional arousal, and in-session resolution of problematic reactions. Journal of Consulting and Clinical Psychology, 64(3), 459-464. Zeman, Janice & Judy Garber (1996). Display rules for anger, sadness, and pain: It depends on who is watching. Child Development, 67, 957-973 Emotion-focused Page 30 of 34 Appendix 1. Qualities Associated with Resilience Qualities Associated with Resilience At least one long-term relationship with an adult inside or outside the family where the adult models pro-social behaviors and values the young person admires and emulates the adult's positive qualities the adult praises and appreciates the young persons pro-social values and behaviors the young person confides personal and sensitive material to the adult the young person seeks out the adult in times of stress and hurt the young persons shares happy news and events with the adult the young person shares with the adult events that occur in peer group At least one long-term friend pro-social friend during childhood and adolescence (longer than five years) who serves a similar role as the pro-social adult described above Has a will to be law-abiding Has a will to engage in pro-social behaviors Is persistent in the face of obstacles Enjoys accomplishing tasks Discusses a sense of inadequacy with others and feels better afterward Views others as deserving of respect Deals directly with persons who are the occasions of anger Makes amends when actions/words hurt others Believes and acts out the idea that negotiating for what you want is respectful Believes and acts out the idea that taking what you want is selfish and wrong Believes that living well is the best revenge Redresses wrongs through negotiation and not through getting back at others Equates masculinity with respect for women Equates masculinity with appropriate expression of emotion Equates being a girl or woman with assertiveness Engages in consensual sexual behaviors with others Goes for a run, a swim, or other physical activity when stressed Uses a wide range of pro-social ways to maintain emotional equilibrium Listens to and learns from criticism Enjoys dating in high school Masturbation related is related to sexual desire Has a wide range of sexual fantasies, primarily of age peers Imagines a positive future Takes specific steps toward an imagined positive future Emotion-focused Page 31 of 34 Appendix 2. Emotional Expressiveness Strength 3=high 2=medium 1=low Risk 3=high 2=medium 1=low 0=not known/not observed 1. Child shows a range of feelings. 2. Child puts own feelings into words. _____ 3. Child’s expression of feelings is appropriate to situations. Strength Risk _____ _____ _____ _____ _____ _____ _____ _____ _____ 4. Child’s feelings and reactions are linked to the events that precipitated them. 5. Child can identify a wide range of feelings in others 6. Child sympathizes with other people’s feelings. _____ _____ 7. Child appears to respect the feelings of others. _____ _____ _____ _____ 8. Child has a person in family and/or community who facilitates appropriate expression of feelings. 9. Child’s moods are fairly even. _____ _____ 10. Child shares emotionally-laden events with others, both positive and hurtful events. 11. Child engages emotionally with others. _____ _____ _____ _____ 12. Child is sensitive to others. _____ _____ _____ _____ _____ _____ _____ _____ 13. Child’s emotional responses match demands of the situation. 14. Child recognizes when her/his emotional responses are inappropriate. 15. Child apologizes for inappropriate expressions of feelings. 16. In general, the child manages his or her emotions well. ____ 17. In general, the child is respectful of the emotions of others. Scoring: add scores in each column. _____ ____ strength _____ score Appendix 3: _____ risk _____ score Emotion-focused Page 32 of 34 Sexuality Scale Strength 3=high 2=medium 1=low Risk 3=high 2=medium 1=low 0=not known/not observed strength risk 1. Parents set limits on child’s inappropriate sexual behaviors. (e.g., exposing genitals, public masturbation, “grabbing” others genitals) _____ _____ 2. Child stops sexually inappropriate behaviors when parents set limits. _____ _____ 3. Child is appropriately interested in looking at nude or semi-nude pictures in newspapers, magazines, and catalogues, such as lingerie ads. _____ _____ 4. Child does not have a known pattern of masturbating while looking at nude or semi-nude pictures in newspapers, magazines, and catalogues, such as lingerie ads. _____ _____ 5. Child respects the sexual boundaries of others. _____ _____ 6. Child does not have a pattern of attributing sexual behaviors to dolls and other toys. _____ _____ 7. Child respects the sexual boundaries of animals. _____ _____ 8. Child’s sexual interactions with others are appropriate; that is, occur with children about the same age and are mutual. _____ _____ 9. Child has a good sense of when to talk about sexual things. _____ _____ 10. Child’s has appropriate bathroom behaviors. (e.g., feces and urine go into the toilet) _____ _____ 11. Parents have provided child with information about sexuality that is age appropriate. _____ _____ 12. Parents respect the sexual boundaries of others, keeping their own sexual behaviors private. _____ _____ 13. Other persons in child’s environment keep their sexual behaviors private. _____ _____ _____ _____ 14. Child has witnessed appropriate sexual expressions (e.g., affectionate kissing, hugging, talk, looks, and tough) Emotion-focused Page 33 of 34 15. Child has not witnessed inappropriate sexual expressions. (e.g., intercourse, coerced sexual contact such as rape, child sexual abuse, and genital touching, even if between age peers). _____ _____ 16. Family sexual talk is respectful. _____ _____ 17. In general, the environments to which the child is exposed is respectful of the child’s sexuality and the sexuality of others. _____ _____ 18. Materials with sexual content to which child is exposed are age appropriate. (e.g., books, magazines, computer games, cable tv, internet information). _____ _____ 19. Child is comfortable with sexual orientation. _____ _____ 20. Child is comfortable with gender identity. (e.g., a boy wants to be a boy and a girl wants to be a girl). _____ _____ 21. Overall, child is appropriate sexually. . Scoring: add scores in each column. strength _____ risk _____ score score ©2003 Jane F. Gilgun. firstname.lastname@example.org _____ _____ Emotion-focused Page 34 of 34 Notes 1 Not real names Jane F. Gilgun, Ph.D., LICSW, is professor, School of Social Work, University of Minnesota, Twin Cities, 404 Gortner Avenue, St. Paul, MN 55108 USA. Phone: 612/925-3569; Fax: 612/624-3744; email: email@example.com; website: http://ssw.che.umn.edu/faculty/jgilgun.htm She has done research on how persons overcome adversities, the meanings of violence to perpetrators, the development of violent behaviors, and strengths-based assessment of children, youth, and families when the children and youth have adjustment issues. She has published and lecture widely on these topics. She was a public child welfare social worker for several years before she studied for her master’s in social service administration at the University of Chicago and her PhD in family studies at Syracuse University, USA. She also has a licentiate in family studies and sexuality from the Catholic University of Louvain in Belgium. Kay Rice, LICSW, ACSW, is a therapist in private practice specializing in children, youth, and their families where the young people are experiencing serious adjustment issues. She has specialized in the sexual issues that children and youth develop. Her address is 2375 University Avenue W., Suite 160, St. Paul, MN 55114 USA. Phone: 651/642-1709; fax: 651/642-0150. She has consulted and lectured widely on her approach to therapy and has published in her specialty area. A licenced social worker, she has a master’s degree in social work is from the University of Iowa, USA. Danette Jones, AAMFT, LICSW, is a therapist in private practice is a therapist in private practice specializing in children, youth, and their families where the young people are experiencing serious adjustment issues. She has specialized in family work with children who have sexual behavior issues. Here address is 2375 University Avenue W., Suite 160, St. Paul, MN 55114 USA. Phone: 651/642-1709; fax: 651/642-0150. A licenced family therapist and social worker, she has consulted and lectured widely on her approach to therapy and has published in her specialty area. Her master’s in social work and in marriage and family therapy are from the University of Wisconsin, Madison, USA.