Self reported experiences of therapy following child sexual abuse: Messages from a retrospective survey of adult survivors

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published online 10 October 2013Journal of Social WorkDebbie Allnock, Patricia Hynes and Martha Archibald

from a retrospective survey of adult survivorsSelf reported experiences of therapy following child sexual abuse: Messages

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DOI: 10.1177/1468017313504717

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Article

Self reported experiencesof therapy following childsexual abuse: Messagesfrom a retrospectivesurvey of adult survivors

Debbie AllnockApplied Social Studies, University of Bedfordshire,

Bedfordshire, UK

Patricia HynesApplied Social Studies, University of Bedfordshire,

Bedfordshire, UK

Martha ArchibaldThe Camden Society, London, UK

Abstract

� Summary: This article explores retrospective accounts of childhood sexual abuse

survivors’ experiences of therapeutic support received before the age of 18 in the

United Kingdom. The survey formed part of a broad programme of research on thera-

peutic interventions for children affected by sexual abuse, by the National Society for

the Prevention of Cruelty to Children (NSPCC) under the Rebuilding Childhoods

programme. The primary aim of the survey was to explore what was helpful in

young survivors’ experiences (n¼ 299) of therapy to inform the development of a

new NSPCC service. Of these 299 respondents (aged 18–35), only 52 reported receiv-

ing formal therapeutic provision following the abuse and this article relates to this

smaller subset.

� Findings: Respondents revealed that therapeutic factors such as therapist character-

istics and interpersonal communication were crucial in informing their perceptions of

therapy received. However, pre-therapy factors such as high level of need and unstable

personal circumstances at the time of accessing support also influenced respondent

ability to engage in the therapeutic process. Although the types of therapy accessed

differed for respondents, there were common elements reported relating to therapist

characteristics and skills which were important in determining respondent views.

Corresponding author:

Debbie Allnock, Applied Social Studies, University of Bedfordshire, Luton, Bedfordshire, UK.

Email: [email protected]

at University of Bedfordshire on February 1, 2014jsw.sagepub.comDownloaded from




� Applications: The findings suggest that while there is no one-size-fits all approach,

there are key characteristics of the relationship between child and therapist that

must be considered and that assessment and on-going professional judgement is key

to engaging children and maximising their therapeutic experiences. The findings also

suggest the importance of listening to children’s preferences and keeping children

informed.

Keywords

Child sexual abuse/or child abuse, counselling, mental health, play therapy, social work,

survivors, therapeutic work

Introduction

Estimates of the prevalence of childhood sexual abuse (CSA) vary widely amongstudies conducted within the UK and abroad. The literature shows lifetime experi-ences of sexual abuse ranging from 1.1% to 32% (see for example, Barter, McCarry,Berridge, & Evans, 2009; Edwards, Holden, Felitti, & Anda, 2003; Euser, VanIjzendoorn, & Prinzie, 2010; Finkelhor, Hamby, Ormrod, & Turner, 2005; Trocmeet al., 2005; Tourigny, Herbert, Jolly, Cyr, & Baril, 2008). More recently, a UKgeneral population study carried out by the National Society for the Prevention ofCruelty toChildren (NSPCC)1 on the prevalence of child abuse andneglect in theUKfound a lifetime rate of sexual abuse by a parent or guardian among 18- to 24-yearolds of 1.0% and 5.3% for abuse perpetrated by non-resident adults (Radford et al.,2011). However difficult it is to gather an accurate picture of the extent of sexualabuse, the treatment and support of children and young people affected by it is ahuman right enshrined in Article 19 of the United Nations Convention on the RightsofChildren (UNCRC) (UnitedNationsGeneralAssembly, 1989). Support canplay acritical role in addressing the adverse impacts of CSA which some children mayexperience in the short and long term, including physical, emotional, behaviouraland relational difficulties (see:Amstadter&Vernon, 2008;Arriola, Louden,Doldren,& Fortenberry, 2005; Birdthistle et al., 2009; Daignault & Herbert, 2009; Davis &Petretic-Jackson, 2000; Fergusson, Boden,&Horwood, 2008; Fliege, Lee,Grimm,&Klapp, 2009; Ginzburg et al., 2009; Johnson, 2004; Maniglio, 2010; NationalScientific Council on theDevelopingChild, 2007). It is always important to recognizethat some children are observed to be resilient after abuse experiences (Finkelhor,Hotaling, Lewis, & Smith, 1990; Kendall-Tackett, Williams, & Finkelhor, 1993).Individual characteristics such as positive coping strategies (Oaksford & Frude,2009) may partly explain this, and/or may be the result of caring, informal supportfrom a trusted adult (Pepin & Banyard, 2006). Finally, although some children con-tinue to encounter difficulties throughout their lives, they may come to considerthemselves survivors of abuse and go on to lead fulfilled lives. Intent on respectingthe experiences of survivors, the researchers of this study sought to retrospectively

2 Journal of Social Work 0(0)





capture the types of help and support important to survivors, a topic neglected in theliterature to date.

Service provision in the United Kingdom

A study of therapeutic services for sexually abused children carried out by theNSPCC revealed significant shortages of provision in the United Kingdom, leavingmany children deprived of services or with lengthy waits for help (Allnock et al.,2012, 2009). The study identified that therapeutic services are delivered through arange of agencies within the statutory sector, the voluntary/third sector and theprivate sector. Some practitioners with special training, qualifications and experi-ence work within specialist post-sexual abuse services. However, such specialistsmake up less than a quarter of all services for CSA. While specialist services wouldappear to be better suited to provide the support required, in the current economicclimate, it is unlikely that resources will materialize to fund their growth to therequired level (see Allnock et al., 2009 for estimations of need). Therefore, it isimportant to recognise the reality that practitioners without specialised trainingmay find themselves working with children affected by CSA. These settings may begeneric, where provision is aimed at a wide range of mental health or behaviouralproblems, but not specifically at CSA (for example, community counselling ser-vices; Allnock et al., 2009; Allnock & Hynes, 2011). In agencies where the medicalmodel predominates, such as the Child and Adolescent Mental Health Services(CAMHS)2 in the United Kingdom, ‘diagnosis’ is often used as a means to cat-egorise children’s mental health symptoms, subordinating the experience of CSA(Allnock et al., 2009). It has been argued that there is a tendency to focus ondiagnostic classification that remove symptoms or behaviours from their contextualenvironment meaning ‘‘reasonable responses to trauma are de-contextualized as‘symptomatic’ behaviour’’ (Warner, 2009, p. 17). This can mean that practitionerswho do not specialise in CSA may be at risk of unintentionally misinterpretingchildren’s responses.

Interventions are varied as are theoretical approaches, although in the UK,statutory provision encourages the delivery of cognitive-behavioural therapy(CBT). This preference is associated with the emphasis given to evaluations ofCBT. Efficacy studies and reviews have found promising evidence for this inter-vention (see reviews for detail: Hetzel-Riggin, Brausch, & Montgomery, 2007;Silverman et al., 2008; Wethington et al., 2008), and as a result, it is seen by theUK government to be the ‘gold standard’ of provision for symptoms associatedwith CSA, such as depression, anxiety and post-traumatic stress disorder (PTSD)(National Institute for Health and Clinical Excellence, 2008). Other common inter-ventions provided in the UK include ‘creative’ therapies – predominantly playtherapy – which are less linguistically based than CBT, psychodynamic psycho-therapy and counselling, however the evidence-base for these creative therapies issmall (see Wethington et al., 2008). The NSPCC is currently developing a newservice incorporating a flexible approach, accompanied by an evaluation in order

Allnock et al. 3





to assess its efficacy – and the survey reported here was intended to inform thisdevelopment.

Understanding children’s responses to CSA

Research indicates that service providers often find it stressful to treat survivorsbecause of their resistance to change and ways of relating to practitioners (Beutler& Hill, 1992; Herman, 1992; Valentine & Feinauer, 1993). Service providers mayencounter further complications when working with children affected by CSAbecause, unlike adults, they are less likely to help-seek independently through atherapeutic route (Palmer, Brown, Rae Grant, & Loughlin, 2001). In the UK,children are mostly referred into sexual abuse services via a social care or otherprofessional pathway or because their parent or carer solicits help on their behalf(Allnock et al., 2009). This can result in practitioners being challenged to engagechildren who either do not understand why they are there or who feel they havebeen forced to attend.

The Four Traumagenic Dynamics Model was proposed by Browne andFinkelhor (1986) to describe the conjunction of four specific dynamics, whichmake CSA unique from other forms of trauma. The first dynamic of ‘traumaticsexualisation’ refers to a process in which a child’s sexuality is shaped in a devel-opmentally inappropriate and interpersonally dysfunctional fashion as a result ofCSA. The second dynamic, ‘betrayal’ refers to how children discover that someoneon whom they are vitally dependent has caused them harm. Thirdly, a dynamic of‘powerlessness’ is the result of a continual contravention of the child’s will, desiresand sense of efficacy. Finally, ‘stigmatisation’ is a dynamic describing negativeconnotations – for example, shame and guilt – that are communicated to thechild about the experiences and then become incorporated into the child’s self-image. Glaser (1991) recommended additional consideration of ‘secrecy’ and ‘con-fusion’ inherent in this form of abuse. These dynamics may help to explain theunique difficulties and complexities practitioners face in engaging sexually abusedchildren. It may also identify why the therapeutic alliance, recognised as a crucialcomponent in therapy (Shirk & Karver, 2003), may hold a special place in thera-peutic work with children who have experienced CSA and who may have difficul-ties trusting others.

Therapist characteristics

The therapeutic alliance is a concept that describes the working relationshipbetween therapist and client. Important aspects of this alliance reside in the thera-pist-offered conditions such as empathy, positive regard and genuineness (Brown &Lent, 2008). A comprehensive review by Ackerman and Hilsenroth (2003) identi-fied 25 studies that examined positive therapist characteristics and techniques,which impact on the therapeutic alliance. They found evidence that a therapist’sability to understand and relate to the patient’s experience appeared to be an






important component in building a strong alliance. Other important factorsinclude: trustworthiness (Horvath & Greenberg, 1989), experience (Mallinckrodt& Nelson, 1991), confidence (Saunders, 1999), lucid communication (Price & Jones,1998) and accurate interpretation (Crits-Christoph, Barber, & Kurcias, 1993;Ogrodniczuk & Piper, 1999). The therapist’s investment in the treatment relation-ship was found to be manifested through enthusiasm (Luborsky, Crits-Christoph,Alexander, Margolis, & Cohen, 1983), interest (Saunders, 1999), exploration(Bachelor, 1991; Gaston & Ring, 1992; Joyce & Piper, 1998, Mohl, Martinez,Ticknor, Huang, & Cordell, 1991), involvement (Sexton, Hembre, & Kvarme,1996) and activity (Dolinsky, Vaughan, Luber, Mellman, & Roose, 1998; Mohlet al., 1991). The key elements of empathy include affirmation (Najavits & Strupp,1994), helping (Coady & Marziali, 1994), warmth/friendliness (Bachelor, 1991;Saunders, Howard, & Orlinsky, 1989) and understanding (Bachelor, 1995; Crits-Christoph et al., 1998; Diamond, Hogue, Liddle, & Dakof, 1999; Najavits &Strupp, 1994; Price & Jones, 1998; Saunders et al., 1989).

Although the literature reporting children’s experiences within therapy directedat CSA is small, two published studies identified issues associated with therapist-offered characteristics as important. Prior and Glaser’s (1994) study sought theviews of 35 boys and girls who had received a post-sexual abuse service. Theyfound that children did not like being forced to talk; liked having a range of cre-ative activities available; felt less isolated as a result of therapy; liked that therapywas a safe place to say things and liked their practical needs to be met. Potter,Holmes, and Barton’s (2002) study focused on adolescents over the age of 14 in apost-sexual abuse service, and discovered they want to be listened to and, as inPrior & Glaser’s study, did not want to talk about the details of the abuse.Although other studies have asked adults to self-report their experiences of CSA(Edwards et al., 2003; Oaksford & Frude, 2001; Tourigny et al., 2008), retrospect-ive studies of adults reporting their experiences of therapy as children could not beidentified, making the findings in this study unique.

Methodology

This retrospective study was one part of a much larger prospective cohort studythat was designed to systematically follow-up children, over a period of five years,who had experienced CSA and were currently undergoing therapeutic interven-tions. The aim of this survey was to gain an understanding, directly from 18- to35-year old survivors in the UK, of the complexities of their experiences of therapy.An online survey containing both quantitative and qualitative questions wasdesigned with a view to gathering information on trends in therapeutic provisionin childhood, alongside respondents’ personal reflections on these experiences.

Following questions designed to gain informed consent and ensure anonymity,section 1 of the survey asked demographic questions and broad details of whenCSA had begun and ended. Questions were posed to elicit qualitative responsesrelating to how individuals were supported at the time of their abuse. Section 2

Allnock et al. 5





gathered quantitative information on the types of therapeutic support received,including therapies such as counselling, play therapy, CBT, psychodynamic psy-chotherapy and eye movement desensitization and reprocessing (EMDR) and alsoasked respondents to rate their feelings about their therapist. These were followedby open-ended questions eliciting further context. The findings in this article relateprimarily to responses from this section of the questionnaire. Section 3 related toother forms of support experienced at the time the abuse became known such asinformal support from family, friends and community members and Section 4explored the traumagenic dynamics of CSA (Browne & Finkelhor, 1986; Glaser,1991), asking respondents to comment on their present sense, for example, ofbetrayal and stigmatisation. Section 5 sought the opinions of participants ontypes of support they felt best suited children who had experienced CSA. Section6 ended with further demographic questions and a non-obligatory offer to provideemail-only contact details to receive any publications resulting from the question-naire or related study.

The use of a self-completion internet based survey was used to provide anonym-ity to respondents. The SNAP software used to generate these surveys was chosento also enable respondents to complete questionnaires at their own pace, leavingand returning to their answers at will. It was considered that this was a strength ofthis research given the sensitivities of conducting research into CSA, building intime for respondents to reflect upon their answers.

The sample was one of convenience, advertised on the NSPCC Inform websiteand Facebook and several other well-known adult survivor organisations gener-ously advertised the study on their sites and in their offices. The choice to limit agefrom 18 to 35 was based on the desire to limit recall bias. This article reports onboth the quantitative and qualitative questions, raising caution to the reader ininterpretation due to the small sample size. Quantitative findings will be reportedonly to give a descriptive perspective to the data, followed by thematic responsesgenerated by the open-ended questions.

The study was governed by an Advisory Group of leading experts, internal andexternal to the NSPCC. Responses from the Advisory Group helped develop thecontent of the survey and practitioners’ views were also sought on the content andappropriateness of language of the questionnaire.

Findings

Study group demographics

The study was not designed to be representative of the population, instead recruit-ing respondents as a convenience sample. This, along with the restriction on age,means that the demographics inevitably do not correspond to UK populationstatistics (see Radford et al., 2011). The average age of the sub-sample of 52respondents was 26 years, based on inclusion criteria of 18–35 years old.From the larger sample of 299, 32 males at least partially completed the survey






but only 3 (9%) of these reported having received therapy under 18, while 49 (18%)of the remaining 267 females reported the same, making the sample for this study 3males and 49 females. This may be unsurprising given that males have been foundby researchers to be less likely to disclose sexual abuse (Finkelhor et al., 1990;Lamb & Edgar-Smith, 1994; Violato & Genius, 1993). If few tell about abuse,this means few are likely to receive therapy as a form of support, reducing thepool of males matching the study criteria. Twenty-five percent (n¼ 13) reportedhaving a disability or long-standing health condition, a particularly high percentfor the 18- to 35-year age group compared with the almost 20% of the total work-ing population in the UK reported to have a disability (Papworth Trust, 2011).Detailed information on types of disability reported was not collected, but severalparticipants described disabilities that they associated directly with their experi-ences of abuse, such as chronic fatigue syndrome. The high disability percentagemay, therefore, reflect self-reported physical and mental health impacts of sexualabuse. The majority (69%) described themselves as White British and 16% as anethnic identity other than White British. The remaining 15% did not provide thisdemographic data. The low number of respondents from minority ethnic groupsmay partly reflect the pattern of representation in social care, which over-representsBlack British and mixed heritage children and under-represents Asian British chil-dren in Children in Need, Looked After and Child Protection Register categories(Owen & Statham, 2009). The over-representation of Black British children insocial care does not appear, however, to have been translated into high referralsto specialist sexual abuse services (Allnock et al., 2009). Low entry into therapeuticservices in this case may be related to a gulf between minority ethnic group’sculture and the delivery of a Western British therapeutic service (Gilligan &Akhtar, 2006) or could also reflect a tendency for members of minority ethniccommunities to rely on informal support to a much greater extent than theirWhite counter parts (Chatters, Taylor, & Neighbours, 1989). It may also simplybe that some non-White groups are less likely to share their experiences withresearchers. Whatever the explanation, it was significantly harder to locate minor-ity ethnic respondents who had therapy following sexual abuse. These findings willtherefore primarily reflect the experiences of White British children.

Reported abuse: Type, age at onset and perpetrators

Closed-ended questions in the survey elicited information about the type of abuseexperienced, when the abuse started and stopped, and who perpetrated the abuse.Of the 52 respondents who had received therapeutic support, 92% (n¼ 48) ofrespondents reported contact sexual abuse in childhood, with the remaining 8%reporting non-contact abuse, some including the use of images. The samplereported frequent sexual abuse experiences, with 55% saying the abuse happened‘too many times to count’. Age at first abuse ranged from 2 to 15 years old, with anaverage age of 7.10 years and median age of 6 years. Age when abuse ended had aneven wider range, from 3 up to 28 years old indicating that some abuse continued

Allnock et al. 7





well into adulthood. The average age when the abuse ended was 13, with a medianage of 14.

Sixty-seven percent (n¼ 35) of respondents reported only one perpetrator, whilethe remainder reported two or more perpetrators. Perpetrators were all known tothe participants and over half of the participants described perpetrators who wereknown adult males not living with them. Just under one-quarter were biological oradoptive fathers, and a small number (10%) reported female perpetrators.

Therapeutic support received

The information in this section derives from the closed-ended questions designed toelicit trends in therapeutic support, with incorporation of qualitative responseswhere appropriate to provide context. Respondents were asked to report thetypes of therapy they had received under the age of 18, displayed in Table 1.Individual counselling was the most common, while ‘other’ therapies were

Table 1. Number (per cent) of participants who received therapy under 18 and the age at

which they received therapy, by therapy type.

Therapy type

Number (per cent)

reporting

they received

this therapy

under age 18

(n¼ 52)

Age range

and average

age (m)a at which

participants

received

therapy

Counselling (individual one-to-one only) 29 (56%) 3–17a,b m¼ 13.55

Play therapy 13 (25%) 3–17 m¼ 8.92

Counselling (some combination of

individual, family and/or group counselling)

6 (12%) 9–17 m¼ 13.25

CBT 5 (10%) 12–16

Art therapy 4 (8%) 9–14

Other therapy 4 (8%) 10–16

Psychodynamic psychotherapy 2 (4%) 14–17

Counselling (group counselling only) 1 (2%) 14

Counselling (family counselling only) 1 (2%) 14

Dance therapy 0 (0%) 0

EMDR 0 (0%) 0

CBT: cognitive-behavioural therapy; EMDR: eye movement desensitization and reprocessing.aAverages have only been reported for categories of therapy that include more than five respondents. For

those with five or fewer respondents, only the range is reported.bTwo participants reported having counselling at age 3 which may reflect errors in participant reporting, or

may be a reflection of memory bias. Participants continued providing detailed information about these

experiences, so they have remained part of the sample, but bias is possible.






described as hypnotherapy; ‘online counselling’; ‘relaxational therapy’ and ‘psychi-atric counselling’. As might be expected, play therapy was received, on average, at ayounger age than the other linguistically focussed therapies.

Forty-two percent (n¼ 22) of the sample group reported experience of only onetype of therapy and the remaining 58% (n¼ 30) of respondents reported experiencewith two or more types of therapy. Of those 30, 16 had multiple experiences oftherapy under the age of 18 only and 14 had more than one therapy which includestherapy in adulthood.

Participants reported that a range of agencies were accessed for therapy, high-lighting that it is not only specialist services where professionals encounter childrenaffected by CSA. Private organisations were the most commonly reported agency,followed by CAMHS, family centres, a large national voluntary organisation, resi-dential homes and ‘other’ voluntary organisations.

The average number of therapies received under the age of 18 was 1.83, high-lighting the persistence of help-seeking either by children or others on their behalf.This persistence in seeking support that is effective underscores the notion thatthere is no ‘one-size-fits-all’ intervention (Itzen, Taket, & Barter-Godfrey, 2010).The often serious and entrenched nature of impacts of CSA will typically requireon-going support and intervention over time as suggested by one 21-year-oldfemale respondent: ‘‘I am still very messed up. After my breakdown (aged 20) Iwas sectioned and am still on the waiting list for psychotherapy’’ (Respondent 30).

For others, new issues emerged at later points in time: ‘‘I did a bit of art therapy(I drew a bottle!) and that’s how my feelings of shame about a particular rape at16 emerged’’ (Respondent 4). This participant persisted in seeking help eventhough to date, at age 21, she has not had positive experiences. As one 21-year-old female respondent explained, it may also reflect the on-going commitment itcan take some to find a therapy and/or therapist who they can trust and feelcomfortable with: ‘‘ . . . if you find the right person who is willing to work withyou and get to know you as a person rather than a number, they are worth theirweight in gold’’ (Respondent 13).

Few reported consistently ’good’ (n¼ 4) or ’bad’ (n¼ 4) therapeutic encounters;perhaps unsurprisingly, experiences over time were more often inconsistent (n¼ 22)with a combination of factors dovetailing in complex ways suggesting that everytherapeutic journey is unique.

Ratings of professional helpfulness

In order to gauge ’positive’ and ’negative/poor’ experiences, respondents wereasked to rate, on a scale from 1 to 10, the helpfulness of each of the therapiesthey had access to.3 For the purpose of focussing on the needs of children, ratingswere only calculated for therapies that were received under age 18.

With the caveat of a small sample size, 44% (n¼ 23) of the sample found at leastone therapy helpful under the age of 18. Table 2 lists the therapy types in order oftheir helpfulness.

Allnock et al. 9





Positive experiences of therapeutic support

Open-ended questions in the survey provided valuable information as to why par-ticipants found therapy helpful or unhelpful, and these will be reported in this andthe following section. Twenty-three respondents reported good experiences of playtherapy, psychodynamic psychotherapy, counselling, art therapy and other types oftherapy under age 18. Notably, the themes identified in this analysis relate to fac-tors other than the type of therapy accessed, with the exception of CBT which wasthe only therapeutic intervention for which none of the respondents (n¼ 5)reported a good experience.

Positive experiences of therapeutic support were attributed to advantageouspersonal impacts such as improved coping skills (n¼ 5) and reflected improvementsin how to deal with new life situations, developing practical day-to-day skills andfinding new methods of expressing and managing overwhelming feelings. As one19-year-old female respondent reflected: ‘‘[Counselling] Helped me with some day-to-day situations [. . .] how to cope with panic attacks’’ (Respondent 44).

Other commonly cited impacts include being able to ’move on’ and getting life ontrack (n¼ 4), as articulated by one 30-year-old male respondent: ‘‘[Individual coun-selling] It helped me get over the past and I started to rebuild my life back up againfrom it being way down low’’ (Respondent 10); positive changes to emotions andfeelings (n¼ 6), such as an increase in confidence, as one 30-year-old female recalledabout group counselling.; and for some respondents, therapy helped them stopblaming themselves for the abuse (n¼ 4). Two of the 23 respondents reporting posi-tive therapeutic experiences focussed on how their feelings of isolation reduced as aresult of therapy: ‘‘[Play therapy] I think it made me realise at a young age that Iwasn’t the only person it had happened to’’ (Respondent 34). Another two partici-pants highlighted changes in negative or destructive behaviours. One 34-year-oldfemale participant said: ‘‘[Psychodynamic psychotherapy] I was ready to give updrugs and start on my healing journey’’ (Respondent 42).

Positive experiences were also attributed to characteristics of the therapist whichthey liked and appreciated. The most common characteristic mentioned by 12

Table 2. Participant ratings of therapy (as measured on a

scale from 1 to 10, with 10 being most helpful and 1 being

not at all helpful).

Therapy type Average rating

Art therapy 8.92

‘Other types’ of therapy 6.00

Counselling 5.23

Play therapy 4.92

CBT 4.40

Psychodynamic psychotherapy 4.00






respondents was the ability of the therapist to make them feel cared for by listening,showing respect and taking an interest in them. One 21-year-old female genuinelyfelt cared for: ‘‘[Play therapy] I felt for the first time, somebody was listening to meand was genuinely interested in what I was feeling’’ (Respondent 21).

Respondents liked that their therapists were friendly, nice and/or down to earth(n¼ 7); warm, calm and relaxed (n¼ 5); non-judgemental and non-patronising(n¼ 5); and provided validation of children’s abuse experiences (n¼ 3). A21-year-old female said of group counselling: ‘‘It[. . .]allowed me to reaffirm mybelief that I was never in the wrong’’ (Respondent 18). Respondents also describedcharacteristics such as open and accepting (n¼ 4); funny and humorous (n¼ 3);happy and positive (n¼ 2); trustworthy (n¼ 2); and non-pressurising (n¼ 2). Theprofessionalism of therapists was mentioned in two examples, as one 18-year-oldrespondent recalled: ‘‘[Counselling] I didn’t want to talk to a family memberabout problems, and it was good to talk to someone who knew how to help’’(Respondent 3).

Poor experiences of therapy/different help desired

Across therapy types, negative experiences were related to either therapeutic fac-tors, which could include waiting times, therapist skills, characteristics or thera-peutic preferences, or to external factors such as intervening circumstances in thechild or young person’s life which meant it was more difficult for them to engage inthe therapeutic process.

Therapeutic factors. Therapeutic factors relate to things, which are a product of thetherapeutic environment, associated with the therapist such as their personality orskills, or to therapeutic needs which were unmet in the respondents’ experiences. Forexample, waiting times underpinned some negative experiences of therapy.According to crisis theory, people are most open to help during the unfolding of acrisis, when their usual defence mechanisms are weakened (Golan, 1986). Therefore,waiting lists can potentially be detrimental to the healing process (Lippert, Favre,Alexander, & Cross, 2008). Twenty-one participants reported waiting times thatoften stretched beyond 2–3 months and, in several cases, well over one year. One21-year-old female respondent had to wait six months for counselling provided byCAMHS and said that the waiting list affected her ‘‘ . . . terribly. I was 12 years oldand dealing with a lot of family conflict due to the abuse as well as being isolated atschool[. . .]I became a brat, very rude and self-destructive’’ (Respondent 17).

Most often expressed was the desire that therapists could have reassured themthat they did not have to talk about abuse experiences if they were not ready or didnot want to. A 22-year-old female who received counselling felt more distressed byfeeling pressured to talk about the abuse:

‘‘They were stressful – I thought I had to immediately describe in detail what had

happened in order to explain why I was so distressed. Because I did not realise that I

Allnock et al. 11





could discuss my emotions surrounding my distress and get comfortable with counsel-

ling, I felt very pressured’’. (Respondent 28)

Additionally, respondents mentioned that they wished their therapy had beendelivered more flexibly. Nine respondents felt that the type of therapy receiveddid not complement their preferred methods of expression. For example, a 30-year-old female respondent recalled: ‘‘[Play therapy] I hated them (sic play therapysessions), I felt that I was being treated like a child when I wanted someone toactually talk to me about what happened’’ (Respondent7). A 32-year-old femalerespondent also said: ‘‘I am, and always have been, an articulate person, although Ido not enjoy talking of such things. I have no problem writing about them, and Ithink an activity based around that would have helped me more’’ (Respondent 20).Related to flexibility is the extent to which children feel they have control over whathappens in the sessions. Several participants felt that they had no control, as one18-year-old male respondent expressed: ‘‘[Counselling] The counsellor tended tocontrol what we talked about during the sessions rather than me’’ (Respondent 22).None of the respondents who received CBT (n¼ 5) found it helpful, with one 21-year-old female reflecting that the diary she was asked to complete was not usefulto her, and she found the sessions boring and repetitive. This respondent foundcounselling much more flexible and open and had good experiences with a goodcounsellor.

Five respondents said they felt uninformed about the therapy, in particular whatit was for, what was going to happen in the sessions, and why it was ending. Thissuggests that the therapists were not successful in communicating the purpose ofthe therapy to their young clients. One female respondent who received play ther-apy recalls that no one explained anything to her. Similarly, a, 30-year-old malerespondent said: ‘‘I received play therapy, counselling and a psychiatrist; I foundnone of these helpful as I was still in fear when I was younger and it was notexplained why I was there’’ (Respondent 10). Three female respondents describedtheir counsellors as unsupportive and sceptical of their experiences. A 33 year oldfemale participant articulated: ‘‘The counsellor was very patronising and disbeliev-ing of me, she frightened and frustrated me’’ (Respondent 51). Another said ‘‘Thecounsellor did not believe me and suggested other reasons for the inappropriatetouching’’ (Respondent 22).

Unmet needs relating to gender were salient in the study. The counselling lit-erature draws attention to the fact that, particularly where CSA is concerned,gender preference of therapist can be highly individualised and should be made apriority if the client has a strong view (Fowler & Wagner, 1993; Getz, 2011).A Delphi report exploring professional views about appropriate therapy for CSAfound complete consensus among professionals that the ideal position is to offer achoice of therapist gender (Itzen et al., 2010). This issue was evident for one 35-year-old female participant in the study whose male counsellor triggered negativememories: ‘‘[Counselling] I hated them[. . .]harsh words I know but I specified thatI did not under any circumstances want a male, especially one with a moustache






(my father who abused me had one) and the centre gave me a man with a mous-tache’’ (Respondent 25). An 18-year-old male respondent also felt he had notbeen heard regarding his preference of therapist: ‘‘I would have preferred talkingto a male but everyone else thinks I am more suited talking to a female’’(Respondent 9).

Continuity is also an issue that emerged in the data, something that was prob-lematic for one 21-year-old female participant who received CBT in CAMHS:‘‘It was hard to build a relationship when she left after about 12 weeks[. . .]shedisappeared from me. Another one’’ (Respondent 28). Consistency was cited byprofessionals in Itzen, Taket, & Barter-Godfrey, (2010) study as an importantelement of the quality of the relationship between therapist and child, and thisexample clearly shows the anxiety experienced when continuity is broken.

Trust after a breach of confidentiality was a factor in two examples. One23-year-old participant explained, ‘‘[Counselling] My counsellor broke a funda-mental rule of speaking to my parents about what I had mentioned. This did notinvolve suicidal risks . . . this angered me with all workers thereafter’’ (Respondent11). A second respondent, a 29-year-old female, also said her trust in professionalshad been damaged following family counselling:

‘‘I was quite suspicious after I found out that their findings were being shared, that

such things were said of me. I never revealed to her, my counsellor, that I was sus-

picious – I would just discuss things in less detail and joke about the sessions with my

sister afterwards.’’ (Respondent 17)

Table 3 provides a summary of factors that could have facilitated better experiencesof therapy for participants.

Table 3. Different help desired.

Category

No. of

respondents

No pressure/reassurance 10

Flexibility in the type of therapy received 9

Being informed 5

Being believed 3

Understanding and listening 2

Choice in therapist 2

Confidentiality 2

More or longer sessions 2

Professionalism 2

Allnock et al. 13





External factors. A range of external issues may impact or interfere with a child’sability to engage in therapy once therapy commences. The few studies in this areafocus on the barriers to parental initiation of and entry of their child into therapy butare relevant in the context of the findings from this study. For example, there is someevidence that caregiver relationship may affect parental motivation to support theirchildren in therapy (Schechter, Brunelli, Cunningham, Brown, & Baca, 2002).Furthermore, some families may ‘close’ themselves off from outside influences (i.e.therapy) and deny,minimize or avoid the effects of abuse (Lippert et al., 2008).Whilethese findings relate to initiation of therapy, they were also evident in participants’descriptions of their inability to engage once they were in therapy. Table 4 brieflyillustrates the main themes which emerged from the questionnaires in terms of chil-dren’s personal circumstances which influenced their therapeutic experiences.

As mentioned in the introduction, many children may not have a say in whetheror not they attend therapy. Unsurprisingly, then, there were numerous examples ofrespondents describing circumstances beyond their control and feeling ’forced’ intotherapy. One 23-year-old female respondent receiving psychodynamic psychother-apy through CAMHS explained:

‘‘I was forced to attend by social services and at the time I intensely disliked being

made to talk to strangers about such issues . . . although I needed some kind of sup-

port, at that particular age I went into foster care and had an intense feeling of lack of

control that made me resent being forced into therapy I didn’t feel I could face’’.

(Respondent 41)

Other respondents did not feel ready for therapy for various reasons. For example,some impacts may not appear for some children immediately, and therefore a childmay not understand why they need to attend therapy. One 24-year-old femalerespondent expressed it this way: ‘‘I also think that I wasn’t as affected so muchat the time by what happened[. . .]it sank in more as I grew up’’ (Respondent 5).Fear of the therapeutic environment and being open about their experiences wasevident in at least five responses. A 23-year-old female respondent said: ‘‘Because Iwas too scared to talk about things properly[. . .]there were things I wanted to say

Table 4. Personal/external circumstances.

Category

No. of

respondents

Not ready/felt forced to attend/too young 15

Home environment (family breakdown,

interference, conflict, safety issues)

10

Chaotic or unsafe situations 4

Too little too late 2






but could not find the words to and some people told me no one would ever believeme so I didn’t think anyone would’’ (Respondent 24). Another 20-year-old femalerespondent just wanted a sense of normalcy in her life yet talking about the abusemade her feel different: ‘‘I was very strong minded and at that age I wanted to justbrush things under the carpet. I didn’t want to discuss them. I just wanted to be anormal child’’.

Some respondents’ home and family life were evident barriers for engaging inthe therapeutic process. In two cases, this was because of on-going court cases andin two others it was due to family interference. One 34-year-old female participantsaid, ‘‘Cause they (counselling sessions) just caused me trouble with family’’ andanother (27-year-old female) echoed this, describing that her difficult family situ-ation made it too difficult for her to take part in the sessions. In one familycounselling example, a 29-year-old female respondent was being actively preventedby her family from talking in therapy:

I hated them (counsellors) because I had been told that they were only there so that

they could take me away from my family and make things up about people I loved.

I was told not to speak in the sessions..I did not trust them., I was told they were bad

people by the abusers who I had put my trust in. No-one was able to tell me different

at that age. (Respondent 11)

A number of worrying impacts regarding poor experiences of therapy were reported.They could be as benign as ‘nothing,’ but more alarmingly, some respondents losttrust in the mental health profession in general or felt more isolated by having to dealwith their problems on their own. Table 5 lists the negative outcomes which canemerge where therapeutic experiences are not optimal.

Discussion

The findings highlighted here indicate the diversity of children’s experiences, prefer-ences and needs, which are all influential on the perception of the therapeutic experi-ence. A comparison of therapy types can be tentatively offered, however caution

Table 5. Adverse personal impacts (self-reported).

Category No. of respondents

No changes 14

Loss of trust (in professionals, in others) 6

Dealing with things in isolation 2

More withdrawn 1

Increased anger (with professionals) 1

Allnock et al. 15





should be taken due to the low numbers of participants’ reporting some therapytypes. For example, art therapy stood out as a key technique (see Table 3), althoughonly four respondents had experience of this therapy. The positive responses pro-vided reflect the creativity involved and the opportunity for expressing oneself non-linguistically, even at older ages (over 10) when ‘talking therapies’ may becomemorerelevant for young people. However, the responses for art therapy also reflected keytherapist characteristics such as warmth and caring, which accord with not onlyparticipant responses for other types of therapy but also with the wider literatureon therapist-offered aspects (Ackerman &Hilsenroth, 2003). Play therapy was ratedlow overall, which may be due to the age of the respondents when they received thetherapy. The negative responses reflected personal contexts, preferences and alsotherapist characteristics as opposed to the technique itself. The only therapy whichattracted strong negative responses regarding technique was CBT, for which no posi-tive experiences were reported. This may be due to the fact that CBT is a highlystructured therapy which is at odds with respondents’ views on the desire for flexi-bility, but it may also be due to the small numbers of respondents who reportedexperiences of CBT. Indeed, the evidence for CBT is not faultless, focussing as itdoes on narrow age ranges of children and on brief durations,making generalizationsdifficult andoptimal ‘dosage’ hard to identify.However, as Itzen et al. (2010) note, thegrowing consensus among professionals delivering CSA provision is the need for achild-centred, holistic and integrative approach implementing age, gender and devel-opmentally appropriate techniques. In other words, CBT is not necessarily appro-priate for all children. Professionals who took part in the Delphi studystrongly believe that it (CBT) should not be delivered in isolation of othersupport (Itzen et al., 2010). Finally, counselling, which was accessed by the largestnumber of participants in this study, received mixed views, most of whichreflected therapist characteristics and skills. Negative responses were associatedwith respondents’ desire for greater flexibility in the sessions and feeling pressuredto ‘talk’. It was most often within a counselling context where respondents’reported breaches of confidentiality leading ultimately to a loss of trust. Positiveresponses again reflected personality traits such as caring, warmth and interest inthe child.

The findings suggest that children express themselves in different ways andappreciate a flexible approach. The many references made by respondents in thisstudy to therapist characteristics and interpersonal communication support thenotion that the therapeutic alliance may be critical in producing positive outcomesfor children, as has been found throughout research more generally in the adultpopulation (Norcross, 2002). The difficulties of engaging children as suggested inthe introduction are particularly relevant here. There is a preference for therapistswho show care and interest, who are warm, friendly and open, and who listen andvalidate experiences, as also identified by Ackerman and Hilsenroth’s (2003)review. Specifically in relation to CSA, children want reassurance that they donot have to talk about the abuse if they are not ready, which confirms earlierfindings from the studies by Potter et al. (2002) and Prior and Glaser (1994).






Children also want the flexibility to express their emotions in the way they prefer todo so, and they want continuity so trust can be built with the therapist.Acknowledging preferences for gender of therapist is important for some childrenwho have experienced CSA. Parallels between the therapist’s gender and that of theperpetrator may prove a barrier to positive engagement with a child.

It is difficult to assess the impact of gender on experiences of therapeutic supportunder the age of 18 because so few males formed part of the sample, and becausethese three males had very mixed experiences, reporting similar views to thefemales. However, the lack of men who fit the criteria for the sample consideredin this study (i.e. who received therapeutic support under the age of 18) may wellunderscore a gendered pattern of reporting or talking about abuse. It is possiblethat so few males took part in the study because males are less likely in general thanfemales to disclose abuse. If so few males disclose abuse in childhood, then theywould not be identified as in need of therapeutic support, therefore the pool ofmales who received support in childhood is much smaller than that of females.

Clearly, when experiences are good, children take away a range of positive self-reported effects that help them practically, emotionally and behaviourally. In con-trast, when experiences are perceived to be poor, children can conclude treatmentwith no improvement and, in some cases, their ability to trust in mental healthprofessionals is adversely affected.

The findings also suggest that it is uncommon that one therapeutic experiencewill be the ’magic bullet’ which solves all of a child’s problems. It may take com-mitment on the part of children and their families or carers to find the right thera-peutic environment that will offer meaningful engagement, succeeding insupporting a child to develop positive coping skills or relieve themselves of self-blame and guilt. This commitment can be positively sustained by practitioners whocan provide the best possible environment and successfully respond to children’sneeds so that they feel listened to, cared for, and believed. Practitioners need tomaximise the information they gather in assessment and recognise that there areparticular circumstances which children who have experienced CSA may be con-tending with outside the therapeutic session. There is a clear message here thatprofessional judgement is imperative, an issue that has been elevated as crucial inthe Munro review of the child protection system (Munro, 2011).

It may not always be possible for practitioners who are working in settings withlimited resources to meet every need, but the findings in this article provide somevery straightforward ideas which can make all the difference to engaging a childwho has been traumatized by CSA. Further, practitioners can be poised to draw inassistance from, or refer a child on, to specialist services where the resources are notavailable to meet all of their needs.

Limitations

There are a number of limitations to note about this retrospective study. Firstly,the sample size is small and it is not representative of the wider UK population

Allnock et al. 17





therefore caution must be taken in interpreting the findings. However, thereare no other studies that could be identified that examine retrospective viewsof therapy from a sample of adult survivors of sexual abuse, making this studya unique one. A second limitation, and a classic concern in studies of this typeis that of memory bias, where it is understood that respondents’ memory mayfade in time, leading to inaccurate reflections (Parry, Thomson, & Fowkes,1999). Memory bias was evident in some responses, which reflected that par-ticipants could not always remember certain aspects of support received.Memories of the past are also inevitably filtered through present perspectiveswhich can potentially distort the reality of what was experienced as a child.Nevertheless, the raw memories left with the child and carried through toadulthood do say something about the impact of the experience on the childand about how informed, comfortable and reassured they felt at the time.These are crucial issues in the provision of child-centred approaches andmuch learning can be gained from understanding children’s experiences.Finally, the study lacks the ability to provide a complete picture of the child’sexperience within therapy. Events may have occurred during therapy whichimpacted on the child’s experience but which they themselves were unawareof at the time. Further research would benefit from a triangulated method ofdata collection in order to produce a more rounded view of the child’s experi-ence by collecting information not only from the child, but from their care-giver and therapist.

Conclusions

This study has contributed to our understanding of childhood experiences oftherapy where CSA is part of a child’s context. It has identified many similarfactors found within the wider literature on the therapeutic alliance within theadult population. At the same time, it has identified specific needs of childrenwho have experienced sexual abuse. It has also drawn attention to the challengesrelated to developmental stages, in particular the recognition that children may notchoose to access therapy in the same way that adults do and that this may producea barrier between the child and therapist.

While this study found some variation in ratings of therapeutic technique,the small numbers reported for some of the therapy types preclude any generaliza-tions at this stage. What is apparent however, is that there seem to be elementsof the therapeutic experience – in particular therapist-offered characteristicsand skills – that are common across all approaches.

While it may seem obvious, it cannot be over-emphasised that if children do nothave good experiences at a young age, this can adversely impact their views oftherapy and, indeed, of mental health practitioners in the long-term creating poten-tial barriers for future support.






Acknowledgements

The authors of this article wish to thank those who gave their time to provide the informa-

tion on which this research was based, and also thank the NSPCC for funding the study andutilising the voices of survivors in the development of a new service.

Declaration of conflicting interest

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial,or not-for-profit sectors.

Ethics

This research was scrutinized and approved by the NSPCC Research Ethics Committee.

Notes

1. The NSPCC is a large national children’s charity in the United Kingdom; it has been in

operation since the late nineteenth century.2. Child and Adolescent Mental Health Services in the United Kingdom are statutory

services situated within the National Health Service. CAMHS provide help and treatment

for children and young people with emotional, behavioural and mental health difficulties.3. ‘Helpful’ was defined as a score over 6 which could be matched to positive qualitative

reports. Similarly, ‘unhelpful’ was defined as a score under 6 which could be matched to

negative qualitative reports. Where respondents gave a ’positive’ rating or a ‘negative’rating but their qualitative reports reflected different experiences, the qualitativeresponses took precedence.

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