Childabuseincaribbean

TREATING CHILD SEXUAL
ABUSE in FAMILY, GROUP

and CLINICAL SETTINGS
CULTURALLY INTELLIGENT PRACTICE FOR
CARIBBEAN AND INTERNATIONAL CONTEXTS
ADELE D. JONES; ENA TROTMAN JEMMOTT;

HAZEL DA BREO; PRIYA E. MAHARAJ
Treating Child Sexual Abuse in Family,
Group and Clinical Settings
Authors, left to right: Ena Trotman Jemmott, Priya E. Maharaj, Adele D. Jones
and Hazel Da Breo
Adele D. Jones • Ena Trotman Jemmott • Hazel Da Breo
Priya E. Maharaj
Treating Child Sexual

Abuse in Family,
Group and Clinical
Settings
Culturally Intelligent Practice for Caribbean
and International Contexts
Adele D. Jones Ena Trotman Jemmott
The University of Huddersfield Florencena Consulting
UK Barbados
Hazel Da Breao Priya E. Maharaj
Sweet Water Foundation The Alpine Project
St. George’s, Grenada La Romaine, Trinidad and Tobago
ISBN 978-1-137-37768-5 ISBN 978-1-137-37769-2 (eBook)

DOI 10.1057/978-1-137-37769-2
Library of Congress Control Number: 2016942787
© The Editor(s) (if applicable) and The Author(s) 2016

The author(s) has/have asserted their right(s) to be identified as the author(s) of this work in accordance
with the Copyright, Designs and Patents Act 1988.
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
the editors give a warranty, express or implied, with respect to the material contained herein or for any
errors or omissions that may have been made.
Cover image ‘The Roach – Landscape’ © Jaime Lee Loy 2008

Cover design by Paileen Currie
Printed on acid-free paper
This Palgrave Macmillan imprint is published by Springer Nature

The registered company is Macmillan Publishers Ltd. London
Acknowledgements
This is the third and final book in a series of three on child sexual abuse in
the Caribbean: the first focused on research, theory and issues; the second
described an integrated systems approach to prevention, and this book is all
about practice in family, group and clinical settings. The four of us (Jones,
Trotman Jemmott, Da Breo and Maharaj) have been working in this field
for decades but came together 8 years ago when we had the opportunity to
conduct the first comprehensive research into child sexual abuse within the
Caribbean. Since then, our working partnership has grown from strength
to strength, generating a body of work of which we are very proud.
Alongside these three books, we have produced journal articles, developed
and piloted interventions, spawned PhD studies, written numerous grant
proposals, presented papers at regional and international conferences, con-
tributed to public education campaigns and conducted training sessions
across the region, all with the aim of advancing knowledge and skills in
preventing gender-based violence and child sexual abuse in particular. Our
work has been referenced by researchers and policy makers throughout the
Caribbean and internationally too. To our certain knowledge, it has influ-
enced research in Tanzania, Ecuador, Costa Rica, Mali, Barbados, Jamaica,
the Maldives, Antigua, Kenya and Colombia.
This all started in 2008 when, together with Sheron Burns, Ijahnya
Christian, Jacqueline Sealy Burke, Cisne Pascal and Denise Tannis and
led by Adele D. Jones, we conducted the study, ‘Perceptions, Attitudes
v
vi Acknowledgements
and Opinions on Child Sexual Abuse in the Eastern Caribbean’ (Jones

and Trotman Jemmott 2009). Since the publication of our research find-
ings, we have been relentless in making sure that the knowledge produced
has been disseminated as widely as possible. In the process, we have met
some remarkable women, men and children who have been willing to
share their experiences with us. We have also come across many human
rights activists in the region and have been humbled by their efforts.
One such person is Trinidad-based artist Jaime Lee Loy, whose work has
graced the covers of all three books and appears throughout this one and
who joins us as a guest author for its final chapter.
We have many people to thank for supporting our work but without
the strategic vision of UNICEF (Caribbean Area Office), which com-
missioned the original research, none of this would have happened. We
therefore dedicate this book to UNICEF (Caribbean Area Office) and we
thank them for their unending commitment to promoting the rights of
children in the region.
Writing this series of books has not been without its emotional costs to
us all, and we thank our friends and families for their dedicated support
and encouragement. We also thank Dr. Debra Joseph for preparing the
diagrams in the book.
Treating Child Sexual Abuse in Family, Group and Clinical Settings:
Culturally Intelligent Practice for Caribbean and International Contexts is
a book of six parts, each of which addresses specific aspects of the topic.
We begin by focusing on the practitioner, although in truth the whole
book is for the practitioner. This is the first book of its kind. It was writ-
ten with Caribbean case studies and based on Caribbean realities, and
we have assessed interventions and models of practice from a wide range
of local and international sources for their relevance. Thus, while the
book faces inwards in that it directly targets the everyday problems of
the practitioner in his or her local context, it faces outwards at the same
time, connecting the practitioner to an external world of potential solu-
tions. As with books one and two, the theoretical threads that hold the
whole together are the theories of intersectionality and ecological systems
theory. Sexual abuse is never just a problem of the individual: structures
of inequality and the intersection of the factors they give rise to help to
explain why some children are more at risk of abuse than others and the
Acknowledgements vii
sub-systems in which lives are lived can compound risk and vulnerability
or alternatively can be sources of support and change. This ethos perme-
ates the approaches and interventions we describe in the book.
The book is unique in that we use the term ‘practitioner’ in a delib-
erately inclusive way. We hope the book will appeal as much to those
who share our commitment to tackling child sexual abuse but may have
had little training as it does to the highly trained professional. We are
reminded here of a strategy used by the government of Grenada follow-
ing Hurricane Ivan in 2004, in which training in counselling was made
available to professionals and interested lay persons alike (albeit at differ-
ent levels). The extent of trauma arising from the devastation of this natu-
ral disaster was so great that it would have been impossible to provide
professional support to everyone, but by increasing the number of people
with counselling skills, a greater percentage of the population could be
helped. Child sexual abuse in the region is a disaster too, though this is
man-made. By increasing knowledge and skills in tackling child sexual
abuse wherever the problem emerges and whoever the practitioner is who
confronts it, we will extend help to a larger percentage of victims, to their
families and to the perpetrators of their abuse.
The three books in this series on child sexual abuse in the Caribbean,
of which this is the final volume, have all featured on their front covers
the work of Jaime Lee Loy, an artist from Trinidad who uses her work to
challenge violence against women and children.
Contents
1 The Gifted Practitioner: Emotionally Intelligent

Practice; Self-care 1
Introduction 1
Applicability of EI in Therapeutic Settings 5
Personal Competencies: Self-Awareness and Self-Management 9
Emotional Self-awareness in Action 10
Accurate Self-Assessment in Action 11
Self-Confidence in Action 12
Emotional Self-Control in Action 13
Adaptability and Initiative 13
Adaptability in Action 13
Initiative in Action 14
Social Competencies: Social Awareness and
Relationship Management 15
Social Awareness and Relationship Management in Action 15
The Book 17
A Note on Self-Care 23
References 25
ix
x Contents
2 Working with Adolescent Girls who have been Sexually

Abused: Abortion and Unwanted Pregnancy as a
Consequence of Rape; Psycho-dynamic Groupwork;
Teenage Mothers: An Attachment Enhancement Intervention 28
Introduction 27
Melissa’s Story 28
Family History 28
Presenting Problem 29
Chronology of Events 31
Summary 32
Family Dysfunction and Intersecting Harms 35
Abortion as a Consequence of Rape: Implications for Practice 39
Concluding This Section 43
Psychological Assessment 45
Psychotherapy 53
In Advance of the Client 53
R.I.S.E. 54
Theoretical Framework 55
Psychodynamic Group Psychotherapy 58
Melissa’s Presenting Symptoms and Our Approaches
to Treatment 59
Mango Tree Moments 59
Dressing the Part 63
Social Work and Attachment: Work with Adolescent
Mothers who have experienced Childhood Trauma 68
A Social Worker-Led Attachment Intervention 75
Role of the Facilitator 79
Conclusion 81
References 81
3 Working with Children with Learning Disabilities:

Vulnerabilities, Needs and Rights; Direct Work with
Children with Learning Disabilities; Empowering
Families to Protect Children 89
Introduction 90
Nina’s Story 90
Contents xi
Family History 90
Chronology of Events Leading up to the Presenting Problem 94
Contextual issues 95
Down Syndrome Aetiology and the importance
of Clinical Assessments and Monitoring 95
Down Syndrome 96
Communication Challenges 97
Concepts and Co-occurrences: Disability and Other Stressors 98
Challenges faced by and posed by Child Protection
Agencies and Schools 100
Working with Children with Learning Disabilities who
have experienced Trauma 101
Doll Play 105
Drawings 109
Social Work with Parents: Crisis Intervention 112
Applying the Model 118
The Family Group Conference 125
The FGC 130
Conclusion 133
References 134
4 Working with Young People with Harmful Sexual

Behaviour: Mother-Son Incest; Restorative Justice for
Juvenile Sex Offenders; Treatment and Rehabilitation:
Individual, Group, Family and Community-Based
Approaches 139
Introduction 140
Levi’s Story 142
Perspectives from the Literature 147
Gender-Specific Sexual Predatory Behaviours 147
Messages from the Research About Mothers Who
Sexually Abuse 152
Recognising that Females Can Be Sexual Offenders 154
Women and Sexual Abuse 155
xii Contents
Theoretical Models to Assist Clinical/Practitioner

Interventions in Sexual Offending 157
Protecting Young Children from Abuse and Neglect 159
Making the Case: Interventions for Juvenile Sex Offenders 165
Making the Case for Providing Treatment to Juvenile
Sex Offenders and Young People with Harmful
Sexual Behaviour 166
Professional Concerns 170
Collaboration, Partnerships and Systemic Practice 175
Working with Levi 177
Psychotherapy 177
Meeting Levi 179
An Insight into Levi’s Stance with the Therapist 180
Sessions with Levi 182
A Breakthrough! 183
Levi Telling his Story 185
Helping Levi Draw Breath 187
Getting the Plan Right for Levi 189
Restorative Justice for Sexual Offences 192
An Ecological Systems Approach to Understanding
the Needs of Juvenile Sex Offenders 196
The SORT Project (Sexual Offence Rehabilitation
and Treatment Project for Caribbean Youth) 199
Possible Areas of Focus 201
The Family Group Conference as a Restorative
Justice Intervention 203
Circles of Support 205
Conclusion 210
References 212
5 Interventions with Children in Residential Care:

Improving Residential Childcare Practice: Nurturance
Care; Attachment, Separation and Loss; Narrative Therapy;
Family Reunification; Life Story Work 219
Introduction 220
Anton and Oriana’s Story 221
Contents xiii
Family History 221

Setting the Context: Residential Child Care
in the Caribbean 224
The Extent of the Problem 226
Why Children Come into Care 227
Is Institutional Care Necessarily Bad for Children? 228
Is Residential Care Bad for Older Children? 229
Improving Residential Care for Children 231
Training 232
Nurturance-Based Care 234
Pillars of Parenting: A Model of Nurturance Care 237
Anton and Oriana: Attachment, Separation and Loss 242
Sending for Help 246
The Therapeutic Presence 247
Transference and Counter-Transference 248
Assessing Risk and Resiliency 250
Developing a Treatment Plan 253
Narrative Therapy 258
Family Contact and Reunification 261
Fathering 265
Life Story Work 268
Conclusion 274
References 276
6 Art as a Therapeutic Modality: Historical and Cultural

Context; Art for Self-Healing; Art for Communal Healing;
Art for Children’s Healing 281
Introduction 282
The Historical and the Contemporary-Culture and Context 282
Art and the Psyche 285
Art as Therapy 287
A Survivor’s Story 288
Art as a Form of Self-therapy 291
Summer Heroes 292
Fictionalising Painful Truths 301
xiv Contents
Scapegoating 302
Sandplay Therapy 304
Regaining Control of Self 310
Sharing 315
Transcendence and Transformation 317
Conclusion 319
References 321
Index 325
Notes on Contributors
Adele D. Jones PhD is professor of social work and former Director of the
Centre for Applied Child, Family and Youth Research, at the School of Human
and Health Sciences in the University of Huddersfield, UK. Previously a lecturer
in social work at the University of the West Indies (UWI) (Trinidad), Professor
Jones specialises in international children’s rights and gender-based violence and
is the author of numerous publications on global issues affecting children: abuse,
residential care, migration, parental imprisonment, child refugees, gender and
HIV-AIDS. Dr. Jones has led over 24 externally funded research projects, includ-
ing a €2.8 million, four-country, EU-funded study on the impact on children of
parental imprisonment, and together with Dr. Ena Trotman Jemmott was prin-
cipal investigator for the UNICEF-commissioned research into child sexual
abuse in six Caribbean countries, ‘Perceptions, Attitudes and Opinions of Child
Sexual Abuse in the Eastern Caribbean’ (Jones and Trotman Jemmott, 2009).
Ena Trotman Jemmott PhD is a chartered organisational psychologist with a
long history of work in the UK with children and families, including work as a
health visitor and director of community nursing services. Dr. Trotman Jemmott
also has substantial experience in research, policy and programme development
in child protection services in the Caribbean, extending to programme support
to UK Overseas Territories in the South Atlantic. Her many contributions
include strengthening the social services infrastructural needs for the legal
reform of family law and domestic violence within the Organisation of Eastern
Caribbean States and Turks and Caicos Islands. She was also a principal investi-
gator in the six-island study of child sexual abuse in the Eastern Caribbean
xv
xvi Notes on Contributors
(see above). Her PhD examined social workers’ and police officers’ responses to
child sexual abuse in Barbados. She is also one of the authors of the other two
books in this series.
Hazel Da Breo PhD is a psychotherapist and Director of the Sweet Water
Foundation, Grenada. This non-governmental organisation is dedicated to end-
ing sexual violence to women and children in the Caribbean. The Sweet Water
Foundation provides training, interventions, research and treatments for victims
and perpetrators of sexual violence. Previously clinical supervisor for several
community-based programmes at the Legal Aid and Counselling Clinic in
Grenada, Dr. Da Breo also provides consultancy to several UN agencies, includ-
ing UN Women, UNICEF, the United Nations Development Program and the
Pan American Health Organization/World Health Organization in the areas of
child protection and intimate partner violence. She is also one of the authors in
the other two books in this series.
Priya E. Maharaj PhD, is a clinical and developmental psychologist formerly
at the Faculty of Medical Sciences, UWI (Trinidad and Tobago), where she
taught at the undergraduate and graduate levels. Dr. Maharaj has been involved
in several research projects at UWI, including Sondai—a multifaceted social
work response to HIV-AIDS—and she was also a member of the research team
for the study of child sexual abuse in the Eastern Caribbean (Jones and Trotman
Jemmott, 2009). Her PhD examined the impact of physical and sexual abuse on
children in residential care in Trinidad. She is also one of the authors in the other
two books in this series; she is currently in private practice.
Jaime Lee Loy is an artist and writer based in Trinidad. An honours graduate
of literature and visual arts at UWI and a postgraduate scholar of an MPhil in
Literature, Jaime has exhibited in Trinidad, London, the USA and Scotland and
has travelled on fellowships for workshops, exhibitions and residencies to places
such as Vermont, Connecticut, Scotland and London. Jaime is founder of
Trinidad Home Studio, whose mission is to provide creative services, such as
writing, video and photography, for projects affiliated with the arts, education,
culture, humanitarian work, not-for-profit organisations and family. She has
produced documentaries and videos, including the feature ‘Bury Your Mother’
(which was named after her short story published in Trinidad Noir and which
won special mention for the best locally produced film at a local film festival in
2009). Her videos have been included in both local and international film
festivals.
List of Figures
Fig. 1.1 Dimensions of emotional intelligence based on the pioneering

work of Goleman (1998), Boyatzis and Sala (2004a) and the
emotional competency training workbook (Hay Group 2008) 8
Fig. 1.2a Self-awareness skills 10
Fig. 1.2b Self-awareness skills 11
Fig. 1.2c Self-awareness skills 12
Fig. 1.3 Self-management skills 15
Fig. 1.4 Emotional Intelligence illustration based on the pioneering
work of Goleman (1998), Boyatzis and Sala (2004a) and the
emotional competency training workbook (Hay Group 2008) 16
Fig. 2.1 Detail from Roaches and Flowers: War in the Home
© Jaime Lee Loy 2008 27
Fig. 2.2 Melissa’s genogram 30
Fig. 2.3 Melissa’s timeline 32
Fig. 2.4 Melissa’s ecomap 34
Fig. 2.5 Melissa’s pre- and post-intervention standard scores
for self-esteem subscales 52
Fig. 2.6 Melissa’s global self-esteem quotients at pre- and
post-intervention 52
Fig. 3.1 ‘Venus traps’ © Jaime Lee Loy (2008) 89
Fig. 3.2 Nina’s genogram 92
Fig. 3.3 Nina’s ecomap 93
Fig. 3.4 Nina’s timeline 94
xvii
xviii List of Figures
Fig. 4.1 ‘Metamorphosis’ © Jaime Lee Loy (2008) 139

Fig. 4.2 Levi’s genogram 144
Fig. 4.3 Levi’s ecomap 145
Fig. 4.4 Levi’s timeline 164
Fig. 4.5 Women could take more action to protect children 161
Fig. 4.6 Men could do more 161
Fig. 4.7 The distribution of child protection resources according to
the iceberg approach 169
Fig. 4.8 A systems model for understanding CSA 197
Fig. 4.9 Levi’s situational analysis using a systems approach 198
Fig. 5.1 ‘Conversation Piece’ © Jaime Lee Loy 2008 219
Fig. 5.2 Anton and Oriana’s genogram 222
Fig. 5.3 Anton and Oriana’s timeline 223
Fig. 6.1 ‘Venus’ © Jaime Lee Loy 2008 281
Fig. 6.2 ‘Still’ © Jaime Lee Loy 289
Fig. 6.3 Volunteers and children at the 2013 Summer Heroes
Workshop © Jaime Lee Loy (2013) 293
Fig. 6.4 Half Woman © Jaime Lee Loy (2013) 294
Fig. 6.5 Velez, dance of darkness series. © Edin Velez. (Work in
progress. Large-scale glicee photographs of Japanese
Butoh dancers) (www.edinvelez.com) 299
Fig. 6.6 The roaches © Jaime Lee Loy (2008)
(http://smallaxe.net/wordpress3/works/2008/10/28/
jaime-lee-loy/) 312
Fig. 6.7 Clay talisman—Summer Heroes Workshop, 2013,
© Jaime Lee Loy (2013) 319
List of Tables
Table 4.1 Possible areas of focus in rehabilitation and treatment 202

Table 5.1 Self-reported training needs of caregivers in children’s
institutions (source: Jones and Sogren 2004, 39) 232
Table 5.2 Adapted from ‘A summary of the pillars of parenting and
some of the staff behaviours and tasks which support these’
(© Seán Cameron and Colin Maginn 2008 in Cameron
and Maginn 2013, 51) 238
xix
1
The Gifted Practitioner
Emotionally Intelligent Practice; Self-care
Introduction
This book is about practice and interventions for abused children, their
families and abusers too. Our work on violence against children and child
sexual abuse (CSA), in particular, continues to be informed by the theoreti-
cal lens of intersectionality,1 ecological systems theory and the public health
approach, Our aim is produce knowledge and interventions to prevent
sexual abuse and other forms of gender-based violence across entire societ-
ies rather than at the individual level. The first two books in this series were
also informed by these lenses. It is important, though, that while we seek to
tackle abuse at the societal level, we pay mind to the needs of individuals
who are harmed by abuse and that we recognise that the statistics the public
health approach seeks to reduce are composed of individual acts of harm
stacked one on top of the other. So, we have written a book that provides
an ecological approach to dealing with the effects of abuse on individuals
1
‘Our interpretation of intersectionality is that social, political, economic and cultural contexts or
“positionalities” (social locations) (Harley et al. 2002) lead to the construction, classification and
assigning of value and status to children according to the beliefs, historical traditions and structures
that define social behaviours’ (Jones et al. 2014, 24).
© The Editor(s) (if applicable) and The Author(s) 2016 1

A.D. Jones et al., Treating Child Sexual Abuse in Family, Group and
Clinical Settings, DOI 10.1057/978-1-137-37769-2_1
2 Treating Child Sexual Abuse in Family, Group and Clinical Settings
and families. Using case studies, we demonstrate the interconnecting

factors that contribute to children’s maltreatment and explore some clinical
and therapeutic approaches to assisting them and their families. Our
approach shows the non-linearity of causes and effects of abuse, reminding
us that the uniqueness of each child’s situation requires a specific and indi-
vidual response. However, we should also be cognisant of the common
factors that contribute to abuse, and where possible we should provide
group prevention and treatment interventions. Children’s resiliency follow-
ing abuse and the extent of any adjustment difficulties they may face (such
as certain mental health outcomes like depression, conduct disorder and
attempted suicide) are influenced by a range of factors. An important
objective of this book, therefore, is to increase critical thinking about the
imperative need for a range of child, family and group interventions within
the Caribbean for responding to the harm of sexual abuse. Sometimes the
interventions we describe are taken directly from practice—these are exam-
ples of actual treatment approaches we have used. Other times we provide
examples of interventions that would be appropriate for the cases presented;
in these instances, these are hypothetical treatment approaches. We have
used approaches from the fields of social work, clinical psychology, psycho-
therapy, art therapy and organisational psychology; for example, we borrow
the concept of Emotional Intelligence (EI), derived from organisational
psychology, to argue for reflective practice.
The academic framework for this book is informed by the theo-

ries of intersectionality, ecological systems and EI. This suits our
focus: the introduction of therapeutic approaches to child abuse in
the Caribbean for family, group and clinical settings. We recognise,
though, that the practitioner’s life story to some extent may mirror
that of some of her or his clients/service users. For is it not true that
the systems and intersecting factors that contribute to the environ-
ments in which abuse flourishes are the very environments out of
which we too are born—the activists, the researchers and the prac-
titioners working to ameliorate its effects. The EI model is intended
to help bridge the client–therapist dichotomy and to generate the
reflective skills that make for the gifted practitioner.
1 The Gifted Practitioner 3
This book is about abused children and practitioners/clinicians/thera-

pists (for succinctness, we often use ‘practitioners’ to cover the range of
professional roles) who assist them and their families to overcome the
effects of harm. The methods and models of practice we describe have
been carefully selected to ensure their relevance to Caribbean contexts.
We begin not by focusing on the clients and service users of abuse and
trauma work but by thinking about you, the practitioner.
Writing about institutional failings within the Caribbean in regard to
the protection of children’s rights to grow up free from abuse, Jones and
colleagues (2014) commented:
there are many committed persons … who are working tirelessly to protect
children and to prevent abuse and … there are examples of excellent prac-
tice in many agencies. These people work with limited resources, little rec-
ognition and often, inadequate remuneration; yet it is to them we owe
thanks for the many children and families who are supported in dealing
with abuse. Child sexual abuse is invisible, but so too are the survivors and
the actions of those who may have helped them out of victimhood …
working in the child protection field is exhausting and leads to fatigue,
emotional burnout and frustration (162).
Jones and her colleagues were making the point that preventing and
treating child abuse is not easy work. There can be few fields of practice
in which one is required to bear witness to some of the worst of adult
behaviours and yet at the same time be humbled by amazing displays
of a child’s resilience. And there can be few fields of practice that exact
so much from the professional. This therapeutic work demands a range
of skills, knowledge and attitudes on the practitioner’s part, over and
beyond the obvious clinical expertise, and therefore it is important that
we also pay some attention to the psychological needs of the professional.
The gifted practitioner is not necessarily the practitioner with the highest
levels of expertise, training and skills; he or she is not the person who can
command the highest fees or who can point to the best results. The gifted
practitioner is a reflective practitioner—this is the person who is aware
of the emotional impact upon themselves of the work they do and uses
the process of self-reflection for personal and continuing professional
development, for their own empowerment and for building the intuitive
knowledge that cannot be obtained in the classroom. Reflective practice
increases the value of therapeutic work, it can produce unexpected out-
comes and solutions to problems that may seem to be beyond imagining,
it helps to generate creative and emancipatory possibilities and it can help
to keep in check biases and judgements that have no place in equality/
human rights-based work. It is beyond the scope of this book to go into
any great detail about the professional requirements of therapeutic work
with survivors of CSA; so we have chosen to introduce the EI model to
help inform the adaptive and emotional functioning of practitioners as
they interface with the myriad of traumatic conditions facing children.
At the outset, we put in a disclaimer of sorts because we are not sug-
gesting that EI is something that should be addressed in the rather super-
ficial manner that we are guilty of here. It should not. Its virtues, however,
need to be known. It speaks to a range of sensitive and cognitive abilities
and capacities of the individual. Its value might be pitted against the
global standard of measuring human intelligence—the intelligence quo-
tient (IQ) yardstick—in our view, a reductionist approach that underval-
ues the breadth and depth of emotional skills (McClelland, 1973).
Emotional skills, which is what EI refers to, reflect a lifetime of learn-
ing (Lopes and Salovey 2004) that people bring to their understanding
of the problems that confront them. Brackett and Salovey (2004) sug-
gest, however, that it may be possible to stimulate the development of
IQ and EI
The EI research shows that it is twice as important as IQ in predict-

ing outstanding performance. A practitioner’s work is not usually
described in such performance terms, because of the sheer number
of unpredictable variables that cannot be foreseen or measured in
as tangible a way as non-therapeutic work. This uncertainty in itself
demands the kind of approach which can best deal with ambigui-
ties. The gifted practitioner requires more than a particular IQ score.
emotional learning even among those (such as children) who have not
had the benefit of a lifetime of varying experiences:
if traditional schooling increases cognitive abilities … it might be possible

that educational programs focusing on social and emotional abilities stim-
ulate EI. In fact, it appears that infusing emotional literacy programs into
existing school curricula can help increase emotional knowledge and work
against the initiation and progression of harmful behaviors such as exces-
sive alcohol consumption, illegal drug use and deviant behavior (Brackett
and Salovey 2006, 39).
The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT)

(Mayer et al. 2003), which measures psychological and behavioural
outcomes of EI-based work, would be one way of putting Brackett
and Salovey’s observations to the test. However, for the purposes of
this book, we are content to accept the general tenet of Brackett and
Salovey’s ideas, that EI is potentially available to everyone and greater
awareness of emotional capacity can ward off the development of self-
harming behaviours (Brackett and Salovey 2006). The starting point for
the gifted practitioner—the emotionally intelligent practitioner—is to
know oneself.
Applicability of EI in Therapeutic Settings

‘There are three things extremely hard: steel, a diamond, and to know one’s
self.’ Benjamin Franklin (1750 Poor Richard’s Almanac, cited in Association
for Psychological Science 2005, 1)
Knowledge of the self is the bedrock on which all other sources of knowl-
edge pertinent to working with survivors of abuse and trauma are layered.
The overestimation or underestimation of the capacities and sensitivities
of the self is a self-deception which clouds judgement and causes us to
stand tall and pre-eminent when humility might be needed or to shrink
away with a lack of confidence when we need to stand tall. This can apply
to all of us, the social worker or psychologist who underestimates or
overestimates his or her skills in helping a traumatised child and mother;

the doctor who may overestimate or underestimate his or her ability to
treat a particular condition or the psychotherapist in his or her self-reflec-
tion of how well an intervention with clients is going. The relationship
between self-assessment of a person’s knowledge and skill and the person’s
actual performance, when measured objectively, reveals some surprising
findings:
In general, people’s self-views hold only a tenuous to modest relationship

with their actual behavior and performance. The correlation between self-
ratings of skill and actual performance in many domains is moderate to
meager—indeed, at times, other people’s predictions of a person’s out-
comes prove more accurate than that person’s self-predictions. In addition,
people overrate themselves. On average, people say that they are “above
average” in skill (a conclusion that defies statistical possibility), overesti-
mate the likelihood that they will engage in desirable behaviors and achieve
favorable outcomes, furnish overly optimistic estimates of when they will
complete future projects, and reach judgments with too much confidence.
Several psychological processes conspire to produce flawed self-assessments
(Dunning et al. 2004, 69).
Achieving congruence between how a person views their performance

and how they actually perform is the goal of EI—but what assists them
in achieving this state, and what would a fully congruent picture of
them painting a picture of themselves look like? Dunning and colleagues
(2004) use this metaphor to describe the complexity of self-evaluation
and why what we see when we are in reflective mode may not be what
others know:
We feel that the psychological literature has painted only a few brush-
strokes toward a portrait of the person as self-evaluator—and there is much
more painting to be done to complete that portrait. But, perhaps more
important, there is also much work to be done about another portrait well
worth painting. That second portrait is one that depicts what an individual
looks like when he or she has achieved an accurate impression of his or her
talents, capacities, and character. How one retouches the first portrait to
create the second is an issue that requires much more theoretical and
empirical work (Dunning et al. 2004, 99).
At this juncture, we should recognise that there is a large body of

psychological research on the ‘presentation of self ’ that we cannot do
justice to in this book, but recommending an EI model is an acknowl-
edgement of this fact. As Dunning and colleagues (2004, 69) state
‘Several psychological processes conspire to produce flawed self-assess-
ments’, the questions arise, therefore, how can we better evaluate our
abilities, needs and areas for development and how can we better man-
age the emotional impact of the work we do? The clinical focus of this
book compels us to recognise these psychological and cognitive pro-
cesses and the part they play in our everyday activities and the shaping
of our behaviours. Writing about EI, Mollon (2002) identifies several
emotions that can impact our well-being, shame being one of them;
‘Shame is a response to failure and to ensuing feelings of inadequacy-
especially a failure when success was expected’ (Mollon 2002, 25).
Without effective emotional management, shame and feelings of inad-
equacy can contribute to the onset of depression (both for the practi-
tioner and the client). An emotionally intelligent approach to practice
requires a deepening of the skills of self-evaluation, so that where these
processes are present, we can learn to regulate them. This could not be
more crucial than in CSA work. Imagine the consequences of inter-
nalising personal failure when, for example, the child you have been
working with discloses continued abuse despite your efforts, or the
juvenile sex offender completes his treatment programme and subse-
quently is arrested for a further rape. Although the impact upon the
self is profound, without managing the emotional fallout of practice,
there is a risk that feelings of failure will generate feelings of shame.
Shame is a difficult emotion to sustain and is easily transposed into
blame. Accountability is a vital component of the work we do, but
blame is not—in fact, blame gets in the way of accountability and so
we can see how the lack of awareness of the effects of our work upon
the self can affect the work itself. We can paint a more truthful portrait
of the self (self-evaluation) by knowing and developing our level of EI
and being able to assess our own performance against several attributes
which we discuss below (Dunning et al. 2004). But, first, let us be
clear about what EI is and what its value is to the self and for day-to-
day relationships with friends, family and fellow professionals.
EI, briefly summarised, is the capacity to effectively handle one’s own

emotions and one’s response to the emotions of others. Daniel Goleman
describes it as ‘the capacity for recognising our own feelings and those
of others, for motivating ourselves, for managing emotions well in our-
selves and in our relationships’ (Goleman 1998, 317). The fundamental
properties of EI are often conceptualised as a hierarchical relationship
between a set of inter-related competencies/behaviours which combine
to determine an individual’s overall level of adaptive emotional function-
ing (Salovey et al. 2002; Mayer et al. 2003). The key processes at play are
shown in Fig. 1.1 below.
These processes refer to adeptness in both personal and social compe-
tencies (separately represented in Figs. 1.1 and 1.2 for clarity), based on
the pioneering work of leaders in the field, such as Goleman (1998) and
Boyatzis and Sala (2004a, b).
Here, we focus only on personal competencies, by way of introducing
the model, since the limitations of this book prevent a discussion of the
Self-Awareness
• Personal Competencies
• Social Competencies
Emotional Self-
Awareness Social
Accurate Self Awareness
Assessment
Self Confidence
Self-Management
Emotional Self-
Control
Transparency
Relationship
Optimism
Management
Achievement
Initiative
Adaptability
Fig. 1.1 Dimensions of emotional intelligence based on the pioneering work

of Goleman (1998), Boyatzis and Sala (2004a) and the emotional competency
training workbook (Hay Group 2008)
whole. The whole EI model is, however, illustrated in Fig. 1.4, and the
reader is encouraged to find out more about the theory and practice of EI.
Personal Competencies: Self-Awareness

and Self-Management
A key quality which characterises the extent of a person’s personal com-
petence—be it a practitioner, the mother of an abused child, a perpetra-
tor of abuse or a police officer—is the degree to which they are sufficiently
self-aware of the effects of their emotions and the extent to which they
can manage said emotions. This can be more clearly demonstrated from
the practice point of view where we discuss treatment interventions as
applied to the case studies, but here is what we say later where Levi (case
study 3—see Part 4) is concerned:
When beginning work with a sex offender, a psychotherapist may expect

to experience the same flood of conflicting emotions as anyone would,
particularly if the therapist and offender reside in the same community,
and particularly if the community is small. Therapists or social workers
may feel outrage, repulsion, fear and despair. Whether these emotions
arise naturally when one is placed in near proximity to a known preda-
tor, or as a result of cultural conditioning, we, as human beings, are
susceptible to the range of them. We would go so far as to say that one
cannot not react to this type of encounter, and it is essential for a thera-
pist to acknowledge this, going in.
Self-awareness and self-management skills (described below) should

underpin our personal conduct in the situations we face or create. The
qualities of these two key components of EI are shown in Fig. 1.1. It is
reassuring to know from research on the EI model that one’s effectiveness
does not rest in being competent in all the qualities identified, but it is
important to acquire those competencies which are essential to optimum
functioning. In other words, the gifted practitioner is the practitioner
who is committed to ongoing personal and professional development

through acquisition of skills and knowledge derived from working in an
emotionally intelligent manner. The Hay Group Emotional Intelligence
Workbook (2008, 2) states that ‘Self-Awareness is key; you need all three
of these competencies to function at your best’; that is, emotional self-
awareness, accurate self-evaluation and self-confidence. It is further stated
in the Hay Group workbook that although some competencies are essen-
tial, others work together in synergies that can lead to outstanding per-
formance. Thus, ‘emotional self-control is essential’ (2008, 2) but, when
balanced with other demonstrable competencies, is potentially even more
effective. Other personal characteristics identified within the model are
‘transparency’, ‘adaptability’, ‘achievement’, ‘initiative’ and ‘optimism’
(2008, 2). We will return to this later.
Emotional Self-awareness in Action

What might the self-awareness competencies of the practitioner look
like, given that these qualities are not evident to the naked eye yet need
to become an intrinsic part of the person’s being and behaviours? Self-
awareness is pivotal to developing personally and professionally. In the
EI model, self-awareness is said to be critical to how well one develops
all other competency skills: both personal competencies and social com-
petencies. The self-aware person is described as having the capacity for
accurate self-assessment and self-confidence.
Below, we begin to build a figure of self-awareness that shows the rela-
tionship between these three EI components: emotional self-awareness,
accurate self-evaluation and self-confidence.
Emotional
self-
awareness
Fig. 1.2a Self-awareness skills

Emotional self-awareness means being aware of one’s feelings/emotions,

knowing why one experiences them and fully recognising the implications
of these emotions. It leads to a greater ability to balance the demands of
work and home life. Through self-awareness, one can better understand,
for example, that some inexplicable bodily aches and pains may be stress-
related, needing some positive corrective strategies. Lack of such awareness
can result in a failure to recognise one’s own shortcoming, insensitivity to
the position of others and the poor treatment of others. Imagine what a
therapist’s lack of emotional self-awareness could do to a bewildered and
traumatised client, who may have taken a very long time before seeking
help only to then experience inadequate treatment or a negative response.
Another self-awareness skill is that of accurate self-assessment.
Accurate Self-Assessment in Action
Accurate
self-
assessment
Emotional self-
awareness
Fig. 1.2b Self-awareness skills
Accurate self-assessment is helped by knowing one’s strengths and limita-

tions and seeking feedback from others about oneself—perhaps one of the
hardest tests in the development of our self-awareness. It takes us back to the
earlier discussion about how we evaluate ourselves; feedback from others can
assist in developing a more grounded reality. An absence of this accurate self-
assessment skill may lead the practitioner to fall into pitfalls such as taking
undeserved credit for outcomes which rightly belong to others and failing to
acknowledge the areas—clinical or inter-personal—in which one is weak or
particularly strong. Positive feedback adds to our self-confidence.
Personal Self-
confidence
competency
skills of self-
awareness Accurate
self-
assessment Emotional self-
awareness
Fig. 1.2c Self-awareness skills
Self-Confidence in Action
The self-confidence competency includes important skills such as possessing
a demeanour which reflects compassion and care and skills in communica-
tion. Nevertheless, it goes beyond this to include attributes such as facing and
handling disappointments in a productive manner. The converse of this self-
confidence skill is fear—anxiety and distress at the thought of failing or lack
of confidence in one’s own judgements, assessment of situations and ability
to take action. These feelings can lead to the ‘shame’ which we mentioned
earlier (Mollon 2002). These are feelings and emotions which negate positive
interventions with clients who need help. Indeed, an emotionally intelligent
approach by the practitioner will help him or her also recognise the level and
quality of emotional functioning in clients and patients.
Where work performance is concerned, the relationship between

the component skills of self-awareness (emotional self-awareness,
accurate self-assessment and self-confidence) and other factors such as
satisfaction with one’s job and level of one’s performance is very
closely linked. One impacts the other. A lack of understanding of
how emotions affect performance can extend to how effectively one
can assist clients with complex needs. By extension, the practitio-
ner’s ability to help clients develop and be mindful of their own
emotional self-awareness needs will be compromised.
Emotional Self-Control in Action

Self-management entails how effectively one handles one’s emotions and how
well one can control responses to new, unexpected or challenging situations.
Emotional self-control is an essential feature of effective self-management. It
speaks directly to our ability to keep impulsive feelings and emotions under
control in varying situations such as working under severe pressure, facing
different stressful situations and dealing with hostility and defiance from
others. Having a keen sense of self-awareness (discussed earlier) can help in
identifying situational triggers which can result in thoughtless behaviours.
The practitioner will undoubtedly be faced with clients who have difficulty
with managing impulsive behaviours, some of which may be harmful to
themselves and others. Such impulsivity may be related to the sequelae
of violence and exploitation the person has been exposed to (bearing in
mind that the practitioner may also have been sexually abused as a child).
Therefore, it is of paramount importance that the therapist develop an abil-
ity to control any impulsive reaction to a client and to prevent themselves
from responding in a negative or impulsive manner because of vicarious or
personal stress or the triggering of one’s own trauma. Developing strategies
for self-control include having a sound knowledge of the causes and effects
of stress and learning practical ways of reducing the harmful effects that
stress has on health, work performance and personal relationships.
Adaptability and Initiative
Earlier in the introduction to the EI model, we highlighted that at least
two skills are needed to ensure the effectiveness of one’s self-management
skills. We introduce adaptability and initiative skills below as examples of
this complementarity.
Adaptability in Action
Taking steps to develop adaptability skills has numerous benefits to the
practitioner. These include the ability to deal effectively with change and
changing agendas, conflicting priorities and competing demands. Being
able to work flexibly with different groups and clientele under circum-
stances which may be outside one’s control and to reassess one’s own
views and adapt where necessary when this is dictated by the evidence—
this is a key quality of the gifted practitioner. An example of the reverse
of this situation is one in which a person has difficulty in seeing the other
person’s perspective. In a therapeutic setting, this can be a great challenge
for the practitioner who may be faced with marked differences of opinion
and disordered thinking in some clients. The ability to adapt one’s think-
ing, to see the perspective of the unusual and unexpected and to control
one’s reactions to them is informed by the EI skill of adaptability.
Initiative in Action
Initiative is the ability to take charge of situations respectfully and in an
accountable manner. It moves us beyond only doing what one is told, to
seeking out ways and opportunities of bringing some added value to the
situation, the client’s position of need or one’s personal and professional
development. The gifted practitioner does more than the bare minimum.
Like adaptability skills, thinking is not static but dynamic to capitalise on
opportunities either created or presented. Let us take the example in the
case study on 12-year-old Nina, who has Down syndrome (see Part 3).
Apart from only responding to the fact she was abused by her teacher, the
therapist can use Nina’s experience as a catalyst for work with the whole
family, to ensure that Nina continues to recover from the experience and
to build more protective factors into the care of her and her siblings.
Additionally, the initiative can be taken to help the school to develop
educational programmes appropriate to the cognitive abilities of children
with learning disabilities. Then there is Nina’s father, who is clearly begin-
ning to have job performance problems at work. With his permission,
the initiative can be taken here to liaise with the employee assistance
programme (or alternative) at work to assist this father, who is a widower
and has to cope with the aftermath of his daughter’s sexual abuse without
the support of her mother. In this way, the therapist remains an active
participant rather than one whose actions are purely reactionary. The two
competencies described above—adaptability and initiative—are parts of
the self-management competency, but there are others, as Fig. 1.1 shows.
Personal Innitiative
competency
skills
(examples) of
self- Adaptability
Emotional self-
management control
Fig. 1.3 Self-management skills
The reader is encouraged to undertake further self-directed learning

on the range of competencies shown in the complete EI model, which
includes the social competencies of social awareness and relationship
management, which we can touch on only briefly.
Social Competencies: Social Awareness

and Relationship Management
Social awareness and relationship management (Fig. 1.4) are the two
inter-related EI skills which help determine how successful we are in our
dealings with others, how socially competent we are.
Social Awareness and Relationship

Management in Action
Social awareness skills include the ability to read and understand the
emotions of others and to empathise. The gifted practitioner has an
understanding of the cultural dynamic within the organisations within
which he or she works and knows where various kinds of power exist.
Relationship management skills allow one to understand the needs
Self-Awareness Social Awareness

• Personal Competencies
Emotional Self- Empathy
• Social Competencies
Awareness Organisational
Accurate Self Awareness
Assessment Social Orientation
Self Confidence
Self-Management Relationship
Management
Emotional Self-Control
Influence
Transparency
Developing Others
Optimism Conflict Management
Achievement Inspirational Leadership
Initiative Teamwork and Collaboration
Adaptability Change Catalyst
Fig. 1.4 Emotional Intelligence illustration based on the pioneering work of

Goleman (1998), Boyatzis and Sala (2004a) and the emotional competency
training workbook (Hay Group 2008)
and interests of others and help the practitioner to build consensus

where needed. Exercising these skills develops other skills of relation-
ship management such as the ability to help develop the capacities of
others through inspirational guidance. A practitioner with these skills
is better able to contribute to successful teamwork and collaboration
and help resolve conflict by focusing on the issues rather than the
personalities (Fig. 1.4).
Each of the case studies presented in this book demonstrates the impor-
tance of the practitioner working in an emotionally intelligent manner.
This is made evident form the discussion on the personal competencies of
self-awareness and self-management and highlighting the social compe-
tencies of social awareness and relationship management. These are criti-
cal characteristics which need to be cultivated and inculcated into one’s
behaviours and actions. They signify a genuine understanding of other
people. Our aspirations resonate with the following statement:
What we know thus far is encouraging, and we are confident that future
research will reveal more about how individuals with higher (and lower) EI
handle situations in which emotions play important roles, and differ in the
other life domains, including mental and physical health, leisure interests,
and career choice (Brackett and Salovey 2006, 40).
We would further argue that the use of the EI model helps coun-
terbalance the power imbalances inherent in the practitioner-client
relationship. Intervening in the lives of persons who are in need
of help is a privilege, but it does not bestow privilege. The gifted
practitioner is acutely aware that emotions are being managed in
the moment by both parties; each person has the capacity for EI,
but personal growth may have been cut off for the client because of
trauma. The dynamism of the EI model means that the practitioner,
in exercising specific EI behaviours relevant to the presenting situ-
ation, can in turn better guide the client to their innate sources of
strength, to assist their own healing and problem solving.
The Book
This book is organised around five case studies in which we anchor our
interventions and models of practice.
One of the case studies—Levi’s (Part 4)—demonstrates the inter-
section between early childhood abuse and neglect and subsequent
offending and criminal behaviour. Levi is now on the cusp of adult-
hood. The negative outcomes of such a chain of life events, charac-
terised by violence and abusive relationships, are played out daily
within many Caribbean families and the communities in which they
live. The involvement of young men such as Levi in the criminal
and judicial systems is prophetic. Although many people who have
experienced violence in childhood become the most peace-loving
of adults, the cyclical nature of violence is all too common; sadly
there are many young people like Levi throughout the Caribbean,
Latin America and globally whose life trajectory, in the absence of
meaningful therapeutic intervention, is almost predetermined—

from being abused, to being an abuser, to being imprisoned, released
without rehabilitation support and to parenthood! The continuing
absence of skilled therapeutic intervention to help ameliorate earlier
childhood trauma should not be in question; it should be an impera-
tive statutory provision, enshrined in the legislation of Caribbean
states. The psychological and economic costs to society, particularly
noticeable in small island developing states, are reason enough and
we all know that these costs need to be reduced and replaced by
gains through the early intervention and ongoing support to (latent
and otherwise) vulnerable and abusive families and abused children.
But not just any old intervention or solution to the problem is good
enough, and the models of practice we describe are underscored by
five principles that set the programme standard for replication:
• They are culturally intelligent in that they challenge harmful cultural

attitudes while being culturally relevant.
• They are supported by evidence of their effectiveness.
• They make use of ecological systems theory and the theory of intersec-
tionality, so while they focus on the individual, they also build family
and community capacity for tackling child abuse.
• They make use of existing infrastructure and, as they do not require
the importation of specialist experts, can be replicated anywhere.
• The models are strengths-based in that they acknowledge and build
resiliency and use indigenous resources.
The first case study is Melissa (Part 2). Her life is heavily influenced
by her early socialisation and experiences of family violence and dysfunc-
tion. This part of the book discusses the role of the psychologist in assess-
ing the needs of adolescent girls who have been abused. It goes on to
describe a group psychotherapeutic intervention for teenage girls, and the
final intervention explores the role of social work in enhancing attach-
ment behaviours between teenage mothers who have been abused and
their babies.
Nina is the name of the child in the second case study (Part 3). Nina
has Down syndrome and has suffered sexual abuse at the hands of a
trusted individual, her teacher. As we explain, children with disabilities

are at increased risk of sexual exploitation and this is consistent with
the fact that they often depend on others for much more of their care
and may lack the cognitive or communication skills to explain what has
happened to them. These factors make them more vulnerable to abuse.
In Nina’s case, family instability, the lack of maternal support (mother
deceased) and a father who is facing several challenges of his own have led
to a major family crisis. In addition to therapeutic approaches for work-
ing with disabled children, the crisis intervention model is described as
a method for enabling the family to regain its equilibrium and optimal
level of functioning. Within this part of the book, we also discuss the
family group conference model as a child protection intervention.
There is then Levi, the young man who is the focus of the third case
study (Part 4) and who has already been introduced. Levi’s case enables us to
explore individual and group treatment for juvenile sex offenders. We dis-
cuss the benefits of developing restorative justice approaches for young peo-
ple with harmful sexual behaviour and introduce the reader to interventions
that build family and community skills in supporting young offenders. In
this section of the book, we also discuss the family group conference model
as a restorative justice approach. The fourth case study (Part 5) revolves
around siblings—Anton and Oriana, who live in a children’s home—and
demonstrates a range of intersecting factors which coalesce to influence the
behaviours and needs of children in residential care settings. We describe an
individualised treatment approach but focus heavily on the role of caregiv-
ers in ensuring that residential care is a positive experience for children and
facilitates their growth and development. We advocate for family reunifica-
tion, where possible, and for life story work as a method for reconnecting
children with their pasts and establishing a sense of belonging—key factors
in ameliorating dysfunctional behaviours.
All the case studies2 are contexted through a discussion of the relevant
literature on the wider environmental issues the case throws up. The ideas,
tools and methods that are described can be adapted for a range of set-
tings in which child abuse emerges: health, education, psychology, social
2
All names used in the book are pseudonyms except for Jaime Lee Loy, who uses her own name;
case stories are based on actual practice examples, but details have been modified to ensure ano-
nymity and protect confidentiality.
work, churches, mosques, children’s homes, juvenile correction centres,

community centres, and, of course, within the family.
The fifth and final case study is told in the first person. It is the story of
a survivor of CSA and physical violence. The storyteller is Jaime Lee Loy,
guest author for Part 6 of the book. Jaime uses the narrative of her personal
experiences as a vehicle for exploring art and culture as therapeutic tools.
Art allows me to speak about my situation with striking detail and intensity
while masking it in plain sight. … In this way I can share a very painful
experience. … We can all pretend for awhile this is fiction, even if all of us
know that much of it is not. Art has that power. Art allows me to look at
myself in the third person. I can almost pretend this is someone else. When
experimenting with materials and playing with concepts built around my
feelings and emotions, the art process allows me to fictionalise myself—to
myself. This is important when dealing with something that is so intense
that it can unravel the artist producing the work aka the person dealing
with trauma. It is no longer about masking to create distance from others
as in the first point, but a way of creating a safe distance between myself
and the reality of the pain (Jaime Lee Loy, personal communication 25
March 2015).
Part 6 of the book draws from the rich cultural traditions of the
Caribbean to demonstrate the potential of art to disrupt and challenge
attitudes that promote violence (and gender-based violence in particu-
lar) and to provide creative, cost-effective and sustainable modalities for
treatment. Although music is not one of the art forms discussed in this
section, the reader is reminded that music therapy is an essential force for
healing. With the traditions of calypso (kaiso and rapso), soca, chutney,
reggae, pan, tassa, parang and other popular Caribbean musical art forms
to draw from, the therapeutic possibilities of this art genre need a book of
their own. Not to be outdone are the benefits of drama, role play, poetry,
digital storytelling and videography as methods for practitioners to use.
These are useful methods not only for interventions with clients but also
in delivering training programmes. Within this book, however, we have
focused on the visual arts. Art is embedded within Caribbean social life
and so it seems is gender-based violence; here, we use one to disrupt the
other—visual and expressive arts as a means of coping with trauma and
transforming states of victimhood to survivorhood.
In several of the interventions described in the book, art and creativity

are presented alongside other methods; the philosophy shared by all the
authors of this book is that creativity is universal and accessible to chil-
dren and adults alike. Creativity imposes no rules, and art is a safe space
which enables the person to establish a sense of control—a safe space is
crucial in situations in which one feels powerless and subject to the con-
trol and domination of others. A child may not be able to confront his
or her abuser or to resolve conflicts with an abusive parent, but making
art about these things can help the child to reframe the experience. It can
provide a sense of freedom to talk back, to act back, in a way that is guilt-
free and for which there are no punishments.
Returning to Parts 2–5 of the book—the case studies presented may,
or may not, resemble the people and circumstances you work with. Every
human experience is unique, and it is likely that the cases will match your
clients’ experiences only in minor ways, if at all. This really does not mat-
ter; the techniques, interventions and strategies we describe are relevant
for a wide range of people who are affected by CSA. The case studies are
a useful tool in themselves—they can be used for training purposes or
for reflecting on one’s own practice, and the interventions described are
cost-effective and strengths-based and are relevant for many social/cul-
tural contexts. None of the approaches we discuss requires extensive exter-
nal resources, and although experience, professional training and skilled
implementation can improve outcomes, the methods can be modified to
match available levels of expertise. The key message is that if there are no
appropriate experts to draw on to provide the support your clients need,
then become that expert—the most important resource your client has
access to outside of their own personal resources may be you! Each case
study includes a genogram, ecomap and timeline which provide a sym-
bolic representation of key relationships, systems of support and chronol-
ogy of events. We encourage professionals to make use of such tools as
a standard aspect of their practice as they provide immediate reference
material for identifying potential blockages and strengths that may need
to be figured within the change process. If used with the client’s input,
these tools can also help a person to bring visual order to a disordered
world, enable the client to make sense of what has happened and identify
strengths that she was not aware of. For example, drawing her timeline, a
young woman may suddenly appreciate that the low grades she achieved
at school in a particular year coincided with a significant event or loss

she experienced and that the negative report she had received reflected
neither her ability nor her resilience.
The first stage in any intervention is to undertake an assessment of the
client’s needs and circumstances. Later, we discuss psychological assess-
ment, but the reader is reminded that there are many social work assess-
ment resources available (see, e.g., Milner and O’Byrne 2009; Holland
2010; Parker and Bradley 2010; and Graybeal 2001). These include tools,
risk assessment approaches, critical reviews and guidance. Some assessment
methods have been subject to rigorous evaluation but many have not; in
any event, since most of the literature is informed by practice in income-
rich Western countries, there is always the risk of ethnocentricity or cultural
bias. While we caution against adopting assessment tools uncritically with-
out giving due consideration to their sociocultural relevance, there are some
excellent resources available that, with minimum modification, would be
applicable to a wide range of circumstances. The scope of an assessment is
also influenced by professional standards: many psychologists and psycho-
therapists regard their primary role as working with the individual, whereas
the social worker, even if working with the individual, is likely to adopt a
broader focus that encompasses the family or wider environment.
Although the book is targeted towards supporting the work of par-
ticular professions, its eclectic nature will hopefully appeal to anyone who
deals with child abuse cases within the course of their daily working life.
Psychology, psychotherapy and social work are three distinct and separate
disciplines, each comprising different schools of thought, theories and
practices. But this is not a book about these professions and so we do
not discuss the various disciplinary specialisations that exist even though
the reader will pick up disciplinary nuance and specificity in the style of
writing which may indicate a particular theory or approach. The asser-
tion and recognition of professional identity require the establishment of
parameters of practice, a specific skill set and the articulation of a body of
knowledge from which methods are derived. As authors, we have skills
in psychology (developmental, clinical and organisational), psychotherapy
and social work and understand well the disciplinary boundaries that exist
and the importance of professional credentialisation. Despite their differ-
ences, however, these professions share common ground in that they seek
to assist individuals, families and groups to address their life circumstances
by exploring strategies for problem solving (Holosko et al. 2012). Most

countries in the Caribbean have a limited number of specialists who have
trained in sexual abuse work; there may not be a psychotherapist, a psy-
chologist or even a child protection social worker at hand and the question
then arises, can non-professionals or those working in other professions
use the approaches we describe? The answer is not simple; it is our belief
that anyone who finds themselves in a helping role with someone who
has experienced CSA or is at risk of committing abuse can learn from
the strategies discussed; however, particular skills and knowledge may
enable a particular intervention to be more effective. There is a wealth of
knowledge available in the two previous books of this three-book series; of
course, there is an abundance of other literature available too. Our advice
to the reader is to read widely, learn from the strategies discussed and
adopt or adapt them for particular situations. First, acquaint yourself with
skills of EI, commit to lifelong self-learning and reflective practice, who-
ever you are and in whatever field you work and pay attention to that most
neglected of areas, self-care (discussed below).
We are mindful that in countries with few professionals with expertise
in treating CSA cases, referring someone to a specialist may simply mean
consigning the client to a lengthy wait for a service, to finding professional
fees they cannot afford or to no service at all. Respecting professional role
boundaries is crucial for effective inter-professional practice but this does
not mean that the nurse, doctor, police officer, teacher, religious leader or
non-governmental organisation worker who is on the front line in deal-
ing with CSA cases in their communities cannot learn from the theories
and practices of psychologists, psychotherapists and social workers. So
although we have targeted this book at these professional groups, we hope
the information it contains is more widely useful to other people too.
A Note on Self-Care
Erickson used to say to his patients, “My voice will go with you”. His voice
did. What he did not say was that our clients’ voices can also go with us.
Their stories become part of us—part of our daily lives and our nightly
dreams. Not all stories are negative—indeed, a good many are inspiring.
The point is that they change us (Mahoney 2003, 195).
We have argued for the development and application of EI as the basis of

reflective practice. We hope this will lead you to recognise the need for
self-care. As Mahoney (2003) makes clear, we are changed by our encoun-
ters with clients. Many of these encounters will enrich us but others will
leave us confused and distressed about human capacity for hurting oth-
ers, especially those who are vulnerable. We may find at times that our
resolve to treat all people with respect and dignity abandons us, especially
when confronted with the perpetrators of heinous crimes against chil-
dren. We will rationalise this and cloak ourselves with righteous justi-
fication, paying little mind to the effect on ourselves of abandoning the
values that underpin the human rights beliefs for which we strive. And
the cumulative affect of hearing story upon story of sexual abuse and
child suffering will deplete our internal resources. The potential impact
of secondary traumatisation, to which this discussion refers, can result in
post-traumatic stress disorder. This is recognised within the Diagnostic
and Statistical Manual of Mental Disorders (DSM), which was updated in
2013 to include those who work with trauma victims. The DSM states
that the criteria for developing post-traumatic stress disorder include
those (such as law enforcement officers, therapists and social workers)
who face repeated or extreme exposure to the details of trauma and abuse
events (American Psychiatric Association, 2013). Mahoney (2013) (cit-
ing Pearlman and Saakvitne 1995, 31) explains that constant empathic
engagement with clients’ ‘traumatic material’ can lead to cumulative
changes in the practitioner that one may be little aware of but which, un-
tended, can have deleterious long-term effects. The gifted practitioner is
the practitioner who sustains empathy for his or her clients but recognises
that, in terms of personal costs, empathy can exact a toll over time with
which they need to deal. These costs include the following:
• Feeling emotionally overwhelmed, exhausted and burnt out

• Feeling anger, sadness and despair
• Depression, apathy and loss of pleasure
• Isolation, alienation, feeling distant and detached from friends, family
and colleagues
• Experiencing guilt, shame and feelings of self-doubt and failure
The emotionally intelligent practitioner, the gifted practitioner, is the

practitioner who knows themselves well enough and can identify when
stresses are generating adverse consequences on the self and on personal and
professional relationships. This type of practitioner knows when personal
help is needed (therapy for the therapist) and what protective factors they
can develop for oneself. Self-care is a professional responsibility—the gifted
practitioner is the practitioner who takes care of herself. For an excellent
source of information, techniques and strategies for self-care, see the manual
by Donald Meichenbaum (n.d.), Self-Care for Trauma Psychotherapists and
Caregivers: Individual, Social and Organizational Interventions, (http://www.
melissainstitute.org/documents/meichenbaum_selfcare_11thconf.pdf ).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders (5th ed.), http://dsm.psychiatryonline.org/doi/book/10.1176/
appi.books.9780890425596. Accessed August 11, 2015.
Association for Psychological Science. (2005). “Know Thyself ”- Easier said than
done. https://www.psychologicalscience.org/media/releases/2005/pr051028.
cfm. Accessed August 4, 2015.
Boyatzis, R.E. & Sala, F. (2004a). Assessing emotional intelligence competencies.
www.eiconsortium.org/pdf/Assessing_Emotional_Intelligence_
Competencies.pdf. Accessed June 29, 2015
Boyatzis, R. E., & Sala, F. (2004b). The emotional competence inventory (ECI).
In G. Geher (Ed.), Measuring emotional intelligence: Common ground and
controversy (pp. 147–180). Hauppauge, NY: Nova Science.
Brackett, M. A., & Salovey, P. (2006). Measuring emotional intelligence with
the Mayer-Salovery-Caruso Emotional Intelligence Test (MSCEIT).
Psicothema, 18(Suplemento), 34–41.
Dunning, D., Heath, C., & Suls, J. M. (2004). Flawed self-assessment implica-
tions for health, education, and the workplace. Psychological Science in the
Public Interest, 5(3), 69–106.
Goleman, D. (1998). Working with emotional intelligence. London: Bloomsbury.
Graybeal, C. (2001). Strengths-based social work assessment: Transforming the
dominant paradigm. Families in Society: The Journal of Contemporary Social
Services, 82(3), 233–242.
Harley, D. A., Jolivette, K., McCormick, K., & Tice, K. (2002). Race, class, and
gender: A constellation of positionalities with implications for counseling.
Journal of Multicultural Counseling and Development, 30, 216–238.
Hay Group. (2008). The emotional intelligence workbook: A guide to developing
your emotional intelligence based on the Emotional Competency Inventory.
Europe: Hay Group. www.haygroup.com/tl
Holland, S. (2010). Child and family assessment in social work practice. London:
Sage.
Jones, A. D., Trotman Jemmott, E., Maharaj, P. E., & Da Breo, H. (2014). An
integratedsystems model for preventing child sexual abuse: Perspectives from the
Caribbean. Basingstoke/Hampshire: Palgrave Macmillan.
Lopes, P., & Salovey, P. (2004). Toward a broader education: Social, emotional
and practical skills. In J. E. Zins, R. P. Weissberg, M. C. Wang, & H. J.
Walberg (Eds.), Building school success on social and emotional learning
(pp. 79–93). New York: Teachers College Press.
Mahoney, M. J. (2003). Constructive psychotherapy: A practical guide. New York:
The Guilford Press.
Mayer, J. D., Salovey, P., Caruso, D. R., & Sitarenios, G. (2003). Measuring
emotional intelligence with the MSCEIT V2.0. Emotion, 2, 97–105.
McClelland, D. C. (1973). Testing for competence rather than for intelligence.
American Psychologist, 28(1), 1–14.
Meichenbaum, D. (n.d.). Self-care for trauma psychotherapists and caregivers:
Individual, social and organizational interventions. Miami, FL:The Melissa
Institute for Violence Prevention and Treatment of Victims of Violence. http://
www.melissainstitute.org/documents/meichenbaum_selfcare_11thconf.pdf.
Accessed November 12, 2014.
Milner, J., & O’Byrne, P. (2009). Assessment in social work. Basingstoke/
Hampshire: Palgrave Macmillan.
Mollon, P. (2002). Shame and jealousy: The hidden turmoils. London: Karnac Books.
Parker, J., & Bradley, G. (2010). Social work practice: Assessment, planning, inter-
vention and review. London: Sage.
Pearlman, L. A., & Saakvitne, K. (1995). Vicarious traumatization: The cost of
empathy. Ukiah, CA: Cavaliade.
Salovey, P., Mayer, J. D., Caruso, D., & Yoo, S. H. (2002). The positive psychol-
ogy of emotional intelligence. In C. R. Snyder & S. J. Lopez (Eds.), Handbook
of positive psychology (pp. 159–171). New York: Oxford University Press.
2
Working with Adolescent Girls who
have been Sexually Abused
Abortion and Unwanted Pregnancy as a
Consequence of Rape; Psycho-dynamic
Groupwork; Teenage Mothers: An
Attachment Enhancement Intervention
Fig. 2.1 Detail from Roaches and Flowers: War in the Home © Jaime Lee Loy
2008

This exploration of a psychological crisis is in fact a visual narrative of

conquest, where gender politics and violence against women become
visible through the vocabulary, iconography and mechanisms of the home
interior. Domestic items such as cutlery and plates intermingled with
flowers and nails, form roaches and other unseemly insect-like forms …
representing invasion, the unwelcome, the uncomfortable, the unfamiliar,
found in a space of familiarity and comfort. (Lee Loy 2008, n.p.)
Introduction
This part of the book explores the wider contexts and impact of intersecting
harms (child sexual abuse [CSA], family violence and gender inequality)
with regard to adolescent girls and teenage mothers. Our entry to the
topic is the story of Melissa (not her real name). Ecological systems theory,
as a basis for practice, would have us acknowledge that children are nested
within family systems, which in turn are nested within community and
societal systems, and that interventions that explore the inter-relationship
of system dynamics can be particularly effective. We agree with and have
written extensively about this, but Melissa’s story reminds us too that
sometimes children are embedded in systems that are so destructive to
their well-being that they must, for their survival, find themselves un-
nested. Melissa represents the child whose family is so dangerous to her
safety that she cannot remain a part of it or at must live on its periphery
and therefore new systems of support need to be created.
Melissa’s Story
Family History
Mr. and Mrs. John are a couple in their late 50s who have been mar-
ried for 37 years. They have five children: four boys and one girl.
All of their children were born in the UK, where the family lived.
Mr. John worked as a mechanical engineer and Mrs. John was a nurse.
Mrs. John went to the UK to study nursing and met her husband,
2 Working with Adolescent Girls who have been Sexually Abused 29
who is from the same Caribbean island. The family returned to the
Caribbean 8 years ago, leaving their eldest children, Paul and Brian,
in the UK. Paul (33 years) is married and has a five-year-old son of
his own, and Brian (25 years) is doing a master’s degree at a British
university. The household comprises mother, father and their sons
George (28 years) and Antonio (18 years). Melissa does not live with
her parents—she is 17 years old and lives with her ‘boyfriend’ (an
older man of 45 years) and his mother. Mr. John has been unable to
find steady work since returning to the Caribbean but supplements
the income his wife brings home as a nurse by repairing cars. George
is also unemployed and relies heavily on his parents for financial sup-
port. The family resettled into the neighbourhood where the Johns
grew up, and as ‘returnees’ living in one of the better properties in
the village, they are highly respected. Although the general percep-
tion is that the family is quite well off, in reality money is in short
supply and they have some serious financial problems. Theirs has
long been an unhappy marriage with incessant rows about Mr. John’s
gambling and the time Mrs. John spends away from the house, tak-
ing part in church activities. Mrs. John is a quiet woman who has
been subjected to beatings at the hands of her husband in the past
and recently George has hit her too. Antonio, the youngest son, is
also quiet, a studious young man who keeps to himself, and like his
mother is heavily involved in the church. Melissa is considered by
her parents to be unruly and rebellious; her closest relationships are
with her brother Antonio and an aunt—Aunt Jenny, who lives on the
other side of the island, too far away for frequent contact. Melissa
struggled with school and with home life but she excelled in sports
and this increased her confidence and won her many friends.
Presenting Problem
Melissa (17 years) has been referred by her doctor to a project designed

for adolescent girls who have experienced abuse; she seems to be in crisis.
She had gone to her GP because she thought she might be pregnant and
during the medical examination stated that she was not sure whether the
baby was her boyfriend’s or her brother’s. It turns out that Melissa had
Mr. John Mrs. John
Melissa
Paul 33 Brian 17 George 28 Antonio 18
18
UK UK Caribbean Caribbean
Caribbean
5 yrs
Fig. 2.2 Melissa’s genogram
recently come out of an unsuccessful court case to hear charges she had
brought against her brother George for rape. Her family have not spo-
ken to her since she reported the abuse to the police, but desperate to see
her brother Antonio, she decided to go to the house. Only George was
at home and she claims that he locked the doors and raped her, saying
this ‘is for the trouble you cause’. Melissa is in crisis—she does not want
to report the rape, as she says no one will believe her, especially after the
court case. Also, she does not get on with her boyfriend’s mother, who
considers that Melissa has ‘loose’ morals and is bringing shame to the
house, and Melissa is worried she is going to be thrown out. The doc-
tor said there was no sign of a pregnancy but Melissa seems to want to
convince herself that she is having a baby because if it is her boyfriend’s
the mother will have to keep her.
Chronology of Events
Melissa was first abused when she was nine years old. She was living in
England at the time. She says that one of her brothers started molest-
ing her when he was babysitting while their parents were at work and
eventually raped her—she refuses to say which brother. At the time,
she told a close friend of the family who informed Social Services.
A child protection investigation was carried out but before it was
concluded, Mr. and Mrs. John decided to return to the Caribbean.
Melissa was not able to say goodbye to anyone, as she was not told
that they would not be returning from their sudden ‘holiday’. Melissa
has always felt that she was blamed for the upheaval of the family
and for the problems they have experienced since coming back to
the Caribbean. Most challenging of all, though, is that she claims she
continued to be sexually abused by her brother George. She told her
parents, but George was always Mr. John’s favoured son and her father
was incensed at the accusation; he beat Melissa and then threw her out
of the house. Melissa was not surprised by her father’s response but
she was distraught when her mother failed to stand up for her. Melissa
went to live with an older man who said she could have a room in
his mother’s house—it was not long before he started demanding sex
and as she had nowhere else to go, she complied. She became preg-
nant shortly after but fearful of the consequences of a ‘statutory rape’
charge, the man insisted that she have an abortion. Melissa calls this
man her boyfriend; he does not beat her and he is kind to her and so
she stays. This month she missed her period. Convinced she was hav-
ing a baby, her main concern was that she might have conceived when
her brother raped her, and she hoped the doctor would be able to tell
because, if so, she would ‘do the abortion thing’ that she had done a
couple of times already. When the doctor told her there was no sign
of pregnancy, she became very distressed. Melissa has been referred
for professional help.
15 yrs,
Born in reported
UK. No abuse to
significant 10 yrs, authorities,
childhood relocated to subsequently 16 yrs,
events the thrown out of had an
recorded Caribbean home abortion
9 yrs, 14 yrs, had 15 yrs, 17 yrs,

raped an moved in
abortion in to live crisis
with an and
older referred
man for
(45). help
Dropped
out of
school
Fig. 2.3 Melissa’s timeline
Summary
Melissa’s story reveals complex trauma at the individual and family
level and raises issues around loss, attachment, family dysfunction,
post-traumatic stress and the relationship between trauma and the
achievement of developmental milestones. It also raises wider (macro-
level) issues about teenage pregnancy, early sexualisation, abortion
and gender inequality in the Caribbean. The next section draws on
literature and theories from the sociological, health and development
field to reflect on some of these issues and to set the context for the
circumstances in which Melissa’s abuse took place. This broader dis-
cussion is not to imply that the practitioner can or should attend to
the multiplicity of factors in complex cases such as this; they simply
cannot and being aware of the limitations and scope of intervention
is a function of the Emotional Intelligence approach discussed in
Part 1—it is as important a professional responsibility as any other.
However, it is always necessary for the practitioner to be aware of the
environmental factors that sustain or contribute to CSA since these
may undermine the effectiveness of an intervention and it is only
through the wider lens of intersectionality (Jones et al. 2014) that
one can see how the different elements of the problem jigsaw together.
Yet the psychologist, psychotherapist or social worker must be real-
istic about the scope and potential outcomes of their practice and
this means focusing on specific goals within a specific time span. In
Melissa’s family, the history of violence, child maltreatment, dysfunc-
tional parenting styles, the failure of the parents to acknowledge the
offending behaviour of their offspring and communication patterns
which sustain rather than confront abuse present a set of dynamics
that raise particular challenges for practitioners. Awareness of these
factors is necessary for planning but this does not mean that the inter-
vention can address them all. Indeed, the professional may identify
issues that he or she will not touch or that are beyond the bounds of
the intervention, time and resources available or simply do not meet
the most pressing needs of the client, which must be the starting
point. In consultation with the client, the professional has a number
of strategic decisions to make:
1. The nature of the problem that help is needed with

2. What the goals and the time span of intervention should be
3. Whether the focus of work will be the individual, the family, a group
or community
4. Which particular theoretical approach is appropriate to achieve the
goals (e.g., structural family therapy, narrative approaches, multisys-
temic therapy, crisis intervention, behavioural approaches, person-
centred counselling and group work)
At this stage, reference to the client’s ecomap would be helpful.

Based on the information in Melissa’s story, it may be that this is a family
with pathological interaction patterns, involving the transmission of val-
ues about gender-based violence and with adverse responses to problems
that make it difficult to engage them in the initial assessment process. The
response of Melissa’s parents to the first report of sexual abuse in the UK
was one of avoidance and fight, and subsequent allegations of abuse were
met with persistent denial, victim blaming and violence. This common
response to allegations of abuse can make it very difficult to engage a family
in any effective work towards changing the pattern of family relationships
Father
Brother-
Antonio
Mother
Health Care
Melissa
Boyfriend’s
Family Criminal Justice
System
Extended
Family
George and 2
Aunt Jenny
brothers in the
Psychotherapy UK
Group
Positive
Stressful
Tenuous
Arrows=energy flow Line

thickness=intensity
Fig. 2.4 Melissa’s ecomap
and dislodging paternal (or maternal) domination in favour of a more con-

structive and protective form of parenting. Under circumstances such as
those presented in Melissa’s story, the most immediate needs are those con-
cerning Melissa, and family oriented work may come later or perhaps not
at all. In the next section, we explore some of the wider contextual factors
that impact young women subject to sexual violence.
Family Dysfunction and Intersecting Harms

The initial presentation of this case suggests that Melissa, at the age of
17 years, embodies the sequelae of the dysfunctional behaviours that
permeated her family life and gave rise to her experience of abuse. The
consequences of her early life traumas include low self-esteem, repeated
sexual abuse, unintended pregnancies and abortions and cohabitation
with a much older man who further exploits her sexually. These expe-
riences of violence began early in Melissa’s childhood, and the multi-
plicity of harms she was exposed to then increase the likelihood of her
being vulnerable to becoming the victim of different forms of abuse
now. The research evidence supports this view, showing that children
coming from dysfunctional family backgrounds are more likely to expe-
rience maltreatment of many kinds (Denholm et al. 2013). Denholm
and colleagues assessed the prevalence of child maltreatments and their
co-occurrence and associations with household dysfunction in a large
population from the 1958 British birth cohort, followed over the course
of four decades. Assessed were childhood abuse, neglect and house-
hold dysfunction recorded at 45 years and during childhood. Reported
findings support evidence from previous studies of child maltreatment
(Cohen et al. 2002; Durrant et al. 2009; Slack et al. 2004) associating
maltreatment with family dysfunction. Domestic violence, a common
phenomenon within many families, is identified as one of the charac-
teristics of family dysfunction. For children, this can lead to two risky
outcomes that are pertinent to our discussion: (a) abuse of the child as
well as of the adult and (b) child psychopathology (McCloskey et al.
1995). Family dysfunction is also associated with physical punishment
and abuse (Cohen et al. 2002; Gaudin et al. 1996; Slack et al. 2004)
and with neglect (Stith et al. 2009). It is important to note that, in
the Caribbean, physical punishment of children, despite evidence of the
harm caused, is widely sanctioned and in most cases would not be con-
sidered evidence of family dysfunction at all. This raises important ques-
tions about universalism vis-à-vis relativism in the cultural assumptions
embedded in the use of terms such as ‘family dysfunction’.
Furthermore, when we speak of family dysfunction, we need to

remind readers that such negative labels, though they can help us to
identify and categorise factors contributing to violence in the family
(which explains our use of the term), also pathologise families. This is
because the term does not allow for consideration of external factors that
reinforce destructive dynamics and family behaviours or, for that mat-
ter, the internal stressors that can determine different norms concerning
what is functional. Consider, for example, a parent who suffers from
schizophrenia and whose children are so accustomed to living with the
voices their father or mother hear that they find ways to accommodate
them (such as encouraging daddy or mummy to take more notice of the
voice that seems most beneficial to the family). To the observer, who
witnesses a family negotiating with non-existent voices and behaving
accordingly, it could be reasonable to conclude dysfunctionality, but the
family is simply adjusting behaviours to accommodate the parent’s men-
tal illness; they have created their own functional norm—What could
be more functional than this? Another example is Sadia (not her real
name), who is the client of a medical social worker and the mother of
four children aged 15, 8, 7 and a 6-week-old baby. The two middle
children both have severe learning disabilities and behaviour problems.
Sadia’s husband worked away from home on an off-shore oil rig off the
coast of Trinidad. She was receiving support because of severe post-
natal depression following the birth of her latest child. On visiting the
home, the social worker finds a scene that looks like chaos. Much of
the furniture had been damaged because of the extreme behaviour of
the children, the kitchen where Sadia was sitting breastfeeding her baby
was strewn about with overturned pots and the detritus from recent
meals. The eldest child was at school and the younger two were tied into
kitchen chairs; one child was rocking and sucking his thumb and the
other was screaming and trying to tear at his skin. It is a terrible thing
to restrain children as if they were animals, a breach of their human
rights and a potential cause of significant psychological harm. Perhaps it
would not be unreasonable to describe the family as dysfunctional given
the scene we have described. But this is not a dysfunctional family—the
parent is responding to dysfunctional circumstances. Although her
actions are not in the best interests of her disabled children, she has
attempted to create a semblance of order out of the disorder of the
moment in the only way she believes is available to her, so that she can
meet the needs of the child who is most vulnerable. Given the appropri-
ate support and interventions, this family would probably function well.
These examples tell us that the term ‘dysfunctional family’ should be
clearly defined and used in very specific circumstances. In this book, we
use ‘dysfunctional family’ to refer to those families in which wilful and
persistent destructive parental behaviours are displayed and which have
a harmful impact on children’s lives or where there are chronic problems
that have an adverse effect on children’s emotional, developmental and
physical well-being and safety. It is important to recognise that nega-
tive parenting can be exacerbated by situational factors (such as poverty,
unemployment or bad housing) which may lie outside of the control
of parents and also that the effects of dysfunction can be minimised
through support and targeted interventions. Also, most families experi-
ence periods of stressful situations and crises (e.g., unexpected violence,
death in the family or a serious illness) which can impair functioning;
this happens in all families. Healthy functioning families, unlike fami-
lies where there are harmful dysfunctional behaviours, tend to return to
their normal and healthier state of working after crises.
The research evidence shows that there is a clear relationship between
child maltreatment (in all its forms) and family dysfunction. Therefore,
clinical intervention into one and not the other may be insufficient to bring
about meaningful change across the life span or from one generation to the
next. Some forms of dysfunctional behaviour can prevent or undermine
constructive engagement with the family and therefore the practitioner
must determine what strategies will be most effective in the given circum-
stances and the resources available. Therefore, a key focus for assessment
must be to identify the particular ways in which a family may be consid-
ered to be dysfunctional and how dysfunctional behaviours may overlap
to create layers of abuse or could undermine positive change. When one
considers the gendered nature of familial and societal violence, there is also
a need to explore patterns of co-occurring forms of abuse since these help
to illuminate the ways in which dysfunctional behaviours are maintained.
The intersection of gender with patriarchal domination (Trotman Jemmott

and Maharaj 2013) evidenced in Melissa’s life story is an illustration of
this: father physically abusing mother; son (Melissa’s brother) physically
abusing mother; father physically abusing Melissa; and brother sexually
abusing Melissa. These layers of violence are likely to have been accompa-
nied by communication patterns and gendered family roles which enforced
silence and demanded the acquiescence not only of Melissa but of other
family members too. Melissa’s father’s position of dominance and a family
dynamic which seems to switch between stultifying silence and open aggres-
sion would have closed down healthy communication channels. These are
most likely to have been closed down along gender lines—that is, between
the five males (father and sons) and two females (Melissa and her mother)
in the household—and this will have made it difficult for the non-abusing
sons to assert alternative, non-oppressive versions of masculine identity, for
the mother to function in a protective capacity, or for Melissa to feel that
she had any rights as a female to speak out about her abuse.
Recognition of the role of gender oppression within the communication
patterns of families that are violent or dysfunctional is a key for determining
the type of intervention that is appropriate. Project R.I.S.E., from which
the psychotherapeutic practice we discuss later is derived, was designed to
empower the girls to speak out and to assert their right as young women to
a life free from gender-based violence. For victims of abuse who have been
constrained by the dynamics of silence (Jones et al. 2014), the value of inter-
ventions which enable them to voice their experiences in an atmosphere of
acceptance and support cannot be overestimated; at the individual level, this
can literally be quite transformative. It is equally important, though, not
to underestimate the power of entrenched communication patterns which
silence victims, and often the transformative power of therapeutic disclosure
can only be achieved by an approach which takes someone out of the fam-
ily setting. This was part of the rationale for offering Melissa a group-based
service rather than a family-based intervention.
It must be stressed that even in dysfunctional families, there are likely to
be strengths that can be used to support change. The ecomap of Melissa’s
home circumstances highlight some of these. It should also be remem-
bered that in most families in which abuse occurs there will be non-abus-
ing adults (usually mothers) and ‘healthy’ family members who may have
an important role to play in supporting therapy. Non-abusing mothers

may themselves have been silenced by psychological domination or physi-
cal violence or (as in the case of Melissa’s mother) both, and interventions
that empower mothers to recognise and assert their protective capacities
can be a very effective way of sustaining positive outcomes of treatment.
Abortion as a Consequence of Rape:

Implications for Practice
Identifying the outcomes of unwanted pregnancy and abortion for physi-
cal and mental health is an important focus for professional assessment,
especially as there are likely to be psychological implications. This is a useful
point at which to remind the reader that assessment is not a one-off event
but a process that may need to be revisited again and again, depending
upon the purpose of professional involvement and in recognition of the
fact that in any counselling situation, circumstances are constantly chang-
ing and information is often disclosed over time. A young person who
has undergone an abortion may not recognise any negative effects or be
able to talk about them at the point of the initial assessment; she might
not face this until her later years, or she may never experience any adverse
effects at all. Bradshaw and Slade (2003) reviewed the post-1990 litera-
ture concerning psychological experiences following induced abortion and
stated that although there were still some methodological weaknesses in
the research, anxiety symptoms were the most common adverse response
recorded and concluded that abortion should be recognised as a source of
potential trauma. The American Psychological Association’s (2008) scru-
tiny of much of the earlier research reminds us of the different but comple-
mentary conceptual typologies that should be considered in assessing the
psychological effects of abortion. These frameworks include the following
psychological theories:
• The stress and coping perspective: abortion is situated as a stressful life

event, reflecting individual differences in how women react to and
cope with an unintended or unwanted pregnancy and abortion; locat-
ing ‘such reactions in women’s appraisals and coping processes and the
personal and social factors that shape those, rather than in the nature
of the event itself ’ (17).
• Abortion as traumatic: the belief that termination leads to feelings of
guilt, grief, remorse, loss and depression (13). As a consequence, there
may be increased likelihood of mental health problems.
• The sociocultural perspective: this centres on the psychological effects
of abortion which are influenced by and intersect with the immediate
and wider sociocultural environment in which abortions occur. For
example, attitudes and behaviours which lead to stigmatisation can in
turn lead to cognitive and behavioural difficulties such as social with-
drawal and feelings of marginalisation. ‘Women who come to inter-
nalise stigma associated with abortion (e.g., who see themselves as
tainted, flawed or morally deficient) are likely to be particularly vul-
nerable to later psychological distress’ (14).
• The co-occurring risk perspective: these are correlated conditions
linked to unintended pregnancies and abortions and which can both
precede and follow abortion. Abortion can be the result of sexual vio-
lence and can be correlated with adverse childhood experiences such as
poverty, emotional problems and lifestyle activities such as drug
taking.
(American Psychological Association 2008).
We return to this later, but firstly let us consider the wider legal and
social environment in which induced abortion occurs; this is essential
knowledge for practitioners as it may help to determine the extent to
which a girl or woman who seeks an abortion may be stigmatised and
may or may not be able to access formal help and support. Abortion in
Latin America and the Caribbean is subject to a wide and disparate set
of laws ranging from ‘complete prohibition’ or ‘legal exception to save
a mother’s life’ (e.g., in Chile and the Dominican Republic) to ‘with-
out restriction as to reason’ (e.g., in Cuba and Guyana) (Guttmacher
Institute 2012, 1). Melissa’s two abortions were probably carried out in
an island which permits abortion for the preservation of the mother’s
health (since these are the most common legislative parameters for abor-
tion in the Caribbean); however, risk to health is usually interpreted as
risk to physical health and as there is no indication that Melissa’s physical
health was at risk, she is unlikely to have been able to access an abortion
legally. Therefore, the termination of her pregnancies will probably have
been illegal and carried out in unsafe conditions. As a sexual crime had
been committed (which is determined by her age irrespective of any
other factor), the abortions will have been kept secret and this means
that Melissa will not have been able to access any pre- or post-abortion
counselling sessions that may be available to other women. Unable to
talk about her abortions and unable to get help to deal with their psy-
chological implications is an example of the enforced silencing of CSA
victims. In this instance, though, Melissa’s silence is enforced not only
by the family to safeguard its secrets but directly as a consequence of
the structural systems that deny abortion services in circumstances such
as hers. Where abortion occurs because of a sex crime against a child
and where this information becomes known to the authorities, the lack
of clear interagency operational protocols which would enable health,
social services and criminal justice agencies to work collaboratively to
support the child and take necessary action against the perpetrator of
abuse can result in the enforcement of silence becoming embedded
within organisational culture. In this respect, the institutional response
mirrors the dysfunctional communication patterns in Melissa’s family.
At the individual level, this meant a lost opportunity to uncover the
abuse she had been subjected to. At a macro level, however, the failings
of agencies to address complex abuse situations which lead to teenage
pregnancy and induced abortion represent a serious breach of a govern-
ment’s reproductive health and child protection responsibilities. There
are many young women in Latin America and the Caribbean who face
unsafe and illegal abortion practices, with tremendous health conse-
quences, including death. Melissa was 16 years old when she had her
second abortion and although there are no statistics on abortion rates
among children younger than 15 years in the Caribbean, findings from
the USA showed that, in 2012, 26 % of pregnancies were terminated
through abortion and of those performed on adolescents, the abortion
rate among children younger than 15 years was proportionately twice
as high than for older teens (Child Trends Data Bank 2014). A global
overview of abortion shows that between 1995 and 2003 the overall
abortion rate (number of abortions per 1000 women aged between
15 and 44) fell from 35 to 29, remaining steady at 28 in 2008. In

Latin America and the Caribbean, figures for 2008 were higher, varying
from 29 per 1000 in Central America, 32 per 1000 in South America
and 39 per 1000 in the Caribbean (Guttmacher Institute 2012). The
World Health Organization (2011) estimates that in the same year
(2008), maternal death from unsafe abortion in Latin America and the
Caribbean was 12 % (1100) of the total number of abortions carried
out and that about one million women in the region are hospitalised
annually for treatment of life-threatening complications from unsafe
abortions, such as incomplete abortion, excessive blood loss and infec-
tion. Other very serious complications from unsafe abortion practices
include septic shock, perforation of internal organs and inflammation
of the peritoneum. That Melissa experienced two abortions 15 months
apart while she was so young and physically underdeveloped signals the
possibility of impaired reproductive ability in later life. In the absence of
effective reproductive health and child protection services for children
who are victims of rape, it is possible for abortion to become a de facto
method of birth control as seems to have happened with Melissa. She
may have been coerced or forced or may have felt that she had no other
option than to have an abortion. In any event, there would have been
significant risk to her health and life had she chosen to continue her
pregnancies; abortion simply replaced these risks with potential long-
term psychological and reproductive health problems.
As well as teenage pregnancy and abortion, other health issues that may
arise as a consequence of rape include sexually transmitted infections and
HIV. These were not factors that emerged in Melissa’s case and we do not
discuss them further; however, the practitioner should be mindful that health
fears, especially concerning AIDS, may feature very highly as a source of anxi-
ety for children who are sexually abused. Unsafe abortion practice is a public
health concern with such alarming consequences that one would expect it
to catapult governments into preventative, protective, remedial and research
action; that it has not, at least in the Caribbean region, may be explained
in part by the institutional embeddedness of enforced silence and the influ-
ence of religion and patriarchal systems of control (Trotman Jemmott and
Maharaj 2013). Social workers, psychotherapists and psychologists need to
be aware of this problem and draw on their experiences of working with girls
like Melissa to contribute to the public policy debate on abortion law reform.
This is clearly needed given that the highly restrictive legislation on abortion
in the region has not been synonymous with lowered rates of abortion.
Concluding this Section

With respect to the psychological effects of abortion identified by the
American Psychological Association (2008) that we referred to earlier, sev-
eral aspects of the theoretical explanations suggested resonate with Melissa’s
life story: the stress and coping perspective; abortion as traumatic; the
sociocultural perspective and the co-occurring risk perspective. Melissa’s
subjugation as a female, experienced directly through her own sexual abuse
and vicariously through her mother’s physical abuse, is likely to have been
played out in the decision to have an abortion. The overriding concern in
the family will not have been Melissa’s health and well-being but the need
to mask the dysfunctional behaviours in the home and protect the abuser.
Melissa is likely to have assessed this reaction to her situation through a
cognitive process which itself was informed and moulded by dysfunctional
family practices and which would lead her to understand that she could
rely only on herself and that she should expect little help from the child
protection and judicial systems. One can therefore theorise that:
A child’s experience of progressive loss and enforced silencing as a conse-

quence of sexual abuse (through violence and dysfunctional inter-personal
relationships) will be twinned with the learned expectation of receiving
little or no help.
Melissa’s life is punctuated by a series of losses which started when

she was still in primary school. The first obvious loss was when the
sexual molestation started: the loss of her trust in and expectation of
brotherly care and protection and the loss of a voice with which to
protest. There are also losses relating to the family’s relocation to the
Caribbean; Melissa may have lost friends and support networks that
were a significant aspect of her resilience and functioning within an
abusive environment. Furthermore, the parenting style of her father
and the challenges faced by her mother in providing her with protec-
tion in a household in which there was domestic violence are both
factors which are likely to have led to a range of losses and difficulties
in achieving developmental milestones, even before the age of nine.
When we meet Melissa at the age of 17 years, she expresses a desper-
ate need to become pregnant again but also presents with indictors of
depression, a common response to sexual abuse and domestic violence
(McCloskey et al. 1995). Untreated, her depressive state is likely to
affect her personal relationships and may jeopardise the formation of
positive attachments with any children she may have in the future
(Wan and Green 2009; Cassidy and Zoccolillo 1996). Earlier research
with mothers who were depressed found that their parenting style was
likely to be more controlling and less responsive to their children’s
needs (Cox et al. 1987; Cohn et al. 1990; Field et al. 1990) and characterised
by a punitive approach to mothering (Robbins Broth et al. 2004). The
children of depressed and anxious mothers have also been found to be
at higher risk of psychopathology—depression, anxiety, behavioural
and emotional problems (Murray and Sinclair 1999)—and chronic
or recurrent maternal depression is particularly related to later effects
on the child (Grace, Evindar and Stewart 2003). Early mother-child
attachment patterns are likely to be affected under these circumstances.
Using attachment theory to explore this further, studies of adults with
psychopathology show patterns of high rates of non-secure adult
attachment states of mind towards their family of origin (Riggs et al.
2007). The evidence suggests that state of mind can influence caregiv-
ing sensitivity and, by extension, attachment bonds. Wan and Green
(2009, 123) conclude from their review of the impact of maternal
psychopathology on child-mother attachment that ‘an effect therefore
of maternal psychopathology on attachment provides a mechanism by
which children are made developmentally vulnerable’ (attachment is
discussed in more detail later).
Viewed through an intergenerational prism, the cyclical and harmful
nature of this interactional process expands our theoretical position fur-
ther and leads us to speculate that:
A child’s experience of progressive loss and enforced silencing as conse-

quences of sexual abuse (through violence and dysfunctional inter-personal
relationships) will be twinned with the learnt expectation of receiving little
or no help and can contribute to an intergenerational cycle of family dys-
function which can be transmitted from mother to child, through routes
such as insecure attachment.
In summary, our discussion has briefly touched upon family dysfunc-

tion, co-occurring abuse, gender and patriarchy, the disempowerment
and silencing of victims of CSA, poorly developed inter-professional
practice and services and the implications of abortion, structural inequal-
ities and loss and attachment. There are many other issues that Melissa’s
story raises but we identify these as particularly pertinent for establishing
the context for professional practice with adolescent girls who have been
sexually abused.
Psychological Assessment
Melissa has experienced multiple traumatic events; she was sexually
abused from the age of nine and has been raped at least twice. She frames
her relationship with her current partner as a consensual sexual one,
although as we will see later in this section, Melissa’s capacity for emo-
tional regulation and rational thought processing may be impaired by
her traumatic experiences—sexual and otherwise. She has witnessed the
physical abuse of her mother by her father, faced physical abuse herself
(for telling about her rape), lost a court case (which she brought up
for her rapes), has been continually blamed for the family’s disruption/
dysfunction, faces the complicity of her mother in her abuse, has had
two abortions during adolescence and is in a disadvantageous relation-
ship with a man 28 years her senior in which sex is traded for her board.
Melissa is only 17 years old.
For most of us, trying to assess and process Melissa’s experiences and
contextualise them in order to deliver on assessment and treatment will
be trying—this includes psychologists who may be involved in Melissa’s

treatment. This is necessarily so. Although psychologists bring particular
psychological tools that can assist Melissa, we must acknowledge our own
limitations that may hinder the progress of Melissa’s treatment. Reflective
practice, along with supervision and inter-professional support, can
help the professional to be better supported to enable an action plan
for Melissa. Complex trauma exposure best encapsulates Melissa’s experi-
ences to date. Kisiel et al. (2014, 1) state:
Youth exposed to both inter-personal violence and attachment-based

(“non-violent”) traumas within the caregiving system had significantly
higher levels of affective/physiological, attentional/behavioral and self/
relational dysregulation in addition to posttraumatic stress symptoms
compared to youth with either type of trauma alone or in relation to other
trauma experiences. These complexly traumatized children exhibited
higher levels of functional impairment.
Although it is difficult to delineate which of Melissa’s trauma expo-

sures were violent or non-violent (and their chronicity and severity), she
has clearly experienced both, regardless of where on the violence con-
tinuum her experiences fall. She has also experienced disrupted attach-
ment within her family system that is telling in her current intimate
relationship with her boyfriend. In sum, her complex trauma exposure
has left her psyche fractured. As Purcell (1996) suggests of traumatic
events, there is a loss of ego control as the integrity of the psyche dete-
riorates. The complex trauma that Melissa has experienced seems to
have taken the shape of a series of particularly traumatic events, each
compounding the other. In a situation like this, there have been many
external threats (e.g., that of being raped, of being physically abused)
and ensuing issues of helplessness and abandonment (Purcell 1996). For
instance, Mrs. John’s complicity in Melissa’s abuse has sequenced her to
perceive the threat of an impending traumatic event with being silenced
and abandoned. It is well researched that a supportive environment can
ameliorate the effects of CSA (Hornor 2010). Melissa has never had
such a supportive environment. Indeed, one psychological approach to
treatment may include bringing about change to Melissa’s environment
in an attempt to reduce the risk of re-victimisation (Lev-Wiesel 2008)

as Melissa transitions through adolescence into young adulthood. A
positive family environment can help facilitate the psychological mecha-
nisms of Melissa’s psychic re-organisation. Given that Melissa’s family of
origin can be described as unsupportive and perhaps debilitating in her
healing, a psychologist’s role here may be to deliver the tools that can
enable Melissa’s empowerment through another system, such as with
her intimate partner. For Melissa, we see that her current intimate rela-
tionship is grounded in unequal power relations and probable sexual re-
victimisation, along with inter-personal problems with her boyfriend’s
mother. Research suggests that CSA may be linked to emotional dysreg-
ulation and that this in turn may be linked to risky sexual behaviour or
sexual re-victimisation or both (Messman-Moore et al. 2010; van Roode
et al. 2009). Group psychological services can offer that first step in ‘the
corrective recapitulation of the primary family group’ (Yalom and Leszcz
2005, 15). Here, Melissa can learn about healthy family dynamics as
the group is akin to the primary family, where, for instance, the group
facilitator(s) may bear resemblance to parental figures.
Being sexually abused starting at age nine may have many implica-
tions. The sequelae of Melissa’s early sexual abuse are apparent through-
out her life. At the age of nine, what were the possible implications
at that point in time? Age nine is considered to be middle childhood.
During middle childhood, children undergo many changes—physical,
social, emotional, cognitive, moral, psycho-social and others. It is not
within the scope of this book to delve into each developmental para-
digm, and readers are encouraged to refer to other literature on devel-
opmental theory to determine which frameworks best fit. For instance,
around the end of middle childhood coincides with the onset of men-
arche, inter-personal relationships with peers and family and becoming
more cohesive and responsible and there is more logical and abstract
thinking than in early childhood (Cincotta 2002). ‘The concept of
the secret underscores the changes occurring in middle childhood’
(Cincotta 2002, 79). Melissa’s first secret was being sexually abused
by her brother. Age nine falls within what Piaget called the concrete-
operational period of development, during which acquired cognitive
abilities are applied to events children have experienced (Shaffer and
Kipp 2014). Melissa’s rape may have led to a fissure in her cognitive
development, essentially a break in the normative developmental mile-
stone of concrete-operational cognitive operations. Melissa’s cognition
remained at an earlier stage of preoperational thought where such com-
plex cognitive operations were yet to emerge. Perhaps too, Melissa’s per-
sonal identity formation during adolescence has been hindered by her
traumatic experiences and can be considered through a psycho-social
developmental framework. That would suggest that Melissa’s identity
versus role confusion (as espoused by Erikson) was not resolved suf-
ficiently and may have affected identity formation (Hook 2009). There
may be particular implications for her sexual identity, as her trauma
experiences included sexual abuse and abortions during adolescence. As
professionals, we run the risk of pathologising clients such as Melissa
whom we may stereotype as developmentally impaired in one way or
another. We must take care not to ascribe a particular theory of any
kind to a specific client without sufficient evidence. Age nine onwards,
Melissa’s cognitive processes like her decision making to engage in early
and risky sexual behaviours may be related to cognitive impairments
as her developmental trajectory deviated from the norm. However, her
decision to bring her case to court is exemplary of a young woman, resil-
ient and courageous—illustrating yet another facet of her personhood.
This situation of standing alone in court is also indicative of another
loss and another ‘abandonment’ which Melissa has faced throughout
her life. It reinforces disrupted early attachment within the family sys-
tem with her mother and father, further evidenced by an unhealthy
intimate relationship with her boyfriend. Herein is a crucible of com-
plexity. We must also be mindful of wider cultural factors, such as early
sexual debut in the Caribbean. Professionals such as psychologists and
others must begin to tease apart each intersecting factor while weighing
the criticalness of each to the traumatic and healing processes.
Bearing in mind possible breaks in Melissa’s cognitive development,
a psychologist can look to any number of frameworks to guide her
treatment. No single intervention may work, and it is up to the psy-
chologist and Melissa to help set realistic short- and long-term goals.
Melissa has never been clinically diagnosed with any psychopathology
and has never been assessed by a mental health professional. However,
at the time we meet Melissa, she presents with low self-worth, depres-
sive symptomatology and patterns of dissociation. All of these are con-
sistent with the evidence base of the consequences of complex trauma,
including CSA. What is crucial here is not to conceptualise Melissa as a
checklist of problems but to prioritise and, where possible, work simul-
taneously on several issues. For example, by using a person-centred
approach to therapy, both Melissa’s self-worth and depression could
be addressed and indeed her capability for awareness of her sense of
self/identity. Though quite dated, evidence from a study by Nash et al.
(1993) is included for its methodological robustness. Nash et al. (1993)
found that sexually abused participants had significantly more dissocia-
tive experiences than their non-abused counterparts. They suggest that
many have tried to attribute causality between CSA and dissociation.
If we look a bit deeper, however, their co-variance results suggest that
family pathology accounted for variance in dissociation and not CSA
alone. In Melissa’s case, this is particularly relevant since a dysfunctional
family system co-occurs with her CSA. Nash et al. (1993) posit:
In short, adult women who were sexually abused in childhood score higher
than their nonabused peers on a host of psychopathology measures.
Although many claims have been made, no delimited, replicable pattern of
sequelae to early sexual abuse has emerged. It is, of course, quite possible
that none exists and that abuse may have a nonspecific, deleterious effect
on adult psychological functioning (Nash et al. 1993, 276)
Therefore, the consequences of CSA are varied and may even shift
within an individual from day-to-day or over the life course or both
(Mullers and Dowling, 2008). For instance, the loss associated with her
two abortions may generate dissociative defences. These will have served
Melissa well—although the dissociative patterns may be pathological,
they are adaptive to her experiences. It is how she copes. Pregnancy loss
may contribute to peritraumatic dissociation and post-traumatic stress
disorder (PTSD) (Engelhard et al. 2003). We believe that current defini-
tions of PTSD are too narrowing to account for complex trauma such
as Melissa’s. Though taken as a constellation of symptoms, PTSD may
help the psychologist begin to tackle Melissa’s complex trauma within
a defined framework. Here, using an existing tool or framework and

extending beyond to suit the needs of the client take precedence over
simply fulfilling the criteria for a disorder that does not encapsulate well
the lived realities of CSA survivors in the Caribbean.
We must acknowledge too that Melissa’s state of readiness to engage in
psychological work is at a tentative stage, where she declines any help but
accepts that joining a group for sexually abused girls might be tolerable
for her. The value of group psychotherapy for Melissa can include, for
example, psycho-educational components like behavioural and reproduc-
tive concerns (e.g., safe sex), inter-personal relationships with family (e.g.,
brothers who raped her/did not rape her, mother’s silence, boyfriend’s
dominance), and her sense of self-worth (e.g., it is probable that she does
not believe she is worthy of healthy relationships and of her intrinsic
value as a human being). Being in the safe environment of her peers
(also sexually abused) with skilled group facilitators can help Melissa to
begin unravelling the depth of her traumatic experiences and understand
how her trauma/loss/abandonment/continued re-victimisation have
compounded to impact on her now. Group work can give affirmation
to Melissa’s trauma. For example, experiencing affirmation is possible
through therapeutic factors, including the instillation of hope (Melissa
exhibits hopelessness and helplessness), universality (her peers were also
sexually abused and some had abortions), imparting information (how to
practice safe sex), the importance of inter-personal relationships (creating
healthy family dynamics where possible) and the corrective emotional
experience (emotional regulation) (Yalom and Leszcz 2005).
Melissa’s involvement in group psychotherapy is discussed in detail
in the next section and at this juncture we address Melissa’s self-esteem.
As a part of measuring the impact of the group intervention, Melissa,
along with the other adolescent girls, completes a questionnaire from
the Culture Free Self-Esteem Inventories, Third Edition (CFSEI-3)—they
completed this before they started the intervention and repeated it at the
end of the programme. The CFSEI-3 model of self-esteem uses the con-
cept of global self-esteem—a general sense of self-feeling and self-respect
that both transcends and is sensitive to cultural nuance and is therefore
regarded as global in nature (Battle 2002). The CFSEI-3 is grouped into
three categories (Primary Form, Intermediate Form and Adolescent
Form) that conform to reading ability and developmental maturity. It

is a 67-item self-administered questionnaire, and the approximate time
of completion is 15 minutes. The Adolescent category (targeted towards
adolescents 13 through 17 years old) was used in this study to measure
self-esteem scores at pre-intervention (time 1) and post-intervention
(time 2). The CFSEI-3 measures self-esteem using five subscales which
relate to five dimensions of self-esteem and enables a global self-esteem
quotient to be derived from the summation of the total scores of the
five subscales. The five subscales are Academic, General, Parental/Home,
Social and Personal. All responses are dichotomous—being either ‘yes’ or
‘no’. The Academic self-esteem subscale consists of 10 items, including
‘Are you satisfied with your school work?’ and ‘Are you proud of your
school work?’—the Academic self-esteem subscale ‘measures self-esteem
in academic and intellectual situations and pursuits’ (Battle 2002, 4). The
General self-esteem subscale consists of 11 items, including ‘Are you happy
most of the time?’ and ‘Are you as strong and healthy as most people?’—
the General self-esteem subscale ‘measures an individual’s perceptions of
his or her emotional states, physical characteristics, successfulness, and
self-acceptance’ (Battle 2002, 4). The Parental/Home self-esteem consists
of 12 items, including ‘Do you trust your family?’ and ‘Do your par-
ents love you?’—the Parental/Home self-esteem subscale ‘measures self-
esteem within the family unit … the individual’s perception of his or
her abilities, attitudes, interests and values as they relate to the quality
of interactions within the home and family unit’ (Battle 2002, 4). The
Social self-esteem subscale consists of 12 items, including ‘Do you have
only a few friends?’ and ‘Is it difficult for you to express your views and
feelings?’—the Social self-esteem subscale ‘measures self-esteem in social
situations and interpersonal relationships with peers’ (Battle 2002, 4).
The Personal self-esteem subscale consists of 14 items, including, ‘Would
you change many things about yourself if you could?’ and ‘Do you feel
as though you are not good enough?’—the Personal self-esteem subscale
‘measures the individual’s most intimate perceptions of anxiety and self-
worth’ (Battle 2002, 4). The Global Self-Esteem Quotient (GSEQ) is an
indicator of overall self-esteem based on the total scores of the five sub-
scales. Below are graphical representations of Melissa’s self-esteem scores.
Fig. 2.5 Melissa’s pre- and post-intervention standard scores for self-esteem
subscales (Jones and Maharaj 2014)
80
70
60
Quotients
50
40
30
20
10
0
Time 1 Time 2
Global Self-Esteem
53 75
Quotient
Fig. 2.6 Melissa’s global self-esteem quotients at pre- and post-intervention

(Jones and Maharaj 2014)
Melissa’s scores indicate that her self-esteem increased in all domains

following participation in the programme, particularly Social, Personal
and Parental/Home. Her Global Self-Esteem Quotient also increased,
from Very Low Self-Esteem to Low Self-Esteem. It is critical to note that
even marginal changes, using this measure, may be a sign of progress
and provide statistical evidence to confirm the clinical gains that Melissa
made during the psychotherapeutic intervention, which is discussed next.
Psychotherapy
In Advance of the Client
When working with individual clients who have been referred from
another professional or agency, a psychotherapist may or may not
read the forwarded case file in advance of her first meeting with the
client. Once the presenting issue is named (e.g., that the client is
suffering from depression, is self-harming, or is a victim of abuse), a
psychotherapist may choose not to read the notes, charts or diagno-
ses of previous professionals until she has had an opportunity to con-
duct her own independent assessment. One reason for this is to avoid
being prejudiced by previous professionals’ opinions. Another reason
is that more lively and pertinent information is certain to come out
of a developing relationship between client and therapist, than can
be captured in case notes or charts. Psychotherapists working in the
psychodynamic tradition are trained in clinical observation skills
which probe beneath a client’s reflexive responses and presentations,
to discover motivations and causes of issues which may lay hidden
from the conscious mind. Psychotherapy is entirely relational. This
means that in the passage of time, given the building of trust and
development of good rapport, a client may reveal feelings and events
to her therapist that she has not ever voiced before. This is not dif-
ferent from the medical profession, where a patient receives a diag-
nosis that he may not completely trust and then will seek a different
professional who he fully expects will conduct his own fresh set of
unbiased diagnostic procedures. The best case scenario is invariably
when a team of trusted professionals, each with a different set of
skills and perspectives, comes together in the best interest of a client
or group of clients. Each will hold to her own tools and processes
and will conduct her own enquiries in accordance with the protocols
of her own profession. But when this team meets to discuss a client’s
case and formulate a collective approach to treatment, this is truly to

say that the client is in the very best possible hands. Dr. Bessel Van
Der Kolk, for example, describes that the team of colleagues who
has worked with him since he established his Trauma Centre over
30 years ago ‘have a long tradition of discussing all our patients in
great depth at weekly treatment team meetings and carefully tracking
how well different forms of treatment work for particular individu-
als’ (Van Der Kolk 2014, 3).
In the R.I.S.E. programme (R.I.S.E. is a psychodynamic group
project developed by The Sweet Water Foundation, Grenada, www.
sweetwaterfoundation.ca), to which Melissa was referred by her medi-
cal doctor, a strict practice is also upheld of weekly team meetings,
in discussion of the progress of participants through the programme,
and of the ongoing applicability of the programme to suit the needs
of each participant.
R.I.S.E.
In the case of R.I.S.E., there was no need for prior ‘diagnosis’ of Melissa or any
participant, as this specific programme is a psychotherapeutic group exclu-
sively for adolescent girls who have experienced sexual violence (R.I.S.E. is
adaptable for other client groups). The R.I.S.E. programme is 16 weeks long.
It runs once weekly, 3 hours per session. Intakes are conducted for a maximum
of 12 participants, with eight being the optimum number. Two co-facilitators
attend each session. The acronym R.I.S.E. (respect, inspiration, self-esteem
and empowerment) highlights the overarching aims of the project:
• To promote respect (in recognition of the fact that CSA involves disre-
spect and disregard of human rights, specifically children’s rights, the
vulnerability of children and their relative lack of power, personal, physi-
cal and emotional boundaries, the right to freedom from sexual exploita-
tion and the emotional, psychological and physical consequences of
abuse. These dynamics of abuse erode self-respect which in turn can
impact capacity to respect the sexual boundaries of others).
• To inspire (this aspect of the programme recognises and builds on the

resilience of young people and aims to facilitate expression of talent,
skills and personal attributes (and the recognition of these in others) in
order to help young people see themselves as more than the victims of
sexual violence).
• To enhance self-esteem and re-establish a healthy self-image (being sex-
ually abused can destroy a person’s ability to value themselves. As chil-
dren blame themselves for their abuse and are often blamed by others,
these feelings are often internalised. Feelings of self-hate, worthless-
ness, that one deserved to be abused or that one’s value lies in being
able to provide sexual satisfaction for others become embedded in the
psyche. Victims often consider themselves to be dirty, amoral or ugly.
If the sexual abuse resulted in pleasurable sexual feelings or seemed to
meet an emotional need, the victim may believe that this is the only
way they can have these needs met. The association of sex with coer-
cion and power may manifest itself in the person’s inter-personal rela-
tions throughout the life span. The programme involves activities to
promote healthy, positive self-esteem).
• To empower (victims of abuse have no responsibility for protecting them-
selves against their abusers, and given the power dynamics of abuse, which
may involve subtle grooming processes, covert and overt psychological
manipulation and often force, it is exceedingly difficult for children to
prevent abuse from happening. It is also the case that CSA disempowers
children and young people in profound ways and this may increase their
vulnerability to being re-victimised, engaging in self-harming behaviour
or acting in ways that disempower other younger children. The pro-
gramme provides young people with tools and strategies for empower-
ment, especially in relation to sexuality and personal relationships).
Theoretical Framework
The project is underpinned by four constructs which are fundamental to

the therapeutic model. The first two of these are the child-centred and
the rights-based approach. Child-centredness (client-centredness) is the
‘soul of the methodology’ that is used in psychotherapy and this ethos
is woven into the warp and weft of the programme design. Rather than
being a traditional educational paradigm which is prescriptive and didac-
tic, the model does not involve the imposition of a fixed programme
but rather allows the client, in this instance the girls, to come with their
own issues. This is what is meant by child-centred in this context; this is
the therapeutic approach that is used. Given the disempowering effects
of sexual abuse, the model offers the opportunity for the growth of self-
empowerment from the outset.
Child-centredness follows the rights-based approach as opposed to the needs-

based approach which relies on the professional to determine what the com-
munity, group or individual needs and delivers an intervention that matches
the professional’s perspective. A rights-based approach is the one in which
the facilitators create the environment for growth and allows the child to say
from her perspective, this is what I feel I need, this is what I want now and
this is how I want to be helped. The facilitators need to be skilful, very fast on
their feet to take what emerges out of the group interaction and turn it into
something “meaty” that the girls can move forward with. The wishes and
concerns the girls raise become a learning point for all. The transfer of knowl-
edge is fuelled by the child. The child should be able to say, “I learned some-
thing today and it makes sense to me, it has come from me, this is my
learning, this is how it can help me” (Jones and Maharaj 2014, 7).
Each programme must be responsive to the needs of the particular

group whose needs it aims to meet. The facilitators must be intuitive and
highly tuned to verbal and non-verbal communication cues, be experi-
enced in counselling techniques, have in-depth knowledge of the causes
and consequences of CSA, be able to work with anger and conflict and
be excellent communicators and enablers. The facilitators use these skills
to encourage reflection and interaction, through the particular activity of
the moment, across the range of personalities, issues, strengths and needs
of the participants. It is through this dynamic that healing and growth
take place. The process of transformation is socially constructed out of
organic evolution of the group and the dynamic of the moment (Jones
and Maharaj 2014). These factors are considered to be non-negotiable;
they must be in place for the model to work. The programme is also
informed by key theoretical approaches:
• Positive psychology (focus on strengths rather than deficits)

• Psychodynamic theory
• Eco-psychology
• Healing circles
• Psychosomatic theory
• Resilience theory
The programme is designed to make use of indigenous resources and a

range of cultural forms of artistic and spiritual expression drawing from
influences from the Caribbean, Africa, First Nations Peoples and Asia.
These influences are evident in some of the activities that are undertaken.
These aspects of programme design are not in themselves fidelity factors
since they can be substituted or complemented by different approaches
depending upon the particular client group. However, the key message
is that although best practice models from other settings may be appro-
priate for transfer to the new setting, this cannot be assumed and each
programme should pay attention to its design to ensure it dovetails with
the particular sociocultural context of the client group. The programme
must make sense to the group participants; it must be relevant.
The R.I.S.E. programme also comprises psycho-educational modules
in which topics like sexual and reproductive health, navigating the court
system during rape trials and techniques for stress reduction are covered
along with art therapy, yoga therapy and creative strategies for preven-
tion. But for the most part, this hybrid intervention is not prescribed and
follows the standard psychodynamic psychotherapy tradition, in which
participants bring their own issues to the table, at their own pace and in
their own manner. Essentially, the programme presents a ‘meld between
structured presentations and open-ended exploration of feelings, private
thoughts, urges and fantasies. Sessions begin without a specific agenda,
and person are encouraged to put their thoughts and feelings into words.
The technique is to focus on the here and now (in the sense of what the
person is genuinely feeling and spontaneously thinking about) because
that is the road to deeper self-awareness’ (Summers and Barber 2012, 37).
R.I.S.E. takes referrals from the State and non-governmental organisa-
tion community and from independent professionals, who complete a
standard referral form. As R.I.S.E. is widely advertised, girls in distress
may refer themselves to the programme as well, without necessarily going

through a referral clinic. Similarly, friends and family members may make
word-of-mouth referrals. In all cases, R.I.S.E. conducts its own compre-
hensive intake process.
Clinical discovery in the case of Melissa and other participants in this
programme would focus on uncovering the core conflictual relation-
ship themes or the manifestations of sex abuse trauma that were causing
the most inter-personal disruption in the healthy functioning of each
girl’s life. Therapists would further focus on those themes that could be
addressed within group, given the time-limited scope of the programme.
Psychodynamic Group Psychotherapy

Summers and Barber (2012, 12) identify six features that are considered
essential in the delivery of group psychotherapy:
1. Use of exploratory, interpretive and supportive interventions as

appropriate.
2. Frequent sessions.
3. Emphasis on uncovering painful affects and understanding past pain-
ful experiences.
4. The goal is to facilitate emotional experience and increase
understanding.
5. Focus on the therapeutic relationship, including attention to transfer-
ence and counter-transference.
6. Use of a wide range of techniques, with variability in application by
different practitioners.
This is the framework into which Melissa was accepted. She had
manifested numerous trauma symptoms and maladaptive behaviours as
a result of the abuse she had suffered since age nine, and some of her
main debilitating issues included the following: (1) a potent hatred for
her father and, by extension, for most adult males; (2) a very present
and dangerous rage against her rapist, whom she frequently and openly
fantasised about murdering; (3) a tragic disappointment in her mother
for failing to protect her from harm, complicated by her overwhelming

desire for Mum’s love and attention; (4) a tendency to recover the sense
of powerlessness she felt as a victim of sexual assault, by using sex to gain
power over others; and (5) a tendency to recover her sense of powerful-
ness by victimising infant girl children.
Melissa’s Presenting Symptoms and our

Approaches to Treatment
Mango Tree Moments
Physical restlessness, hyper-activity and jittery movements expressed the

shock, disbelief and outrage that Melissa continued to feel in regard to
the physical and psychic pain she was made to endure over years. Melissa
did not sit in any one place for too long and was wont to get up and
walk around or to walk off altogether, depending on the level of threat
or discomfort she felt. Not only would Melissa walk away if one of the
other girls in group discussed experiences which brought up bad memo-
ries for her, but Melissa would walk off if she was in the middle of her
own sharing and suddenly felt out of her depth. She could not tolerate
contradictions or ambiguity; these elements seemed to shake the founda-
tions of her very fragile selfhood, where Melissa seemed to inhabit a shift-
ing and nebulous borderland. Melissa easily found herself plunged into
hopelessness and she walked about to discharge emotions that threatened
to overwhelm, to dissociate herself both from her inner feelings and from
the people in the room. She would aggressively fling her arms and body
around (masked as a tough-girl swagger or dance) and toss off sarcas-
tic comments, or she would get up and circle like a caged animal, then
choose a different seat and collapse dramatically into it, going completely
silent. Or Melissa might leave the room altogether for a while.
This uncontrollable tendency has disrupted Melissa’s classrooms, the
workplace during her last summer job, athletic teams she joined and any
structured environments in which Melissa might begin to feel hemmed
in. She once made the comment, to the great consternation of the rest
of the group, that the only thing which calmed her body down was sex.
During one session, there was a deep emotional exchange, following

which a lot of fear and anger arose in the room. One of the younger
participants disclosed her abuse, in which she believed several family
members were complicit. She described a world that many abuse vic-
tims perceive themselves to inhabit, where all ‘women were preoccupied
and men were potentially dangerous’ (Summers and Barber 2012, 9).
Strong emotions were triggered among everyone in the circle and as the
therapists worked to bring calm and to elucidate and process what was
happening in the room, Melissa found herself unable to endure her intra-
psychic conflicts and stormed out. She went into the yard, climbed a big
mango tree, and sat there for the duration of the session. Needless to
say, this proved entirely disruptive to the rest of the group, particularly
the girl who was left stranded in the middle of her disclosure. Every one
of them filed outside behind Melissa, gathered at the base of the mango
tree and began cajoling her to come down. Frankly, this very unexpected
and highly explosive therapeutic moment brought both facilitators to
their own distraction. Not for the first time did they wonder, on Melissa’s
behalf, what to do, what to do?
Taking from the Core Conflictual Relationship Theme (CCRT) method
(Luborsky and Crits-Christoph 1998), we followed the protocol of sup-
portive therapeutic technique (a second technique is described below) in
which Melissa was made to feel comfortable, safe and accepted, as a priority.
Truthfully, we (the facilitators) could see how desperately she was struggling
with a torrent of hurt, stirred up by the group process. While one therapist
eventually led the other participants back inside, into circle, in order to rescue
their own experience, the other stayed outside with Melissa to help her pro-
cess hers and to identify and bolster the strengths and competencies she had
that would allow her to climb down out of the mango tree, feeling accepted
and resourced. Once everyone was inside again, both therapists helped par-
ticipants to articulate the depth of emotion that had just rocked the room
and caused a rupture in our process. The second technique in CCRT involves
moving from Support through Expression (Luborsky and Crits Christoph
1998). We helped bring awareness to the extreme avoidance and dissociative
mechanisms that had first flooded Melissa and then washed the entire group.
We focused on new techniques for identifying dysfunctional relating patterns,
becoming courageous enough to sit through extremely uncomfortable or
distressing situations and articulating thoughts and feelings in those moments.

Ironically, as Melissa continued to take to the mango tree whenever she felt
the need to get away, she became the participant who most helped others
learn to stay the course during challenging moments and to replace Melissa’s
flight reflex with more grounded self-expressions of their own.
Melissa was not used to receiving focused, supportive, non-judgemental
attention in her life and particularly not from other females. Naturally, it
felt good. She needed more. She allowed her unconscious wish for depen-
dency on this profoundly supportive brand of nurturing to have reign,
and Melissa would pout, sulk and act in contrary, avoidant ways in an
effort to re-create the original scene of complete focused attention on her
needs. This provided a wonderful opportunity for the entire group of girls
to discuss among themselves how they planned to handle the inevitable
painful feelings that were sure to rise in the future, given the nature of the
work we had gathered to do. They were able to articulate the difficulties
they faced together and identify what behavioural patterns they wanted
to change. They helped Melissa understand that they were definitely there
for her but would not be following her up the mango tree anymore. They
encouraged her to learn, alongside them, to say what she was feeling.
As the weeks progressed, Melissa’s demeanour began to change. She
was less moody and her powerful startle-reflex was held more and more
in check. As calm came into her body, her verbal expression softened as
well and her original anger, though by all means still there, did not con-
tinue to lead her around by the neck, so to speak. As many different chal-
lenges arose as time went on, Melissa kept pace. Even as more disturbing
and contentious issues were brought by participants for exploration, they
examined their urges (including the most controversial and troubling
ones) without breaking down or fragmenting.
Following the mango tree example, they learned to imagine conse-
quence as a function or association of urge and to plan for compromise
and mitigation.
‘The first step in all therapeutic change is responsibility assumption. If
one feels in no way responsible for one’s predicament, then how can one
change it?’ (Yalom 2012, 114). Without the therapists announcing any
prescribed goals of psychotherapy, participants themselves defined their
intentions. Simply put, they wanted to become more aware of how they
felt subconsciously, how their feelings influenced their thoughts and vice
versa, and how behavioural patterns which had become embedded as a neg-
ative consequence of rape trauma risked becoming the driver of their social
interactions. They determined to explore more empowered, positive ways
of being in the world, even under the stress of powerfully painful feelings.
It would be remiss of us not to mention the healing grace of humour
during very difficult sessions such as these. Several times towards the end
of the programme, we witnessed Melissa hang on to herself, stay in one
place, and mutter ‘I’m going back on that mango tree any minute now’.
She never fled the room again but the metaphor took root. When other
girls encountered strong resistance to issues arising, it became natural to
signal the need for safe, silent, supportive space by saying ‘Hold on. I’m
having a mango tree moment here’.
Regarding other means of soothing the somatic manifestations
of trauma described in Melissa’s case, psychotherapy has a built-in
approach to assisting the release of pent-up emotions. It begins with
the simple choice of location for group; yes, in this endeavour too, one
key success indicator is location, location, location. Sessions need to
be held in a dedicated space, which is private, safe and protected and
will not change in character from one week to the next. The environ-
ment must be welcoming of participants who unambiguously receive
non-judgemental and compassionate acceptance, so that they can in
fact fling themselves, flounce, collapse or climb, without repercussion.
Furnishings must also be conducive to cosy relaxation, much in the
same way that a yoga studio is left empty and clean for floor exercises
or a bank manager’s office provides hard upright chairs and desks for
attention to accounts. Optimally, the space should be well lit and well
ventilated and have access to nature or a garden. Above all, it should
be welcoming, safe and consistent.
The R.I.S.E. programme provides yoga therapy at various points dur-
ing the 16-week curriculum. Mindfulness-based yoga, performed without
reference to thoughts, feelings, traumatic events or the subject matter
of the group programme, encourages a targeted release of anxiety and
traumatic stress and teaches stress-preventive methods, including breath
work (Brown and Gerbarg 2005; Novotney 2009). Incorporating physi-
cal work into the business of talk therapy provides a holistic treatment
for stress reduction in child victims of sexual abuse that has been assessed
as extremely effective.
Dressing the Part
Self-hatred coupled with a fear of rejection is common to sex abuse vic-

tims. Memories of the abuse bring up images of a submissive, weak self,
unable to prevent bad things from happening. Particularly if the abuse
was chronic, happening over and again during a protracted period of
time, deep self-loathing can set in, with the victim scarcely able to stand
her own self. Certain that other people who know her story must see her
in the same light, self-loathing often comes with a gambit to reject oth-
ers first before being rejected by them, while in fact desperately needing
reassurance and intimacy.
Melissa’s manner of dress reflected her fear that she might ever be
disregarded as ugly, tainted and used, that she would appear to have
no value. From the top of her head to the soles of her feet, Melissa
was meticulous with her grooming and wardrobe. Each week brought
a new hairdo, including an assortment of weaves and extensions, and
elaborately painted nails. She was rail-thin (pointing to an eating dis-
order which we later identified and which signalled her need for strict
control over whatever physicality remained within her own purview),
and she often exposed much of her midriff and legs. Each check-in
(which is a round of sharing conducted at the start of each session)
would find Melissa bringing attention to her fashion choices of the
week and soliciting comments and approval from the others. This
approval was readily given. Melissa stood nearly six feet tall in her
heels, was a poser, and wore a mask of extreme, flirty, self-confidence.
However, the R.I.S.E. programme comprised a group of girls all dis-
playing the same needs and traits in varying degrees. With one of our
primary goals being to bring awareness to emotions, thoughts and
behaviours transpiring in each present moment, participants soon
recognised themselves in Melissa’s mirror and began to call her out
on hogging attention. This is one of the reasons for which Melissa
would pout and stomp off, leaving scornful comments in her wake.
She craved visibility above all. She longed to be seen, to be respected,

to be popular and she worked overtime to illicit admiration from her
peers in group. To be seen, respected and popular would of course
mean that she would no longer be counted as without value, and
available for raping.
We learned that outside of group, Melissa competed fiercely with other
females in every realm that she could and particularly in regard to her com-
portment. She acted rude and dismissive, coarse and hostile and did all she
could to provoke other females to tears—proof of their inferiority to her.
On the other side of the coin, Melissa flirted openly with men, giving off a
vibe of being able to conquer them all if she so willed it. She earned the title
of Diva, when in fact nothing could be further from the way Melissa felt
about herself inside. Psychotraumatologists speak of a ‘trauma membrane’
as a defense mechanism used to create a spiritual or psychic shield between
a severely traumatised individual and the world outside or even between
the intrapsychic parts of the one self. The trauma membrane is a ‘temporary
psychosocial structure, a buffer zone or covering that protects traumatized
people as part of the healing process in the aftermath of catastrophic stress’
(Martz and Lindy 2010, 27). It is a ‘thin protective layer forming over
psychic wounds. The dual purpose of this membrane is to facilitate psychic
healing by keeping curative membranes in and toxic, contaminating or
aggravating materials out, but because the membrane is fragile, especially
in the initial stages, it can be ruptured quite easily’ (254). It also performs
an inter-personal function, shielding the victim from the rest of the world,
including preventing the therapist from stepping too far inside her inner
psychic sanctum. In the case of Melissa, she presented her gilded mask, her
made-up exterior, as a filter through which she hoped to witness eyes of
adoration turn towards her, while containing what she perceived as her ugly
worthlessness inside. Her make-up membrane became her addiction, with-
out which she felt unsure of her identity until she had painted it on. She
became victim to it, increasingly unable to tolerate her naked, unadorned
self where she could see only a tortured soul reflected back.
This issue threatened Melissa’s actual sanity, as insignificant as the issue may
sound. ‘Traumas may be acute, externally evident, obviously overwhelming
and destructive, or they may be subtle’ (Summers and Barber 2012, 31).
Not only was she rendered unable to leave her home each day without a
mask on, but she began to act out a puzzling personification of the colour
schemes she selected from week to week. Seductive when wearing red,
vigorous in yellow, sombre and destructive in black.
The effect of the contemporary fashion industry on the mental health
of adolescent girls has taken up much time on the feminist agenda in
recent decades. The effect of the fashion industry on girls with eating
disorders has similarly driven the medical field berserk. All the more so
for psychotherapists, witnessing victims of rape trauma with very poorly
defined ego-boundaries give themselves entirely to the makeover, trust-
ing that it will provide that spiritual, emotional and lifestyle makeover
as well. Nevertheless, this issue of Melissa’s trauma membrane construc-
tion and subsequent deconstruction was successfully handled within the
group process. It began and ended with consistent, compassionate and
non-invasive articulation of the dynamics playing out in the room. ‘It’s
the relationship that heals, the relationship that heals, the relationship
that heals—my professional rosary. I say that often to students. And
say other things as well, about the way to relate to a patient—positive
unconditional regard, nonjudgmental acceptance, authentic engage-
ment, empathic understanding’ (Yalom 2012, 112).
We saw Melissa without full regalia only three times in 16 weeks.
The first two times represented occasions where, for whatever reason,
she was unable to access her paint and her wardrobe, and she came
to group ‘naked’, as it were. Those days began with her slouched over
in the darkest corner she could find, face turned away, eyes unable
to meet ours, voice unable to speak. Other participants would begin
by cajoling, cat-calling and teasing her. But, guided to attend to the
rules of engagement that they themselves had devised for group con-
duct during the orientation session, participants soon returned to a
model for non-judgemental acceptance, leaving Melissa to struggle
with her naked face on her own, while carrying on with group busi-
ness. Melissa was led to realise that nothing in the room or in the
world would change one iota, based on the presentation (or not) of
her mask. Even when she elected to hide in plain sight, the group
provided an environment which was consistently loving; which itself
wore paint, or not; which placed all of its attention on the process
of self-discovery, including self-love, and on building resources and

resiliencies from the inside out. We could virtually observe Melissa
begin to grow her skin, in a manner which no words can adequately
convey. The third time we saw Melissa without her paint on was when
she turned up to group, bare-faced, by choice, and challenged us to
not find her beautiful. It was a moment of subtle triumph for Melissa
and it wasn’t lost on the rest of us. Several streets away they would
have heard our cheer.
These two presenting issues of Melissa illustrate some of the intentions
that psychodynamic psychotherapy has for the emotional bolstering of
its clients, particularly in regard to those who suffer the traumas of sexual
violence. Group psychotherapy aims to help participants do the following:
• Develop increased self-awareness and insight into themselves, which

includes re-experiencing painful affects, thoughts, feelings and memo-
ries (feelings of loss, separation, fear, worry over the impact of angry
urges, loneliness, insecurity and shame are intensified by the expecta-
tion that experiencing these feelings will make things worse. Usually
the opposite is true).
• Develop an empathic close relationship with the therapist(s) and other
group members which is different from other relationships, past and
present, and which models potentials for all relationships, present and
future.
• Find new ways of perceiving old situations that allow them to try new
behaviours in response to them.
(Adapted from Summers and Barber 2012, 33–4).
Our evaluation of the R.I.S.E. programme (Jones and Maharaj 2014) iden-
tified the processes of implementation and the organic transformations of
the approach in empowering and giving voice to survivors of sexual abuse.
For example, in the role-play exercise on preparing for court in the event
that the abusers of these girls might be prosecuted, Melissa had her day.
Although she did not get justice from the criminal proceedings she had
initiated in real life, she was able, through re-enactment, to reflect on the
ways in which male power and status transfer from the bedroom to the
courtroom. She realised she could not have done better; the odds were
stacked against her long before the matter was heard before a judge.
Recalcitrance on the part of social services to follow through, combined
with the inefficiencies of the criminal justice system, conspired against her.
The passage of time meant that recall of the specifics of times and
place of her (Melissa’s) abuse were sketchy and she was easy fod-
der for cross-examination. She was also regarded with derision in
the courtroom because of her new sexual relationship with an older
man. Against this backdrop, her brother’s account carried more
credibility and he, not Melissa, was believed. Such miscarriage of
justice is easy to perpetuate against children and youths, an irony
which should not be lost on practitioners and therapists.
In group, Melissa saw all of this through the lens of theatre—most

importantly, the other girls saw it too and they believed her. One of
the recommendations from the evaluation study was that a group psy-
chotherapeutic programme such as this would be strengthened by a
simultaneous intervention with the girls’ families (those non-abusing
family members who are significant within the young person’s life).
The model recommended was the Family Group Conference (dis-
cussed in Parts 3 and 4), which is a culturally appropriate approach
for Caribbean contexts and enables the use of individual and family
strengths. Had this service been available to Mellissa, the practitio-
ners may have managed to bring the family together (her aunt, non-
abusing brothers and possibly her mother) to come up with a plan for
her future support. We imagine, for example, that Aunt Jenny would
agree for Melissa to go and live with her; that Melissa’s eldest brother
would offer to finance a vocational course for her; that Melissa would
agree to long-term counselling; that in the safety of this new envi-
ronment, Melissa’s mother may commit to trying to rebuild her rela-
tionship with her daughter and that Antonio would feel free to stay
in touch with his sister and support her in taking up her interest in
sports, where she clearly has some talents. This would be culturally
intelligent, strengths-based practice at its best.
Social Work and Attachment: Work

with Adolescent Mothers who have
experienced Childhood Trauma
We have established that Melissa has experienced complex trauma,
and by this we mean that she has experienced a range of different
forms of trauma from early childhood throughout her life as a result of
maltreatment, the secondary traumatisation of domestic violence and
multiple loss.
Child maltreatment, together with domestic violence and other
attachment-related trauma occurring within the family context, is con-
sidered ‘complex trauma’ because of its typically chronic nature and its
cumulative impact on psychological adjustment … Children raised in
a maltreating context are subjected to experiences that evoke intensely
negative affect, including fear and feelings of powerlessness (Bailey et al.
2007, 141).
These experiences generate insecure attachment strategies that involve
either minimising the expression of attachment (avoidant styles) or maxi-
mising such expression (anxious/enmeshed styles) (Bifulco et al. 2004).
They also lead to difficulties in the integration of memories and experi-
ences that influence perceptions of self and others. Bailey et al. (2007)
state:
A chronic exposure to maladaptive relationships involving abuse gives rise

to representations of others as self-serving and untrustworthy and to asso-
ciated feelings of relational ineffectiveness, distrust of others, and difficulty
maintaining relationships (Bailey et al. 2007, 141).
The harms Melissa has experienced are intersected, layered and accu-
mulative, and despite evidence of exceptional inner strength and resil-
ience, she is at risk of drawing on representations of untrustworthiness in
her interactions with any children she may have. Melissa has twice experi-
enced the early stages of pregnancy, which were terminated at an age and
within circumstances in which she is unlikely to have had any choice, and
she may be pregnant for a third time. Depending upon whether she can
confirm that the father is her boyfriend (and not her brother), she aims to
keep the baby, although her desire for motherhood seems motivated pri-
marily by a belief that this would prevent her abandonment. We cannot
be sure that Melissa would be anything other than a sensitive, responsive
and nurturing parent, but there is sufficient evidence from other studies
to show that mothers with a history of psychological trauma and liv-
ing in adverse social circumstances may be at risk of developing insecure
attachment styles with their children and of replicating pathogenic family
relationships (Bailey et al. 2007). Within the psychotherapeutic group
(Project R.I.S.E.) that Melissa was a part of, several of the young women,
all of whom were survivors of sexual abuse, were mothers. Pregnancy for
these young women was associated with trauma and fear of loss, alien-
ation and abandonment. In addition to the psychological impact on the
women, parenting behaviours observed within the group raise questions
about the impact on their attachment styles too. We turn our attention
to this issue next.
Experiencing secure emotional attachment early in life is widely
acknowledged as a key developmental process that regulates and influences
the child’s expectations of self and others. Internal lessons learned through
attachment-forming behaviours determine strategies for processing attach-
ment-related thoughts and feelings within inter-personal relationships
throughout the life course. There is an expansive literature about the ori-
gins and tenets of attachment theory (Bowlby 1973, 1980; Ainsworth et al.
1971; Goldberg et al. 2013) and here we are able to pay only cursory atten-
tion to this theory of emotional development that was first propounded over
half a century ago. Bowlby’s initial work provided the spawning ground for
generations of researchers who have sought to increase knowledge on the
formation and implications of infant-parent attachment, while Ainsworth
and others have argued the need for an appreciation of individual variation
in children’s psychological development:
Central to Ainsworth’s elaboration of Bowlby’s theory of attachment was

the proposition that a sensitive, responsive caregiver is critically important
to the development of a secure, as opposed to insecure, attachment bond
during the opening years of life. Such a person understands the child’s
individual attributes, accepts his or her behavioral proclivities, and is thus
capable of orchestrating harmonious interactions between self and infant,

especially those involving the soothing of distress (Belsky et al. 1995, 153).
Later scholars have expanded the ethnocentric limitations of early

research and provided critiques of the universalist assumptions based on
narrow population samples. This rich discursive meld provides the prac-
titioner with a range of theoretical orientations, and the approach we
adopt in our discussion is one informed by an ecological systems perspec-
tive. This requires that, in addition to emphasising the mother-infant
bond, broader questions be explored: questions such as the emotional
attachment of the infant to non-maternal caregivers (e.g., fathers), the
impact of environmental factors on attachment capacity (e.g., alcohol
and drug misuse; the effects of parental mental illness or impairment; and
the availability of emotional support to the caregiver), and the influence
on the parent-child relationship of early trauma and loss that the primary
caregiver may have experienced. It is this last question which we are con-
cerned with and our entry point is the recognition that attachment not
only is an attribute of the parent-child relationship but is a process which
has its roots in the attachment history of the parent and the internal
working model (Bowlby 1980) the parent draws from in relating to the
child which in turn is influenced by a range of external factors.
Thus, attachment is a life-span issue (Belsky et al. 2013) that involves
consideration of the psychological traumas and developmental processes
of the parent as well as the child and the support systems available. Bailey
et al. (2007) examined the associations between unresolved attachment,
abuse history, and a wide range of trauma-related symptomatology in an
at-risk sample of 62 adolescent mothers. They concluded:
Childhood physical abuse, sexual abuse, and general maltreatment were

associated with unresolved status [U/d]. Furthermore, sexual abuse history and
general maltreatment predicted unresolved loss, suggesting that they adversely
affected the integration of other emotional and/or traumatic experiences (139).
The significance of studies such as this is that unresolved/disorgan-

ised/disoriented attachment classification (U/d) is considered an indica-
tor of the degree to which traumatic experiences have been integrated
into cognitive processes and become part of the internal working model
that parents draw upon in parenting their own children. Egeland (2004)
argues that these inner working models are carried forward from infancy
throughout the life course and influence parenting in the next generation.
The intervention we discuss below does not include arrangements for
the assessment of attachment classification either before or after the pro-
gramme, because, as is explained, the clinical expertise and licences for
the administration of such tests are not always readily available. Although
testing is an important component of measuring effectiveness, this should
not be a determinant of whether services are provided. The reason we
raise the issue of classification is that assessment of attachment style has
long been a cornerstone of the evidence which signals insecure and dis-
organised infant attachment as a predictor of problematic behaviours in
children (van IJzendoorn et al. 1995) and shows that it also heightens
the risk of a range of psychopathologies for young mothers themselves,
including anxiety disorders and emotional distress (Bailey et al. 2007).
Secure attachment relationships involve caregiving that is sensi-
tive and attuned to the needs of the infant and a timely and empathic
response to affective and behavioural cues. This affirmation leads to
the child developing the expectation that his or her needs will be met,
and over time, with the appropriate parental responses, the capacity to
trust is developed and the foundation established for self-regulation and
relationship-building.
One of the earliest developmental tasks facing infants is to begin to regu-

late their own stress. Babies are born with little capacity to sooth them-
selves and are completely dependent upon adults to respond to and manage
their stress. Healthy adults respond to distressed babies by trying to comfort
them and they use techniques such as holding, stroking, rocking, singing
or walking up and down to calm them. The regular, sensitive provision of
such comfort, combined with a timely response to physical needs, teaches
babies how to deal effectively with physiological arousal without being
totally dependent on adults. These are also the caregiver characteristics
which promote secure attachment. Babies whose physical needs are dealt
with harshly or insensitively or whose distress is responded to with aggres-
sion or neglect are left in a state of high arousal and cannot learn how to
relax … Securely attached infants seem to have a lower reactivity to stress
compared to those with a disorganised attachment (Furnivall 2011, 16).
Although we have no information about her early childhood, it is

likely that when she was an infant, Melissa’s needs were responded to
with the aggression and neglect that characterised her parents’ responses
to her in later childhood. Like the other young women in the group,
she had little reason to trust anyone. These young women are likely to
draw on an internal working model which reflects the influence of child-
hood trauma on their own attachment security and which may lead to
maladaptive parent-child interaction patterns with their children. The
evidence is strong. Research on maternal behaviours shows distant, with-
drawn, intrusive or punitive parenting to be more common among moth-
ers who have experienced trauma or are living with depression (Murray
and Sinclair 1999), and as Belsky et al. (1995) state:
much theory and evidence suggest that a parent’s psychological health and
well-being are related to the quality of care that she or he provides… A thor-
ough review of evidence involving both normal samples and clinical ones and
pertaining to the relation between parental personality/psychological well-
being and infant-parent attachment security reveals, in the main, that psy-
chologically healthier parents are more likely to have infants who are securely
attached to them than are less psychologically healthy parents (164).
If we consider these findings within the context of systems theory, we

find that the maternal mental well-being and quality of parental care may
be mitigated when mothers and their children are nested within supportive
family relationships and are provided with appropriate professional help
when needed. It is important to note, however, that children or mothers
in a single-parent, female-headed household are not necessarily vulnerable
to psychological harm or social disadvantage. This is a particularly com-
mon family form in the Caribbean. For example, in 2004, it was estimated
that 34 % of households in Dominica and 48 % in Grenada were headed
by women, and figures for 2007 for St. Kitts and Nevis reported 45 %
of families as single-female-headed (UNICEF 2009). Since child develop-
ment and well-being in the region are at a good level overall compared with
international standards (Jones et al. 2014), this would suggest that many
single mothers have healthy adaptive skills and that their children have
secure attachments. Teenage mothers, however, experience greater exposure
than other single mothers to adverse social circumstances such as poverty

and a lack of educational attainment (teenage mothers in the Caribbean
are at high risk of exclusion or withdrawal from formal education), fac-
tors which are also associated with negative outcomes for their children.
Although we must not add to the pathologisation of single-parent teenage
mothers, it is the case that without adequate family and social supports,
their children may experience higher levels of disadvantage than others
and are more likely to have attachment difficulties than children of older
mothers (Lounds et al. 2005). Teenage mothers confront structural and
social inequalities at many levels, and isolating attachment as a determin-
ing factor in the problems their children may face is virtually impossible;
nevertheless, where there is a childhood history of abuse, as in Melissa’s
case, professionals may be doing teenage mothers a disservice unless attach-
ment issues are addressed. This is because the attachment relationship is a
key factor in resilience among vulnerable populations (Berlin et al. 2008).
It is clear, then, that even when little can be done to improve a young
mother’s social conditions, interventions that help her address the parent-
ing implications of her own childhood adversities may increase the chances
of positive outcomes for her children (Berlin et al. 2008; Ciccetti et al.
2006; Hoffman et al. 2006; Juffer et al. 2012). Melissa and the young
mothers in her group seem to have little access to support, and a social
work intervention that helps to improve parental attachment style within
a supportive environment may be one of the best means available to pre-
venting the intergenerational cycle of behaviours which contribute to poor
family functioning and of disrupting the transmission of insecure attach-
ment which poses psycho-social risks for their children. Below, we describe
a social work intervention for achieving this.
There are numerous examples of interventions that aim to facilitate
healthy child-parent attachment. See, for example, the Attachment
and Biobehavioral Catch-up Intervention (Dozier et al. 2005), the
Circle of Security Intervention (Marvin et al. 2002; Berlin et al. 2008)
and the Mellow Babies Intervention (Puckering et al. 2010; Quinlivan
et al. 2004; Chaffin et al. 2006). However, empirical evidence of their
sustained effectiveness is not always available. Furthermore, we are not
aware of any research involving such interventions with young moth-
ers in a Caribbean sociocultural context. There are parent training
programmes (Webster-Stratton et al. 2004; DeGarmo et al. 2004; Knerr

et al. 2013) which have been adapted for the Caribbean (Williams
et al. 2006). However, although these approaches may share common
principles, the goal of attachment-based interventions is directed spe-
cifically towards improving the attachment relationship rather than
improving parental management of children’s behaviour which is the
usual focus of parenting training.
Designing an attachment intervention that is for adolescent mothers who
have experienced CSA and that is relevant for the Caribbean requires consid-
eration of organisational, social, cultural and environmental factors (some of
which have already been discussed; see Jones et al. (2014) for more on this).
For example, there is a paucity of family support, midwifery and health visit-
ing services in most Caribbean countries. Furthermore, reproductive health
and abortion counselling may not always be easily accessed, and where pre-
natal programmes exist, it is doubtful that these would include strategies
to engage adolescents who have experienced complex trauma such as the
prior termination of pregnancy arising from rape. The region is impacted by
natural disasters, gender-based violence, drug-related crime and the vagaries
of global economic policies, all of which place heavy demands on public
expenditure. This means that resource-intensive programmes (e.g., home-
based interventions or those that require implementation by highly trained
specialists) are unlikely to be adopted or sustainable. Another important con-
sideration is the need to examine the effectiveness of interventions designed
to reduce the risk of insecure attachment and to produce evidence on what
approaches work best in the Caribbean. Although there are numerous tools
to measure family functioning on a wide range of dimensions (Pritchett et al.
2010), many organisations may not have the capacity, expertise or funding
for pre-test–post-test longitudinal assessments or the randomised control
trials necessary for robust research. We recommend partnering with higher
education institutions that may have the necessary expertise; however, we do
not consider that the absence of attachment assessment tools or evaluation
studies should hold up the delivery of much-needed services. There is also
much that can be learned from studies in other countries.
Juffer et al. (2012, 173) conducted a meta-analysis of research results
from 88 attachment interventions and concluded overall that short-
term cognitive/behavioural-focused interventions were most effective.
This was the case regardless of the absence or presence of multiple fam-
ily problems, family type or sample characteristics, suggesting that
these approaches may have wide applicability. Other research suggests
that short-term interventions may be appropriate with low-risk par-
ents who are highly motivated towards improving their interactions
with their children, but for families who present a high risk in terms of
functionality and child maltreatment, long-term interventions may be
necessary. We are mindful, however, that few agencies in the Caribbean
would have the resources to sustain long-term involvement with a fam-
ily. Unsurprisingly, interventions that focus on proximal parent-child
interactions are more effective in developing attachment security among
infants. In reviewing the literature and considering social and cultural
factors and the specific needs of our target group (adolescent mothers
who have experienced childhood trauma), we highlight 15 principles
for consideration in the design of an attachment intervention.
A Social Worker-Led Attachment Intervention

The intervention we describe is one specifically for adolescent mothers who
have experienced childhood trauma but with minor modification it would
be suitable for young fathers, for foster parents or caregivers or for parents of
children with attachment difficulties. We propose that this model be led by
a social worker; however, it could be delivered by other professionals with
the appropriate expertise and would be a good model to deliver in part-
nership with a maternal health professional. The model is one that draws
from three programmes that have been positively evaluated: the AMPLE
programme (Nicolson et al. 2013), the Mellow Mums project (Puckering
et al. 2010) and an intervention for pregnant teenagers (Feldman 2012).
The proposed model is a 12-session group intervention for four to
six pregnant teenagers. The target group is likely to be alienated from
other teenagers and their families and may experience feelings of shame.
A group-based intervention (two individual sessions are built in) is
suggested in order to provide a peer support system. The goals of the
intervention are borrowed from an intervention developed for pregnant
adolescents and described by Feldman (2012):
15 Principles Enhancing Attachment Behaviours of Adolescent

Mothers in the Caribbean
1. Short-term brief intervention

2. Relevant for sociocultural context (some projects we examined
involved observing parents in their caregiving role at home;
however, this is unlikely to be appropriate in many cases)
3. Uses cognitive-behavioural methods
4. Can be delivered without costly, time-consuming assessment
procedures
5. Can be delivered by a social worker, psychologist or psycho-
therapist (partnerships with health or education workers are
encouraged) and uses easily understood techniques that could
be cascaded through training to volunteers and lay persons
with basic counselling skills
6. Uses low-tech, easily accessed and easily reproducible
methods
7. Not intrusive or overly demanding of the participants
8. Available to young women in the pre-natal period (we regard
this as necessary to help soon-to-be mothers process adverse
experiences related to their pregnant status, such as sexual vio-
lence, previous miscarriage or abortion)
9. Should include components that:
a. Improve parental sensitivity (i.e., the predictability, sensitiv-
ity, consistency, reliability and warmth of the parent’s inter-
action with their child) (Bakermans-Kranenburg et al. 2003)
b. Improve parents’ capacity to think about the feelings and
thoughts of their children and not just their behaviour
c. Helps mothers to support the child in developing skills in
self-regulation
d. Recognises and addresses material disadvantage (e.g., child
care, transportation and refreshments/food are provided)
(continued)
(continued)
10. In addition to focusing on parent-child interaction, the inter-
vention explores parental representations of attachment. For
example, it is not unusual for parents with poor attachment
behaviours to ‘misinterpret child distress signals (‘My baby is
trying to control me’ or ‘If I answer her cries, I will spoil her’) or
otherwise hold erroneous ideas concerning child development
(‘I want my child to be tough, so if he is hurt, I shouldn’t com-
fort him’). Sometimes parents will attribute negative intention-
ality to infants’ (Tarabulsy et al. 2008, 326)
11. Focuses on parent’s own emotional and practical needs—enables
mother to reflect on her own childhood experiences and how
these may impact her parenting
12. Provides opportunities for mothers to develop reciprocity
through shared play or enjoyable activities
13. Incorporates young women’s perspectives in project planning
14. Is empowering and builds on women’s strengths
15. Provides opportunities for building support networks that can
survive outside of the scope and life of the project
1. To serve as a supportive framework to provide a safe haven in which

new feelings and experiences are tested
2. To explore and modify internal working models of self and others
3. To encourage awareness and working-through of past and present hurts
4. To encourage sensitivity and responsiveness towards pregnancy/infant
signals
5. To provide a peer group to serve as attachment figures
Feldman (2012, 159).
Session 1 is the intake interview. In addition to gathering important

information about health, well-being and social background, this interview
should enable the young woman to talk about the meanings of pregnancy
for her, within her cultural context. As Feldman (2012) suggests, the intake
interview should provide an opportunity for pregnant teenagers to:
talk about her history, family, significant others, and other personal situa-
tions. A major focus will be on what choices, if any, she had about the
pregnancy, who may have been some of the leading family members or non-
related individuals, and/or cultural factors influencing the pregnancy. …
She would also be able to speak about the meaning of friendships and/or the
impact of social isolation due to the pregnancy (Feldman 2012, 157).
During the intake interview, the young person is asked to draw and
discuss her ecomap in order to identify the individuals closest to her
and any support systems she will be able to get help from. The second
session is the first of four 2-hour pre-natal group sessions; these are
held weekly beginning at an appropriate stage during the pregnancy
(e.g., once pregnancy is confirmed, the teenager has decided to keep her
child and the foetus is assessed to be developing normally). The focus
in the first of these is on goal setting, group bonding, getting the young
women’s views about how the group should proceed and beginning
the process of reflections on childhood experiences (using art therapy
techniques—this is a non-threatening approach for the early stages of
group work). Sessions 3 and 4 aim to increase the adolescent’s sensitiv-
ity to attachment issues. Six to ten (2- to 3-minute) video clips which
focus on maternal interactions with newborn infants are shown and
after each clip, the social worker leads a group discussion on parental
interactions. The video clips are created in advance of the programme
by the facilitators and should reflect a range of caregiving situations
and represent social circumstances, the young women can relate to. The
discussions enable the young women to explore views about the self
and representations of the unborn child in order to alter representa-
tions that could negatively affect attachment. The facilitator weaves in
opportunities to reflect on own childhood experiences of attachment.
In the last of the pre-natal group sessions (session 5), the facilitator
uses techniques such as role play, role reversal, group reinforcement
and counselling methods to help the young women revisit earlier trau-
mas and to ‘make the connection between being a parent and being
parented. As Fraiberg, Adelson and Shapiro stated ‘when our therapy

has brought the parent to remember and re-experience his childhood
anxiety and suffering, the ghosts depart and the afflicted parents become
the protectors of their children against repetition of their own con-
flicted past’ (cited in Feldman 2012, 160). The sixth session takes place
3–4 months after the birth of the child. This is an individualised session
which allows the young mother to explore her childbirth and post-
childbirth experiences; if appropriate, the session involves the person
who provides the young mother with support. The focus of this session
is on the mother’s interaction with her child; it should be empowering
and seek to build self-esteem. During the session, the social worker
encourages the support person to take a short video of the mother-
infant interaction (as homework) using a personal cell phone; this is
used as the focus of the next group meeting (session 7). Sessions 7–11
focus simultaneously on building the group relationships; sensitivity to
attachment issues between mothers and their children (discussions are
based on the homemade videos the mothers have taken of their interac-
tions with their children); exploration of past trauma and building of
self-esteem. The final session (12) is a celebration of the group and the
achievements of the young mothers.
We recommend that simultaneous child care be provided for the group
meetings. Although some therapists argue that attachment interventions
are most effective when parents and children interact during the pro-
gramme, for adolescents with a history of trauma, the need for reflective
space without the diversion of children is crucial in enabling the explora-
tion of painful memories.
Role of the Facilitator
The professional training social workers undergo should equip them for
the range of roles involved in delivering the intervention. These include
the following:
1. Skills in relationship building and establishing rapport
2. Assessment and interviewing skills
3. Group work skills (leading, challenging, enabling, conflict resolu-
tion, motivating and boundary setting)
4. Working in empowering ways (e.g., reinforcing and validating posi-

tive insights, modifying negative perceptions or powerless thoughts
and identifying and building on strengths)
5. Advocacy skills
6. Teaching skills (explaining, suggesting and guiding)
7. Interpreting skills
8. Strengthening family and group support systems
9. Experience in using a range of learning techniques (e.g., role play,
role reversal, confrontation and mirroring)
10. Reflective skills
11. Organisational skills
12. Monitoring and evaluation skills
The most important role the group leader plays, however, is described
by Feldman (2012):
she serves as a “safe haven” figure who allows the group members to test out
painful feelings simultaneously being available to provide comfort, as
needed. The leader is instrumental in functioning as an attachment-support
giving person and helps the members connect to other support person(s) in
the group during times of fear or need as they deal with their uncomfort-
able feelings. She/he encourages the support expectations person(s) to be
responsively attentive to the particular adolescent member working
through traumas. Concurrently the adolescent members are integrating
new experiences that help them become more sensitive to their pregnancy
and responsive to their infant (fetus) signals (2012, 159).
The positive long-term developmental outcome associated with a

secure parent-infant attachment relationship provides all the rationale
needed for the implementation of programmes such as the one described.
Egeland (2004) agrees:
Design (and evaluate) prevention and intervention programs to promote a

secure parent-infant attachment relationship in order to improve
developmental outcomes of infants and children who are at risk for poor
developmental outcomes and prevent behaviour problems and psychopa-
thology (2004, 2).
Social workers have the appropriate training and skills for this work
and because of their involvement with vulnerable children and families
are well placed to initiate attachment interventions. We hope you feel
encouraged to do so.
Conclusion
In this part of the book, we introduced you to Melissa, whose circum-
stances, if not typical, include issues that you are likely to encounter in
working with adolescent girls who have been sexually abused. In set-
ting the context for your practice, we have discussed relevant literature
on the wider environmental factors that often impact such cases and
highlighted key theoretical considerations for you to take into account
in planning your strategies and interventions. We have explored the
potential role of psychologists, psychotherapists and social workers and
presented ideas for practice that can be adapted and adopted for use
in a wide range of settings and by a wide range of professionals. In
our work, we have often been struck by perceptions that the expertise
to work with cases of complex trauma is out there, that it requires the
importation of highly trained (and often very expensive) consultants
or specialists. This may be the case in some exceptional circumstances
(although we cannot imagine what these might be), but for the most
part, the people with the skills, commitment and attributes needed for
such sensitive and important work are right here, in our midst—they
are the people who confront these problems in their everyday working
lives—they are you. We trust that the information we have provided
may go some way to helping you extend your knowledge and develop-
ing your practice.
References
Ainsworth, M. D. S., Bell, S. M., & Stayton, D. J. (1971). Individual differ-
ences in strange situation behavior of one-year-olds. In H. R. Schaffer (Ed.),
The origins of human relations (pp. 17–56). London: Academic Press.
American Psychological Association. (2008). Report of the task force on mental health
and abortion. Washington, DC: American Psychological Association. http://
www.apa.org/pi/wpo/mental-health-abortion-report.pdf. Accessed August 4,
2012.
Bailey, H. N., Moran, G., & Pederson, D. R. (2007). Childhood maltreatment,
complex trauma symptoms, and unresolved attachment in an at-risk sample of
adolescent mothers. Attachment and Human Development, 9(2), 139–161.
Bakermans-Kranenburg, M. J., van IJzendoorn, J., & Juffer, F. (2003). Less is
more: Meta-analyses of sensitivity and attachment interventions in early
childhood. Psychological Bulletin, 129, 195–215.
Battle, J. (2002). Culture-free self-esteem inventories, Examiner’s manual (3rd ed.).
Austin: Pro-ed – An International Publisher.
Belsky, J., Rosenberger, K., & Crnic, K. (1995). The origins of attachment secu-
rity. In S. Goldberg, R. Muir, & J. Kerr (Eds.), Attachment theory: Social, devel-
opmental, and clinical perspectives (pp. 153–183). Hillsdale: Analytic Press.
Berlin, L., Zeanah, C. H., & Lieberman, A. F. (2008). Prevention and interven-
tion programmes for supporting early attachment security. In J. Cassidy &
P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical
applications. New York: The Guilford Press.
Bifulco, A., Figueiredo, B., Guedeney, N., Gorman, L. L., Hayes, S., Muzik, M.,
et al. (2004). Maternal attachment style and depression associated with child-
birth: Preliminary results from a European and US cross-cultural study. The
British Journal of Psychiatry, 184(46), s31–s37.
Book, H. E. (1998). How to practice brief psychodynamic psychotherapy: The
core conflictual relationship theme method. Washington, DC: American
Psychological Association Press.
Bowlby, J. (1973). Attachment and loss (Vol. 2). Separation: anxiety and anger.
New York: Penguin Books.
Bowlby, J. (1980). Attachment and loss (Vol. 3). Loss: sadness and depression.
New York: Penguin Books.
Bradshaw, Z., & Slade, P. (2003). The effects of induced abortion on emotional
experiences and relationships: A critical review of the literature. Clinical
Psychology Review, 23(7), 929–958.
Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan kriya yogic breathing in the
treatment of stress, anxiety, and depression: Part II-clinical applications and
guidelines. Journal of Alternative & Complementary Medicine, 11(4), 711–717.
Cassidy, B., & Zoccolillo, M. (1996). Psychopathology in adolescent mothers
and its effects on mother–infant interactions: A pilot study. Canadian Journal
of Psychiatry, 41(6), 379–384.
Chaffin, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., & Zeanah, C.
(2006). Report of the APSAC Task Force on attachment therapy, reactive attach-
ment disorder, and attachment problems. Child Maltreatment, 11, 76–89.
Child Trends Data Bank. (2014). Teen pregnancy. www.childtrends.org/?
indicators=teen-pregnancy. Accessed September 8, 2014.
Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2006). Fostering secure attachment
in infants in maltreating families through preventive interventions.
Development and Psychopathology, 18(03), 623–649.
Cincotta, N. F. (2002). The journey of middle childhood: Who are “Latency”-
age children? In S. G. Austrian (Ed.), Developmental theories through the life
cycle. New York: Columbia University Press.
Cohen, A. J., Adler, N., Kaplan, S. J., Pelcovitz, D., & Mandel, F. S. (2002).
Interactional effects of marital status and physical abuse on adolescent psy-
chopathology. Child Abuse and Neglect, 26(3), 277–288.
Cohn, J. F., Campbell, S. B., Matias, R., & Hopkins, J. (1990). Face-to-face
interactions of postpartum depressed and nondepressed mother-infant pairs
at 2 months. Developmental Psychology, 26(1), 15–23.
Cox, A. D., Puckering, C., Pound, A., & Mills, M. (1987). The impact of
maternal depression on young children. Journal of Child Psychology and
Psychiatry, 28, 917–928.
DeGarmo, D. S., Patterson, G. R., & Forgatch, M. S. (2004). How do out-
comes in a specified parent training intervention maintain or wane over time?
Prevention Science, 5(2), 73–89.
Denholm, R., Power, C., Thomas, C., & Li, L. (2013). Child maltreatment and
household dysfunction in a British birth cohort. Child Abuse Review, 22(5),
340–353.
Dozier, M., Lindhiem, O., & Ackerman, J. P. (2005). Attachment and biobe-
havioral catch-up: An intervention targeting empirically identified needs of
foster infants. In M. Dozier, O. Lindhiem, J. P. Ackerman, L. J. Berlin, Y. Ziv,
& L. Amaya-Jackson (Eds.), Enhancing early attachments: Theory, research,
intervention, and policy. Duke series in child development and public policy
(pp. 178–194). New York: Guilford Press.
Durrant, J. E., Trocme, N., Fallon, B., Milne, C., & Black, T. (2009). Protection
of children from physical maltreatment in Canada: An evaluation of the
Supreme court’s definition of reasonable force. Journal of Aggression,
Maltreatment & Trauma, 18(1), 64–87.
Egeland, B. (2004). ‘Attachment-based intervention and prevention programs for
young children’ in Encyclopedia on early childhood development [online]
(pp. 1–7). Montreal: Centre of Excellence for Early Childhood Development.
Engelhard, I. M., van den Hout, M. A., Kindt, M., Arntz, A., & Schouten, E.
(2003). Peritraumatic dissociation and posttraumatic stress after pregnancy
loss: A prospective study. Behaviour Research and Therapy, 41(1), 67–78.
Feldman, J. B. (2012). Best practice for adolescent prenatal care: Application of
an attachment theory perspective to enhance prenatal care and diminish
birth risks. Child and Adolescent Social Work Journal, 29(2), 151–166.
Field, T., Healy, B. T., Goldstein, S., & Guthertz, M. (1990). Behavior-state
matching and synchrony in mother-infant interactions of nondepressed ver-
sus depressed dyads. Developmental Psychology, 26(1), 7–14.
Furnivall, J. (2011). Attachment-informed practice with looked after children and
young people. IRISS Insight no. 10. Glasgow: IRISS, http://www.iriss.org.uk/
sites/default/files/iriss_insight10.pdf. Accessed July 10, 2013.
Gaudin Jr., J. M., Polansky, N. A., Kilpatrick, A. C., & Shilton, P. (1996).
Family functioning in neglectful families. Child Abuse and Neglect, 20(4),
363–377.
Goldberg, S., Muir, R., & Kerr, J. (2013). Attachment theory: Social, developmen-
tal, and clinical perspectives. London: Routledge.
Grace, S. L., Evindar, A., & Stewart, D. E. (2003). The effect of postpartum
depression on child cognitive development and behavior: A review and critical
analysis of the literature. Archives of Women’s Mental Health, 6(4), 263–274.
Guttmacher Institute. (2012). Facts on abortion in Latin America and the Caribbean.
www.guttmacher.org/pubs/IB_AWW-Latin-America.pdf. Accessed September
8, 2014.
Hoffman, K. T., Marvin, R. S., Cooper, G., & Powell, B. (2006). Changing tod-
dlers’ and preschoolers’ attachment classifications: The circle of security inter-
vention. Journal of Consulting and Clinical Psychology, 74(6), 1017–1026.
Hook, D. (2009). Erikson’s psychosocial stages of development. In J. Watts.,
K. Cockcroft., & N. Duncan (Eds.), Developmental Psychology (2nd ed.).
Cape Town: UCT Press.
Hornor, G. (2010). Child sexual abuse: Consequences and implications. Journal
of Pediatric Health Care, 24(6), 358–364.
Jones, A. D., & Maharaj, P. E. (2014). Evaluation report: Project R.I.S.E.
Grenada/Toronto: The Sweet Water Foundation.
Jones, A. D., Trotman Jemmott, E., Maharaj, P. E., & Da Breo, H. (2014). An
integrated systems model for preventing child sexual abuse: Perspectives from
Latin America and the Caribbean. Basingstoke/New York: Palgrave Macmillan.
Juffer, F., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (Eds.)
(2012). Promoting positive parenting: An attachment-based intervention.
London/New York: Routledge.
Kisiel, C. L., Fehrenbach, T., Torgersen, E., Stolbach, B., McClelland, G.,
Griffin, G., et al. (2014). Constellations of interpersonal trauma and symp-
toms in child welfare: Implications for a developmental trauma framework.
Journal of Family Violence, 29, 1–14.
Knerr, W., Gardner, F., & Cluver, L. (2013). Improving positive parenting skills
and reducing harsh and abusive parenting in low-and middle-income coun-
tries: A systematic review. Prevention Science, 14(4), 352–363.
Lagerberg, D. (2000). Secondary prevention in child health: Effects of psycho-
logical intervention, particularly home visitation, on children’s development
and other outcome variables. Acta Paediatrica, 89(s434), 43–52.
Lev-Wiesel, R. (2008). Child sexual abuse: A critical review of intervention and
treatment modalities. Children and Youth Services Review, 30(6), 665–673.
Lounds, J. J., Borkowski, J. G., Whitman, T. L., Maxwell, S. E., & Weed, K.
(2005). Adolescent pregnancy and attachment during infancy and early
childhood. Parenting: Science and Practice, 5(1), 91–118.
Luborsky, L., & Crits-Christoph, P. (1998). Understanding transference: The core
conflictual relationship theme method (2nd ed.). Washington, DC: American
Psychological Association Press.
Martz, E., & Lindy, J. (2010). Exploring the trauma membrane concept. In
E. Martz (Ed.), Trauma rehabilitation after war and conflict (pp. 27–54).
New York: Springer.
Marvin, R., Cooper, G., Hoffman, K., & Powell, B. (2002). The circle of secu-
rity project: Attachment-based intervention with caregiver-preschool child
dyads. Attachment and Human Development, 1(4).
McCloskey, L. A., Figueredo, A. J., & Koss, M. P. (1995). The effects of systemic
family violence on children’s mental health. Child Development, 66(5),
1239–1261.
Messman-Moore, T. L., Walsh, K. L., & DiLillo, D. (2010). Emotion dysregu-
lation and risky sexual behavior in revictimization. Child Abuse and Neglect,
34(12), 967–976.
Mullers, E., & Dowling, M. (2008). Mental health consequences of child sexual
abuse. British Journal of Nursing, 17(22), 1428–1433.
Murray, L., & Sinclair, D. (1999). The socioeconomic development of 5 year
old children of postnatally depressed mothers. Journal of Child Psychology and
Psychiatry, 40(8), 1259–1271.
Nash, M. R., Hulsey, T. L., Sexton, M. C., Harralson, T. L., & Lambert, W.
(1993). Long-term sequelae of childhood sexual abuse: Perceived family
environment, psychopathology, and dissociation. Journal of Consulting and
Clinical Psychology, 61(2), 276–283.
Nicolson, S., Judd, F., Thomson-Salo, F., & Mitchell, S. (2013). Supporting the
adolescent mother–infant relationship: Preliminary trial of a brief perinatal
attachment intervention. Archives of Women’s Mental Health, 16(6), 511–520.
Novotney, A. (2009). Yoga as a practice tool. Monitor on Psychology, 40(10), 38.
Posavac, E. J., & Miller, T. Q. (1991). Some problems caused by not having a
conceptual foundation for health research: An illustration from studies of the
psychological effects of abortion. Psychology and Health, 5(1), 13–23.
Pritchett, R., Kemp, J., Wilson, P., Minnis, H., Bryce, G., & Gillberg, C.
(2010). Quick, simple measures of family relationships for use in clinical
practice and research: A systematic review. Family Practice, cmq080.
Puckering, C., McIntosh, E., Hickey, A., & Longford, J. (2010). Mellow Babies:
A group intervention for infants and mothers experiencing postnatal depres-
sion. Counselling Psychology Review, 25(1), 12.
Purcell, W. J. (1996). The attachment-trauma complex. The American Journal of
Psychoanalysis, 56(4), 435–446.
Quinlivan, J. A., Tan, L. H., Steele, A., & Black, K. (2004). Impact of demographic
factors, early family relationships and depressive symptomatology in teenage
pregnancy. Australian and New Zealand Journal of Psychiatry, 38(4), 197–203.
Riggs, S. A., Paulson, A., Tunnell, E., Sahl, G., Atkison, H., & Ross, C. A.
(2007). Attachment, personality, and psychopathology among adult inpa-
tients: Self-reported romantic attachment style versus adult attachment inter-
view states of mind. Development and Psychopathology, 19(01), 263–291.
Robbins Broth, M., Goodman, S. H., Hall, C., & Raynor, L. C. (2004).
Depressed and well mothers’ emotion interpretation accuracy and the quality
of mother–infant interaction. Infancy, 6, 37–55.
Shaffer, D. R., & Kipp, K. (2014). Developmental psychology: Childhood and
adolescence (9 ed.). California: Cengage Learning.
Slack, K. S., Holl, J. L., McDaniel, M., Yoo, J., & Bolger, K. (2004).
Understanding the risks of child neglect: An exploration of poverty and par-
enting characteristics. Child Maltreatment, 9(4), 395–408.
Stith, S. M., Liu, T., Davies, L. C., Boykin, E. L., Alder, M. C., Harris, J. M.,
et al. (2009). Risk factors in child maltreatment: A meta-analytic review of
the literature. Aggression and Violent Behavior, 14(1), 13–29.
Summers, R. F., & Barber, J. P. (2012). Psychodynamic therapy: A guide to
evidence-based practice. New York: Guilford Press.
Tarabulsy, G. M., Pascuzzo, K., Moss, E., St-Laurent, D., Bernier, A., Cyr, C.,
et al. (2008). Attachment-based intervention for maltreating families.
American Journal of Orthopsychiatry, 78(3), 322–332.
UNICEF. (2009). Children in Barbados and the Eastern Caribbean: Child rights –
the unfinished agenda. http://www.unicef.org/barbados/Child_Rights_-_
The_Unfinished_ Agenda.pdf. Accessed September 21, 2014.
Van Der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the
healing of trauma. New York: Viking.
van IJzendoorn, M. H., Juffer, F., & Duyvesteyn, M. G. C. (1995). Breaking the
intergenerational cycle of insecure attachment: A review of the effects of
attachment-based interventions on maternal sensitivity and infant security.
Journal of Child Psychology and Psychiatry, 36, 225–248.
van Roode, T., Dickson, N., Herbison, P., & Paul, C. (2009). Child sexual abuse and
persistence of risky sexual behaviors and negative sexual outcomes over adult-
hood: Findings from a birth cohort. Child Abuse and Neglect, 33, 161–172.
Wan, M. W., & Green, J. (2009). The impact of maternal psychopathology on
child–mother attachment. Archives of Women’s Mental Health, 12(3),
123–134.
Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children
with early-onset conduct problems: Intervention outcomes for parent, child,
and teacher training. Journal of Clinical Child and Adolescent Psychology,
33(1), 105–124.
Williams, S. G., Brown, J., & Roopnarine, J. L. (2006). Child rearing in the
Caribbean: A literature review. Barbados: Caribbean Child Support Initiative.
World Health Organization (WHO). (2011). Unsafe abortion: Global and
regional estimates of the incidence of unsafe abortion and associated mortality in
2008 (6 ed.). Geneva: WHO.
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy.
New York: Basic Books.
Yalom, I. D. (2012). Love’s executioner: And other tales of psychotherapy. New York:
Basic Books.
3
Working with Children with Learning
Disabilities
Vulnerabilities, Needs and Rights; Direct Work
with Children with Learning Disabilities;
Empowering Families to Protect Children
Fig. 3.1 ‘Venus traps’ © Jaime Lee Loy (2008)

These clams were collected from dinner the night before at the studio cen-
tre and placed upright and open, alluding to moths and Venus fly traps. In
the centre of the clams were rusty nails, slim phallic symbols inserted in the
Yonic clam. These hard-shelled creatures, which are fleshy in the interior,
now lie forced open with threatening protrusions (Lee Loy 2008, n.p.).
Introduction
In this part of the book, we focus on the rights of children with learn-
ing disabilities to be protected from abuse and we also discuss strategies
for family support. The case study highlights issues of loss, non-fam-
ily abuse and the impact on parenting capacity of alcohol misuse. The
discussion emphasises the importance of taking into account children’s
communication needs, intellectual impairments and any specific abili-
ties and interests the child has in the planning of interventions. Two
approaches to practice are provided for working with children, and two
for empowering families. Although we have applied these methods to
children with learning disabilities and their families, they can be adapted
for many children and the family-based approaches are generic.
Nina’s Story
Family History
Mr. Dewan is a 48-year-old man who is a single parent to three children:

Kamal, 15 years; Nina, 13; and Tanik, who is five. Mr. Dewan is a widower;
his wife died four years ago from breast cancer, shortly after the birth of their
younger son. The Dewans had been very happily married, they had known
each other since childhood and their families were close. Mr. Dewan is an
engineer with a petroleum company, he is well paid and the family enjoy
a high standard of living in one of the wealthier neighbourhoods in the
country. Mr. Dewan took his wife’s death very badly; feeling the need for a
change of environment, he got a transfer with his job and moved his fam-
ily to a new area, somewhat distancing himself from the extended family.
3 Working with Children with Learning Disabilities 91
Always a heavy drinker, Mr. Dewan began drinking excessively after his wife
died; this has affected his ability to function effectively in his job—he has
had several warnings from his employers. He has worked hard at control-
ling his drinking but often has relapses and when drunk alternates between
behaving irrationally and becoming very morose. Kamal, his eldest child,
has become adept at covering for his father’s absenteeism and drunken
behaviour but is finding this increasingly difficult to manage. Kamal is gen-
erally a happy, outgoing teenager; though initially devastated at the death of
his mother, he excels at school and cricket and has many friends and these
positive aspects to his life have helped him to cope. He has become a major
source of support to his father and helps out with his younger siblings, tak-
ing Tanik to and from school, babysitting until his father gets home from
work and cooking the evening meal. Nina is a 13-year-old girl with Down
syndrome; she is also hearing-impaired and has a hearing range of less than
20 %. Nina has a functional age of seven and attends a special school where
she is making steady progress; she has good social skills and often helps chil-
dren with more severe learning difficulties. Nina has always been the dar-
ling of the family, a joyous girl who sings and dances incessantly and loves
playing tricks on her older brother. She is, however, jealous of her younger
brother and they have to be closely supervised when together because she
tends to bully him. Following the death of her mother, Nina developed
some behavioural difficulties; she had periodic episodes of rage when she
would try to hit and bite anyone attempting to calm her and cried inconsol-
ably. Mr. Dewan sought the help of a psychologist and the episodes became
less frequent—so much so that she has not seen the psychologist for over
18 months. Tanik, the youngest child, is a healthy, rather quiet, little boy of
five; he is developing intellectually and physically in line with expected mile-
stones for a child of his age. Tanik is very close to his father and especially
likes it when Nina goes to her dance classes on Saturdays because he and his
daddy usually go to the park together.
Presenting Problem
Over the last 12 months, Nina’s behavioural problems have started up

again and seem to be getting progressively worse; her temper outbursts
have become more frequent, and when her father tries to comfort her,
Mr. Dewani Mrs.

48 Dewan
Died breast cancer 4 yrs ago
Kamal Nina Tanik

15 yrs 13yr 5 yrs
Fig. 3.2 Nina’s genogram
she screams at him and pulls his hair. Although she is often still cheerful
overall, she spends a lot of time rocking and sucking her thumb, behaviour
that she grew out of years ago. She has also started wetting the bed at nights;
she is very embarrassed at this and usually tries to hide the wet sheets by
pushing them under her bed and then attacks Tanik, saying he did it. The
school has also reported some difficulties; her teacher, Mr. Johnston, said she
fights with the other children, and although he has always been her favourite
teacher, it seems she now refuses to do anything he asks her and gets very
jealous whenever he shows attention to other children. Mr. Dewan has been
trying to manage as best he can but he has been avoiding professional help
as he is worried that his drinking problem might be uncovered. One evening
while babysitting, Kamal caught Nina trying to pull down Tanik’s trousers;
when confronted she said ‘Sir does it’. Mr. Dewan went to the school the
next morning to discover that Mr. Johnston had been suspended earlier that
week because of allegations that he had sexually abused two children in the
class. The principal was not sure whether other children had been involved,
because the investigation had only just started but on reflection wondered
about Nina as he seemed to take a special interest in her and was always giv-
ing her treats. The school nurse interviewed Nina and was able to glean that
Mr. Johnston had sexually molested her; it seems this started around about
the same time she started her periods at the age of 12. Following this dis-
closure, Mr. Dewan broke down; he has threatened to get a gun and shoot
the teacher but deep down seems to be blaming himself. He feels guilty that
he had not picked up on what was wrong earlier and believes he has let his
daughter down. Although the full extent of Nina’s abuse is not yet known,
he is sickened by the thoughts of what she might have endured and has
taken to drinking again. He has not been to work for a week, and constantly
drunk, he has hardly emerged from the bedroom. Kamal has been trying
to keep the family together but simply cannot manage; in desperation, he
called his grandmother, who is too far to visit often but with whom he has a
close relationship; she has persuaded Mr. Dewan to accept help.
Maternal
grandmother–
lives some
distance away
Psychologist
Tanik 5 yrs old
Younger brother
Nina
13 yrs
Down Syndrome
and hearing
impaired
Kamal 15 years Father

old. Older Drinking
brother problem
Mr. Johnston
Special Needs Teacher and Other children at
School reportedly sexual school
abuser
Positive
Stressful
Tenuous
Arrows=energy flow Line thickness=intensity
Fig. 3.3 Nina’s ecomap

Chronology of Events leading up to the presenting

problem
The presenting problem concerns Nina, a child with learning disabili-

ties and a hearing impairment. Nina reacted badly to the death of her
mother and developed behavioural difficulties but she responded well to
professional help and by the age of 11, the episodes had virtually ceased.
For the past year, however, her behaviour has progressively deteriorated,
becoming increasingly aggressive especially towards her younger brother
who is five. In the last week, Nina’s father has discovered that for more
than 12 months Nina was being sexually abused by her favourite teacher
at school. Switching between states of rage, guilt, sadness and despair, he
has been drinking constantly since he found out. He has all but aban-
doned caring for the children, leaving everything to Kamal and he has
not been back to work since the disclosure.
Mom
Nina born died
with when
intellecual she 9 yrs Maternal
disability was got grandmother
(Down 9 yrs help contacted
Syndrome). afer from 13 yrs, a
She is birth psychologist behavioural psychologist
also of for problems for
hearing younger behavioural have assistance.
impaired brother difficulties reoccurred.
Functional 9 yrs, when 12 yrs, 13 yrs,

age of mom died sexually alleged
7 years. she molested abuse
Attends developed since from
a Special behavioural seeing favourite
Needs problems. her teacher
School. periods Mr. Johnston
Making
steady
progress
Fig. 3.4 Nina’s timeline

Contextual Issues
Down Syndrome Aetiology and the Importance
of Clinical Assessments and Monitoring
Children become vulnerable to abuse and exploitation for a host of rea-

sons which in themselves may not be risk factors1 until they intersect
with other influences; then, together they can heighten children’s vul-
nerability to harm and victimisation. The experiences of children with
disabilities exemplify this intersectional relationship where two or more
factors in their lives can place them at risk of abuse. Some of the earlier
research (Gauthier et al. 1996; Ney et al. 1994) suggests that factors such
as chronological age, gender and physical and cognitive stages of develop-
ment may impact children’s risk of maltreatment. An exploratory study
of adolescents in Israel also showed confirmatory evidence of higher levels
of various types of abuse among young people with intellectual and other
disabilities compared with non-disabled teenagers from the same socio-
economic background (Reiter et al. 2007). Children such as Nina, who
have some intellectual impairment and hearing loss, have a heightened
level of vulnerability because of their increased dependence on adults,
some of whom, such as Mr. Johnston, may use positional power and
status to create opportunities for abuse. These risks to disabled children
were also reported in the Jones and Trotman Jemmott (2009) Caribbean
research in which adult abusers ‘who know no boundaries’ were dis-
cussed to be ‘taking advantage of innocence and vulnerability including
the sexual abuse of learning disabled children’ (117). This study revealed
that patriarchal power and gender inequalities positioned women and
children as vulnerable on the one hand and enabled men to exploit this
vulnerability on the other:
All focus group participants believed that [child sexual abuse] was also as a
result of powerful men in society taking advantage of vulnerable mothers
and children. Vulnerability was discussed in terms of poverty, the power
1
Risk factors in this case are behaviours and conditions in the family and wider environment that
may contribute to child maltreatment.
imbalance in families, persons marginalised/discounted by their communi-

ties, [and] disabled families (learning disabled) (159).
Sullivan and Knutson (2000) found that children with disabilities

were more likely to be subjected to physical, emotional and sexual abuse
or neglect than were children who were not disabled. This was a large
population-based epidemiological study of 50,278 children enrolled in
the Public and Archdiocese schools of Omaha, Nebraska, during the
1994–5 school year.
Although there was an overall rate of maltreatment of approximately 11 %

in the population, the overall rate of maltreatment among children who
had an identified disability for which they were receiving special education
services was 31 %, a rate more than three times that of children without an
educationally relevant disability (1261).
Down Syndrome
Nina was born with Down syndrome and although this is not in itself a
risk factor, the statistical odds reported by Sullivan and Knutson do sug-
gest that she is more vulnerable to abuse than a non-disabled child. Down
syndrome is described as the most common genetic cause of intellectual
disability and occurs in approximately 1 in 700 live births (CDC 2006).
The National Down Syndrome Society (NDSS) of America identifies
three causes for Down syndrome. An error in cell division called ‘non-
disjunction’ can occur, resulting in an embryo with three copies of chro-
mosome 21 instead of the usual two. As a result, the developing embryo
has an extra chromosome replicated in every cell of the body. This type
of Down syndrome is named trisomy 21, accounting for approximately
95 % of cases. In about 4 % of other cases, translocation occurs where part
of chromosome 21 breaks off during cell division and attaches to another
chromosome, typically chromosome 14. The characteristics of the other
1 % of children with Down syndrome are caused when non-disjunction
of chromosome 21 takes place in one—but not all—of the initial cell
divisions after fertilisation—the type called mosaicism.
This additional genetic material informs growth and development,

causing the characteristics associated with Down syndrome. These features
can include a range of medical and physical conditions such as low muscle
tone, congenital heart defects, intestinal obstruction, hearing impairments
and hypothyroidism. There is a wide variation in mental abilities, behav-
iour and developmental progress in individuals with Down syndrome.
Early intervention and regular assessment of each child’s ability are impor-
tant as the level of intellectual disability may range from mild to severe;
the majority of people with the condition function in the mild to moder-
ate range. Nina’s level of cognitive impairment (which most commonly
relates to attention, learning, memory and judgement) would typically
limit her adaptive behaviours and intellectual ability and performance.
These are all known factors which should inform any multidisciplinary
plan of action for Nina, be it for an acute medical incident, family sup-
port or a child protection case conference. Practitioners’ and clinicians’
understanding of the intersecting link here between Nina’s medical needs
and treatment, educational needs and developmental milestones and how
they can influence each other is important to clinical assessment and
intervention.
Communication Challenges
Children with Down syndrome are known to have a wide range of learn-
ing styles and behaviours, necessitating careful and informed educational
approaches in the classroom as well as in the administration of any ‘stan-
dardised’ testing of performance or ability. In Nina’s case, proper monitor-
ing and assessment of overall progress, including academic progress, can
alert special education professionals to signs that something has changed
in her behaviour and overall performance from what is expected within
her level of ability. The possibility of maltreatment needs to be given care-
ful consideration when concerns in these areas arise. As mentioned ear-
lier, children with disabilities are shown to be three times more likely to
suffer one or more forms of abuse compared with non-disabled children
(Sullivan and Knutson 2000). This is especially the case for children with
communicative and cognitive difficulties as they are often less able to
convey their experience of abuse to adults and others (Gilbert et al. 2009a).
Furthermore, even when disabled children do disclose abuse, their reports
are often regarded as lacking credibility and as Gilbert et al. (2009b) point
out, parents, professionals and other adults are less likely to follow up by
reporting incidents to the authorities (Gilbert et al. 2009a). Evidence of
increased risk of sexual abuse among children with sensory impairments
was also supported by a Scandinavian study of adults (Kvam 2004) which
found that among deaf women who lost their hearing before the age of
nine, 177 reported that they had been sexually abused as children. This was
more than twice as often as hearing females, whereas deaf males reported
child sexual abuse more than three times as often as hearing males. The
abuse was also reported as being more serious (241).
Approximately two thirds of children with Down syndrome experience
sensorineural hearing loss or conductive hearing loss (or both) in one or
both ears (Roizen 2007). This can coexist with other challenges such as
lack of expressive language (Paul 2007) which may make it more difficult
for children with Down syndrome to talk about abuse. It is helpful to
remember that, in Down syndrome, receptive language skills are often
stronger than expressive ones and therefore, where possible, capitalising
on these receptive skills should feature in assessments and intervention.
Undoubtedly, the medical, developmental and cognitive challenges inher-
ent in Down syndrome require much of a practitioner’s and clinician’s
skills in finding creative and sensitive ways of interacting commensurate
with children’s abilities as much as their disabilities. Often, the route taken
is to interact with the parents rather the child (Stalker et al. 2010), and
although the involvement of parents in planning treatment and interven-
tion is a key principle of partnership working, it is almost always necessary
to ensure that there is direct communication with the child.
Concepts and Co-occurrences: Disability

and other Stressors
Nina’s vulnerability is arguably compounded by some significant stress-
ors (the death of her mother and the increasingly excessive alcohol con-
sumption of her father) which have been shown to disrupt children’s
lives and their sense of security. Her diagnosis with Down syndrome
is likely to have been a significant stressor for her family. Her father’s
increasing inability to cope, exacerbated by the revelation of Nina’s
abuse, has heightened the family’s problems since Mr. Dewan has all
but abandoned paternal responsibility to his eldest child, Kamal, who is
15 years old. We do not know the extent to which Mr. Dewan’s drink-
ing problems may have contributed to a lowering of parental supervi-
sion and protective factors, but it is important that professionals do not
imply that his behaviour has placed his daughter at risk. Child abusers
can target children irrespectively of parental and family circumstances,
and the abuse took place outside of the home, where parents like Mr.
Dewan will have had very little influence. Nevertheless, it is the case
that parental drug and alcohol addiction can reduce parental protec-
tive capacities and also that abusers will seek out children they con-
sider to be especially vulnerable. A combination of parental factors, the
loss of maternal support, dad’s emotional and physical disengagement
from the children, coupled with Nina’s developmental challenges, may
have generated a need for affection and attention that may have made
her more vulnerable to being targeted for abuse. Whereas other chil-
dren acquire the ability to comprehend the intentions of others through
‘socio-cognitive abilities that develop in infancy’ (Poulin-Dubois et al.
2009, 55), children with intellectual impairments may not have the
psychological tools to assess the goal-directed actions or language2 of
others (Hahn et al. 2013). Such children can be especially vulnerable
to manipulation and control by others. Alongside risk factors, there are
protective factors, most prominent in Nina’s case will be the family’s
capacity to ‘pull together’ and the likelihood that early childhood attach-
ment behaviours were positive. Bowlby speaks of a securely attached
relationship between child and caregiver as a ‘lasting psychological con-
nectedness between human beings’ (Bowlby 1969, 194). This can help
act as a protective buffer in the face of stressful experiences and adversity
(Ainsworth and Bell 1970). When this attachment is healthy, strong and
positive, it helps to ensure children’s proper survival, development and
2
‘The study of intentionality focuses on how children come to understand the goal-directed actions
of others and is an important precursor to the development of more complex social cognitive skills,
such as theory of mind’ (Hahn et al. 2013, 4455).
protection. It holds the power to assist in the assimilation of a range of

inter-subjective3 experiences which help cement developmental capaci-
ties, including memory and cognition. In the case of a child with Down
syndrome, such an attachment might be difficult to assess. Nevertheless,
it is this healthy attachment to significant persons which may help mini-
mise harm and abuse.
Challenges faced by and posed by Child

Protection Agencies and Schools
We have seen from the foregoing discussion that children with disabilities
are more at risk of being abused than non-disabled children. Despite this,
they are less likely to benefit from interagency assessments and child pro-
tection interventions because, as Stalker et al. (2010) point out:
• Practitioners may lack the skills to communicate with children with

specialised communication needs.
• Misinformation and misunderstandings about disabled children can
lead to poor practice.
• Some professionals show reluctance in challenging caregivers about
child protection concerns.
• Assumptions are often made that disabled children cannot act as cred-
ible witnesses.
These areas of concern are compounded by the fact that child protec-
tion services in the Caribbean are under-resourced and there may be little
recognition of the specialised needs of disabled children. Although there
are pockets of good practice, individual practitioners cannot achieve sus-
tained improvements in isolation. What is required is a multidisciplinary
team approach that works to ensure protection from harm and the acqui-
sition of specific skills and techniques for working with children with
3
Trevarthen and Aitken (2001, 31) state that ‘[A]ll persons are capable of detecting rhythmic
impulses and qualities of other person’s behaviours that are contingent upon and related emotion-
ally to their own expressions. These principles of fundamental intersubjectivity, which underlie but
are not dependent on reason and language, are involved, though often not deliberately employed,
in all therapeutic and educational procedures, just as they are continually present in family life and
the daily activity of social groups’.
disabilities. The role of schools in working with other professions is fun-

damentally important. One of the big challenges to advancing multidis-
ciplinary assessment planning for children with disabilities, particularly
when there is an abuse concern, is that child rights and child protection
arrangements appear not to be a priority for Caribbean governments,
despite the ratification of international treaties. However, the sterling
work of UNICEF and other agencies is undeniable in seeking to change
this situation for all children. The informed and supportive role of par-
ents, special needs educationalists and social workers/psychologists is
critical in the promotion of disabled children’s rights. Stalker et al. (2010)
identified several key policy, practice and research implications that could
achieve many of these rights. Three of these are highlighted as being
critical to advancing services for disabled children in the Caribbean:
• Child protection systems need to be more sensitive to disabled chil-

dren’s needs, having accessible routes for children to disclose, allowing
extra time to interview them, promoting independent advocacy, sup-
port for communication and a review of court procedures.
• There is a need for a comprehensive training programme which should
include messages from research, communication with disabled chil-
dren, disability awareness, disability legislation and rights and making
child protection systems appropriate for disabled children.
• Alongside other children at school, disabled children should receive
sex education, safety skills training and information about their rights.
In the next section, we discuss some of the practice skills and tech-
niques that can aid the professional in working with children with learn-
ing disabilities who have experienced abuse.
Working with Children with Learning

Disabilities who have experienced Trauma
Working with sexually abused children with learning disabilities
requires the practitioner to consider the developmental maturity of the
child. Although Nina is 13, she is generally functioning at the level of a
seven-year-old; however, this does not mean that the worker can take this
for granted in all aspects of the assessment and intervention that follow.
Children with learning disabilities show more variance in levels of matu-
rity across different spheres of functioning than non-disabled children,
so, for example, development of a child’s sexuality or social skills may
hide a lack of development at the emotional or cognitive levels, or vice
versa (Allington-Smith et al. 2002). Mr. Dewan is distressed that he did
not pick up on the symptoms of sexual abuse, but sexual abuse is difficult
to detect in many circumstances and can be even more difficult to pick
up on when children with learning disabilities are involved. For example,
inappropriate displays of sexualised behaviour are quite common among
children with learning disabilities, especially those experiencing puberty
(Allington-Smith et al. 2002). Of itself, this would not necessarily indicate
abuse and may have more to do with a young person’s sexual frustration,
exploration or inability to understand their sexual feelings, but alongside
significant changes in behaviour that are out of character or are regressive
should cause adults to look deeper. Allington-Smith et al. (2002, 65) iden-
tify the following behaviours as possible indicators of abuse:
• Sexualised behaviours
• Behavioural problems
• Avoidance of people or places
• Regression of abilities
• Elective mutism
• Increased stereotypical behaviour (e.g., rocking)
• Running away
• Self-injury
• Generalised anxiety
• Encopresis and enuresis
• Nightmares
• Eating or sleeping problems or both
Nina displayed several of these factors: behavioural problems; regression,

generalised anxiety, enuresis, increased stereotypical behaviours (rocking
and thumb-sucking) and her attempt to involve her younger brother in
sexualised behaviour. The combination of these factors and the fact that
these are recent changes are strongly suggestive that something was wrong.
The sexual abuse of a child generates massive guilt for parents (excepting
cases where the parent is responsible), but for a child with learning disabili-
ties, the anguish generated can be enormous. Parents of disabled children
often feel over-protective towards them and are acutely aware of their
children’s vulnerability. They know that their children have few defences
against the duplicitous behaviours of child abusers. Also, although sexual
knowledge is no protection against abuse, parents can be particularly reluc-
tant to talk about sexual matters with children with learning disabilities.
In their assumptions about what children need to know, they may be
guided by the child’s level of cognitive, rather than sexual development
and then blame themselves when children are unable to distinguish abuse
from other behaviours. Nina has faced the additional trauma of the death
of her mother and Mr. Dewan may feel that the challenges of raising
three children have left him with reduced time to spend in protecting
his daughter. However, in much the same way as we must impress on
children that they are not responsible for their own abuse, we must also
reassure parents that although we can help them to improve parenting
skills and protective care, they are not responsible for abuse that happens
outside of the home. The only person responsible for the abuse is the per-
son who committed it—Nina’s teacher. As is clear, though, Mr. Dewan
is tortured by self-blame but his response to what has happened can only
compound Nina’s distress and confusion. Support for non-abusing par-
ents can be even more crucial than support for the child as helping par-
ents to recover is one of the most effective ways of helping their children.
Later, we discuss crisis intervention as a social work approach to help Mr.
Dewan regain his role as a parent, but for now we turn our attention to
Nina. Should she be provided with therapy and, if so, what form of help
is appropriate?
In terms of determining whether Nina needs therapeutic support,
Allington-Smith et al. (2002, citing Finkelhor and Berliner 1995) point out
that ‘sexual abuse is an experience and not a disorder or a syndrome. The
experience can lead to disorders and syndromes but up to 40 % of sexually
abused children … are asymptomatic at the time of presentation. Some may
develop symptoms later. This leads to the question of whether all children
who have been abused should be offered therapy’ (68). A review of 45 stud-
ies comparing sexually abused children with children who had not been sex-
ually abused (both groups having been referred to child psychiatric services)
found that the first group presented with two symptoms that differed from
the other children: sexualised behaviour and post-traumatic stress disorder
(Kendall-Tacket et al. 1993 in Allington-Smith et al. 2002). The study con-
cluded that not all children who have been sexually abused will need thera-
peutic help but that there are symptoms that do indicate the need for an
intervention. Treatment is more likely to be needed among children who:
• Are older
• Have experienced oral, anal or vaginal penetration
• Have been subject to a high frequency of abuse
• Have endured abuse over a long period
• Had a close relationship with the perpetrator
• Lacked maternal support
• Had experienced the use of force
(Allington-Smith et al. 2002, citing Kendall-Tackett et al. 1993).
The findings of Kendall-Tackett et al. were not specifically related to chil-

dren with learning disabilities but Nina matches this taxonomy on three
counts: she is an older child, had a close relationship with the perpetrator
and lacks maternal support; on this basis, therapeutic support would be
appropriate. At this stage, we do not know the frequency of abuse, whether
force was used or whether any penetration took place. We believe that the
abuse may have started a year ago, but children with Down syndrome often
have limited memory recall and from Nina’s perspective, the ‘special relation-
ship’ she had with her teacher may have existed as long as she can remember.
The key to supporting children with intellectual and sensory impair-
ments is effective, developmentally appropriate communication. Each
child will have his or her unique communication style, and if the profes-
sional does not have the skills to be able to communicate with Nina, then
it may be necessary to work alongside a sign language interpreter. Nina
may use sign language but she has 20 % hearing and so she may supple-
ment her hearing by lip reading or use a hearing aid or she may use a
combination of words, gestures and pointing. Whatever her usual method
of communication, this should be adopted as the medium for therapeu-
tic work. Although there may be few sign language interpreters in some
countries in the Caribbean, it is important that practitioners avoid the
temptation to use Nina’s teacher or father to help with communication, as

this may be an inhibiting factor and restrict what the child is able to say.
Another factor to take into account is Nina’s level of cognitive impairment
since it is important to ensure that the methods used are developmentally
appropriate. The term ‘learning disability’ covers a constellation of gener-
alised conditions and specific disorders and spans a range of intellectual
impairments and differing abilities. Down syndrome itself impacts chil-
dren differently, and although the condition affects attention, learning,
memory and judgement, there is nothing uniform or predictable about its
manifestations. Children’s needs are further complicated when there are
sensory impairments, mental health issues or physical disabilities. When
children with learning disabilities experience trauma, the behaviours they
present can easily be wrongly attributed to their disability or to assump-
tions about the onset of other disorders. With these complexities to con-
sider, there can be no standard treatment approach—what works with
Nina may not be appropriate for another child, but the skills that are used
are most definitely transferable.
As mentioned earlier, Nina’s receptive language skills (the ability to
understand and comprehend what is said) may be more advanced than
her expressive abilities (being able to put her thoughts into words or
actions). This suggests that the use of experiential, sensory and creative
techniques, such as play and drawing, may be appropriate.
Sensory-based, hands-on methods are an essential part of effective treat-

ment in cases of trauma. For those children who are withdrawn or fear dis-
closure of abuse or violence, the sensory nature of creative activities allows
expression of the unspeakable and circumvents “talk” that may be difficult
or temporarily impossible. For others, the use of creative interventions pro-
vides the opportunity to immediately engage in experiences of mastery over
the events that have disrupted their lives (Malchiodi 2014b, xvii).
Doll Play
Anatomical dolls (dolls that have genitalia) constitute one creative

medium that may be effective for working with Nina. These dolls have
been used for decades by social workers, psychologists, therapists and
law enforcement officers to carry out investigative interviews with young

children and children with learning disabilities who may lack the verbal
ability, vocabulary or cognitive skills to describe sexual abuse.
Many therapists believe that anatomical dolls can help children recall
their experiences and to provide the detail of an offence that can aid
treatment plans. For children who have been coerced, frightened or
shamed into silence, they can be a means for children ‘to tell without
telling’ (Welsh 2007, 257). As a method for gathering information for
criminal proceedings, however, anatomical dolls can lead to false claims
and some jurisdictions do not allow evidence gathered in this way at all
(Faller 2005; Dickinson et al. 2005). There are a number of reasons for
this. For instance, the influence of the interviewer—use of leading ques-
tions, prompts and pointing to parts of the doll’s genitalia—has been
shown to lead to false memory, and even though young children can often
accurately remember what happened to them, they are also extremely
suggestible (Welsh 2007). Another challenge is that pre-school-age chil-
dren and children with intellectual impairments lack perceptual capacity
for cross-mapping their body’s experiences onto the body of dolls. They
do not have a sense of body as a representational schema outside of their
immediate and literal realities. They cannot show abuse happening to a
doll, because it did not. Welsh explains it like this:
Just imagine being given a small doll and being told: “With the doll, please
represent how you served a tennis ball last Saturday,” or, “Take this doll and
show me the difference between a tango and a foxtrot.” A more accurate
recall would likely spring from you describing your entire experience or
re-enacting it yourself and not from trying to use a figure to re-enact a
particular moment. We simply do not add up moments of experience into
a whole and then recall them at will. Lived experience is so much more
than the motions our bodies make in an abstract space (2007, 261).
Welsh continues: ‘A small, ragdoll is simply not a person for a 3-year-

old even if it arrives with a small cloth penis or vagina. For the pre-
schooler, asking her to act “as if ” is not a possible world’ (2007, 265). We
are told that Nina is functioning at the level of a seven-year-old, but we
do not know to what aspect of her development this refers. It is likely that
she, as a child with Down syndrome, will have some level of difficulty
with perception and recall, and although she may be at a more advanced
stage of cognitive maturity than a pre-school child, she may be no more
able to use a doll to re-enact abuse than a three-year-old or than you or
I could to demonstrate the foxtrot. But the fact that Nina may not be
able to ‘abstract herself from her own existence’, to borrow Welsh’s phrase
(Welsh 2007, 265), does not mean that she does not know what hap-
pened to her. Although anatomical dolls may not be helpful in getting
Nina to re-create the abuse in order to produce evidence for court, their
use in non-directive play may help her express feelings and sadness in a
way that gives her a sense of control. The question arises then, why not
simply use ordinary dolls—why anatomical dolls? It cannot be denied
that many people find dolls with genitalia freakish; we are all accustomed
to asexual dolls and the idea of introducing even the idea of sex into the
imagination of children’s play is anathema to many.
Anatomically correct dolls appear at first glance to be rather perverse

things. The combination of a small toy with complete genitalia seems to
bring the sexual into a realm reserved for the innocence of childhood.
Certainly, no small part of this reaction is our own upbringing where
despite Barbie’s prodigious breasts, her pelvis area is simply smooth. Ken,
perhaps more amusingly, wears a permanent set of plastic underpants. Soft
dolls tend to have no buttocks, the legs reach straight to a rectangular torso.
Gender is marked more by the length of hair rather than any distinguish-
ing bodily features. My, as I imagine many women’s, most interesting doll
“down below” was one that you could feed and the food came out on a
small diaper. But even this doll, who possessed a rather disturbing perma-
nently open anus, did not possess any distinguishing genitalia (Welsh
2007, 256).
We must remember, though, that children are sexual beings; Nina,

entering puberty, is likely to have sexual feelings, but even if not, the
abuse she experienced has generated sexual awareness (as evidenced by
her sexualised behaviour towards her younger brother). Sexual abuse
causes huge anguish for children about boundaries, the body, pleasure
and guilt, what is appropriate, what makes people angry or sad. Once
Nina becomes accustomed to the idea of dolls with genitalia, their use
may be an effective non-verbal method to help her create some order in

an experience that will have left her deeply confused. Our argument is
that rather than seeing anatomical dolls primarily as a forensic tool, we
should view them as a method for helping children re-establish, through
play, some of the boundaries and roles that make them feel safe. Therefore,
our recommendation is to have anatomical dolls (a whole family of them)
available as a one of the therapeutic aids children can draw upon. The
play should be child-directed; the professional should take her cues from
what the child says and does, not the other way around. We illustrate this
in the example below:
A 5-year-old girl who had been abused by her father played out all kinds of
sexual combinations between the male and female dolls, for example,
father and grandmother, grandfather and mother, mother and father,
brother and sister, father and daughter, mother and son. She seemed com-
pletely confused, the game becoming quite frantic. The dolls were also
required to change clothes as if in an attempt to disguise, for example, the
mother as grandmother for the grandfather to partner. It looked as if the
child could make no sense of it in her own mind—would change in appear-
ances be enough to convince herself or me that it was acceptable? All the
combinations made this little girl equally anxious. The game with the dolls
ended repeatedly with them being put to bed, laid side by side making sure
that the mother was between the daughter and the father, the grandmother
being given the position of authority as the head of the family. In the game
the mother was given the role of protecting the daughter, which in reality
she had been unable to do through necessary absence. In her games the
child seemed to be trying to structure the family in its boundaries and
hierarchy as she wished it to be for her own safety needs. The influence of
other family members, especially that collusive aspect which mothers can
unconsciously or half-consciously adopt, is important and, although pas-
sive, actively colludes with the abuse (Sagar 2002, 97).
The purpose of therapy is to help a child deal with their reality—imagine

Nina in place of the five-year-old child and think about the potential of doll
play in helping her to deal with her reality: her mother is dead, the teacher she
trusted and made her feel special has abused her and has gone, her father has
withdrawn from her, she is sad and feels alone. Playing with a family of dolls
that stand as proxy for her own family can enable her to position them in the
spaces and places that make her feel safe or that express her confusion. Where
might she choose to position her mother (though dead), for example, or her
father, grandmother, brothers, and even the teacher who abused her? The
verbal and non-verbal messages she sends are powerful cues for the worker
to guide her as she attempts to ‘sort out’ her own family. Even though the
role of therapist in this instance should be primarily one of observation and
accepting and reflecting back emotions, the opportunity may arise to resolve
confusion. For example, by using play to help Nina re-bury the mum doll (a
later suggestion to dad to follow up with a visit to the graveyard might be a
good idea too) and depending upon where the teacher doll has been placed
(if he is in the scene at all), the worker might want to explain that he has
done something very wrong and to ask Nina where she thinks he should go
(having dolls with genitalia might be crucial here in helping Nina understand
what was wrong); also, it might be a good way to end a session like this by
making sure the little girl doll gets extra hugs from the dad doll. Clearly, these
are ideas based on imaginary happenings, but you get the picture.
Drawings
Children’s drawings have been used by therapists as a non-threatening

way of getting children to express their feelings and to gain a bet-
ter understanding of the meanings children ascribe to their experi-
ences of abuse (Malchiodi 2014) (Case & Dalley 2002). There are
dangers, however, of adults overlaying their own meanings onto chil-
dren’s drawings, and Angelides and Michaelidou (2009) suggest that,
in order to avoid this, the adult must engage in conversation with
the child about the drawings as they happen. Drawing is something
that most children enjoy and our technique for working with Nina
is to marry Angelides and Michaelidou’s (2009) sensitive approach
to exploring children’s drawings with Steinhardt’s (1985) body out-
line technique, which is more directive. The body outline technique
consists of placing the child against a piece of paper (on the floor or
against a wall) large enough to fit their body and then drawing around
the body. The child then fills in the ‘body space’ as she or he wishes
(this may take more than one session). The method is common in
art therapy and with children of all ages—for very young children
(Santen 2014) and children with learning disabilities, it is a good tech-
nique for helping children develop body awareness and to learn about
the names, function and relationship of body parts. As children draw
objects in their bodies, clothe them or colour them, the worker should
engage in conversation with the child to explore the meanings of the
drawing—in this way, the child’s story (whatever story the child wants
to tell) unfolds. So, for example, Nina draws an object in the middle
of the body and tells you ‘it’s the girl’s heart’, you might respond by
saying ‘oh, but it looks as if it is in the same place as her stomach’, ‘yes
it eats a lot so it has to be there’. Without imposing meaning inap-
propriately, Nina’s revelation may relate to a problem with over-eating;
her linking of the heart with the stomach may be an insight into the
possibility of this being a response to her distress (‘comfort’ eating
is a common response to stress and unregulated emotions). Another
example demonstrates the importance of sensitive exploration on the
part of the therapist. Imagine that on the head of the body, rather than
the straight black hair she has, Nina has drawn something that looks
like a bird’s nest. Rather than asking what it is or why she has drawn
the hair that way, the viewer, following advice from Angelides and
Michaelidou’s article on the role of art in addressing children’s margin-
alisation (2009, 31), would describe what she sees in the drawing. ‘I
can see some squiggly lines going round and round her head’ and then
wait for Nina’s response—‘most of the time children will add further
information’. Nina states ‘her hair needs combing’. The therapist can
facilitate conversation by thinking aloud about the drawing—‘I won-
der who could brush her hair’, ‘I bet she likes it plaited with a hair
slide at the side’ and so on. Perhaps Nina will explain why her hair isn’t
combed—she might say something like ‘Daddy used to comb it but
he’s not well’ or ‘She’s not combing it till her mummy takes her to get
it cut’. As Angelides and Michaelidou state, ‘by showing our interest
with open questions we give children the chance to explain the differ-
ent elements of their drawing from their point of view’ (2009, 32) and
provide them with the opportunity to express feelings that otherwise
might be repressed. Nina’s drawing may contain significant emotional
content, yet by drawing within the boundaries of her body’s outline,

she is able to contain emotions that may actually feel out of control for
her for much of the time.
Steinhardt (1985) points out that doing a body outline for the first
time can generate anxiety for children and that the therapist can help by
discussing whether the child would like to take a particular position for
the drawing and what colours they might like to use. ‘The simplest posi-
tion is lying on the back with hands and feet straight down or pointing
slightly outward. … The simple form has the great advantage of being
the actual size of the child, who is usually surprised to see how big he or
she really is. Incredulous reactions often follow as the child steps back to
view himself or herself, contrasting the proof of growth on paper with the
previous internalised image of the self as very small’ (1985, 26). For chil-
dren who have been sexually abused, it can be helpful to talk about things
that happen to the body: ‘If these parts could talk, what would they say?
What has happened to them? What do they remember? … Does his head
remember being patted, his hair being cut or combed?’ (Steinhardt 1985,
29). In the example below, Steinhardt demonstrates the ways in which a
child’s trauma may surface when using the technique.
Yosi, a ten-year-old, very angry and destructive child, agreed to do a body

outline… and chose black for the outline. The first thing he drew was an
arrow sticking into the stomach of his outline and “killing” himself. At that
moment I felt that not only was Yosi testing me, but that it was an inap-
propriate point in our relationship to explore his feelings of self-destruction.
So I “saved” him by obliterating the wound and elongating the arrow, as if
it were stuck into a belt. However good my intentions, they apparently
denied Yosi’s feelings, and he continued to project his violent imagery by
changing the drawing from an Indian, to a hunter, to an arms smuggler;
unable to focus on any of them he finally abandoned the drawing. I asked
him to do an outline of me, which he did very well, in black again. He
drew inside, making me look diabolically fierce. I accepted the drawing
and hung it, and we went on to talk about his anger aimed at adults who
always disappointed him and certainly did not understand him ... Later
work with Yosi was concentrated on helping him overcome his obsessions
with death, suicide and sickness in his family (1985, 27).
In Part 6, we discuss the role of art for therapeutic purposes in more

detail, but next we turn our attention to helping the parents of abused
children recover from the sense of crisis that can engulf them.
Social Work with Parents: Crisis Intervention
Crisis intervention refers to the approach and techniques used by social

workers to help an individual or family in crisis; as a social work method,
it has a long history. The method seeks to help individuals and families
achieve a level of functioning as good as or better than their management
of their problems up to the pre-crisis point (Goff and Smith 2005). A
crisis (key terms in this discussion are italicised to emphasise their sig-
nificance for this approach), as defined in Parad and Parad (1990), ‘is an
upset in a steady state, a critical turning point leading to better or worse,
a disruption or breakdown in a person’s or family’s normal or usual pat-
tern of functioning. The upset, or disequilibrium, is usually acute in the
sense that it is of recent origin’ (cited in US Department of Health and
Human Services 1994, 15). The term ‘crisis’ as used within this method of
intervention refers to an individual’s inability to solve a problem because
of a precipitating event. Although one might consider the event to be the
crisis, it is actually the inability to cope with the event that is the crisis. A
problem may create stress and difficulties; however, if this can be resolved
through the use of problem-solving repertoires without external help, this
is not a crisis. Crises may be caused by anticipated events (such as child-
birth or death following a terminal illness) or unanticipated events (such
as natural disasters, accidents, loss of employment or child abuse). These
events are part of human life experiences and usually invoke psychologi-
cal responses that strive to maintain a level of equilibrium by drawing on
internal coping strategies that are familiar and have worked in the past.
Problems occur when the precipitating event causes such imbalance that
usual coping mechanisms do not seem to work, the person is unable to
function or the event has reactivated an earlier unresolved crisis that gener-
ates feelings of helplessness. As the US National Center on Child Abuse
and Neglect (1994) points out, in the field of child protection, family
crises are common:
A child’s disclosure of sexual molestation, the birth of a drug-addicted

infant, the discovery of a teenager’s dependence on drugs, a parent’s arrest
for violent behavior, the threat of a family’s eviction from public housing,
or a parent overwhelmed with the needs of a child illustrate just some of
the crises experienced by families. Although the state of crisis is short lived,
generally lasting 4 to 6 weeks, it is a period of heightened family vulnerabil-
ity and imbalance that requires a carefully planned response (US National
Center on Child Abuse and Neglect 1994, 15).
A crisis that threatens to overwhelm the individual or family can pres-

ent a significant risk as it can lead to a chain of other problems and may
contribute to mental illness, relationship problems, difficulties in parent-
ing children, inability to manage finances, household and job responsi-
bilities or even the breakup of the family.
Crisis intervention is a strength-based approach which works to enhance
and use individual or group resilience in problem solving. Resilience can be
summarised as the capacity to resist or bounce back from adversity. Crisis
intervention work enables clients to use this capacity to discover their poten-
tial for problem solving. A person in crisis is at a turning point; though faced
with a heightened level of stress and anxiety, he or she is more likely to be
receptive to the idea of change and, if new problem-solving methods are
found to be effective, may adopt these strategies in the future. Because the
client is open to new approaches and positive therapeutic influences, crises
present a unique opportunity for change. Crisis intervention is an inexpen-
sive short-term time-limited method of intervention that focuses on solving
specific and immediate problems; the goals are to reduce the individual’s
feelings of distress, helplessness and isolation; to activate social and personal
resources; and to enable effective coping. The ability to cope with stressful
life events is influenced by attitudes and beliefs and wider environmental cir-
cumstances. Families that have demonstrated good coping skills through past
adversities and are temporarily overwhelmed can benefit most from the crisis
intervention method; however, seriously dysfunctional families, families in
which there are long-standing child protection issues or families that seem to
be in a perpetual state of crisis are less likely to change by using this approach.
An initial assessment should determine the extent to which a family or
individual may be helped—crisis intervention is not a suitable method
for everyone. It is not appropriate, for example, in working with people

who seem to have chronic difficulties in coping or who have intractable,
long-standing social or relationship problems. Indeed, in some families,
how the individuals respond to problems may actually cause the event
that precipitates the crisis:
People with chronic coping difficulties tend to be constantly in stressful

situations and must cope with several major problems which occur simul-
taneously. ... Any new stress, such as the utilities being disconnected, may
be “the straw that breaks the back” of these families. Instead of being sup-
portive to each other, family members try to place blame. Arguments or
violence between the adults may lead to child abuse or neglect or vice versa
(US National Center on Child Abuse and Neglect 1994, 18).
In Nina’s case study, there are potentially three people who are in crisis:
Nina herself, her father or even her older brother Kamal. Crisis interven-
tion is a useful method for working with individuals, but in a case such
as this it would be more beneficial to work with the family system (James
and Gilliland 2013); this is because, restored as an effective father, Mr.
Dewan is the best person to help his children. The social worker’s early
decision about the focus of the intervention will determine how the work
proceeds. Crisis intervention is guided by overarching principles aimed at
stabilising and strengthening family functioning:
• Relieve the acute symptoms of family stress

• Restore the family and family members to optimal pre-crisis levels of
functioning
• Identify and understand the relevant precipitating event(s)
• Identify remedial measures that the family can take or that community
resources can provide to remedy the crisis situation
• Establish a connection between the family’s current stressful situation and
past experiences and initiate the family’s development of new ways of per-
ceiving, thinking and feeling and adaptive coping responses for future use
(Rapoport 1970, 24).

The key terms that are important to understand when using crisis inter-
vention social work are precipitating event, equilibrium-homeostasis, imbal-
ance, coping strategies, unresolved crises, resilience, time-limited and steady state.
The precipitating event for the purposes of a family-system interven-

tion is the discovery by Mr. Dewan that his daughter has been sexually
abused by her teacher (had our focus been on strengthening Nina’s abil-
ity to cope, the precipitating event may have been her favourite teacher’s
sudden absence from her life, and had our focus been on helping Kamal,
the precipitating event may have been his father’s drinking relapse). In
using a systems approach, the focus of the intervention will be on helping
the family restore functioning to a level as good as or better than its pre-
crisis state by drawing on the family’s strengths and helping Mr. Dewan
to problem-solve. The genogram and ecogram provide the social worker
with a symbolic representation of the patterns of relationships over time
and the wider support systems that can be used. Our intervention begins
with an assessment of family functioning to determine how the crisis
has affected the different dynamics within the family system (Myer et al.
2013).
According to Myer et al. 2014), a family’s usual developmental trajectory

becomes disrupted when a crisis occurs consequentially changing the
nature of relationships among family members within the family system.
The experience of a crisis is dependent on the meaning the family assigns
to a specific event…and/or its impact on the ability of the family to main-
tain normal levels of functioning...The crisis can be perceived to disrupt six
common family characteristics: (a) roles, (b) boundaries, (c) communica-
tion, (d) rules/processes, (e) goals, and (f ) values. Understanding these
characteristics from the crisis intervention perspective can help mental
health professionals provide more effective and efficient crisis intervention
services to families (Myer et al. 2014, 180).
The discovery of Nina’s abuse is a crisis because it has created an imbal-

ance in the family roles, boundaries, communication patterns, rules,
goals and dynamics. Coping strategies that worked well in the past are
not helpful for the current problem partly because they have reactivated
the earlier crisis caused by Mrs. Dewan’s death, which precipitated Mr.
Dewan’s periodic drinking bouts. Mr. Dewan’s alcohol problem has been
a long-standing threat to the family’s state of equilibrium. Nevertheless,
this is clearly a family with a high level of resilience, and a time-limited
intervention that helps to restore the system to a steady state is likely to
be beneficial. Crisis intervention focuses on a few specific goals chosen

by the family. The intervention is time-limited, usually between 4 and
12 weeks, and involves the following nine steps:
Step 1: Rapidly Establish a Constructive Relationship

In the first step, the emphasis is on the worker’s sincerity, respect
and sensitivity to clients’ feelings and circumstances. Crisis workers
must listen and observe for long periods of time. ... By assuming
that clients are motivated, they are supported in thinking through
their solutions, which enhances their self-respect. “The worker ...
must assure that the client feels that something useful has been
accomplished in the first session and that there is promise of some-
thing useful being accomplished in the next”. Rapport is enhanced
by showing respect and unconditional positive regard for clients.
Step 2: Elicit and Encourage Expression of Painful Feelings and

Emotions
Anger, frustration and feelings related to the current crisis, rather
than issues in the past, are the focus of the intervention. Linkages to
past crises and repetitive, ineffective responses to problems can be
explored at a later time.
Step 3: Discuss the Precipitating Event

After rapport is established, the focus turns to the family percep-
tions of the situation, the chain of events leading up to the crisis and
the problem that set off the chain of events. Discussions examine
when and how the crisis occurred, the contributing circumstances
and how the family attempted to deal with it.
Step 4: Assess Strengths and Needs

Family assessment of strengths and needs begins immediately and
continues throughout crisis intervention. The crisis worker draws
conclusions regarding the family’s strengths and needs related to
the current crisis and, with the family, evaluates the potential for
recovery. Client strengths are tapped to improve self-esteem while
also providing energy and skills for problem solving.
Step 5: Formulate a Dynamic Explanation

This step looks for an explanation not of what happened but why
it happened. This is the core of the crisis problem. The meanings
of the crisis and its antecedents as seen by the clients are explored.
Why do they ascribe that meaning or perceive it as they do?
Step 6: Restore Cognitive Functioning

In this step, the crisis worker helps the family identify alternatives
for resolving the crisis (i.e., reasonable solutions towards which the
family is motivated to work).
Step 7: Plan and Implement Treatment

The crisis worker assists the family in the formulation of short- and
long-term goals, objectives and action steps based on what the fam-
ily chooses as priorities. With a concrete plan of action, the family
feels less helpless and more in control, allowing members to focus
on action steps. Objectives and action steps need to be simple and
easy at first, ensuring client success. The family members are respon-
sible for action steps or homework, but the crisis worker continues
to counsel them, seeks to help find appropriate resources in the
community, and becomes the family’s advocate.
Step 8: Terminate
Termination occurs when the family achieves its pre-crisis level of
stability. Crisis workers review with the family the precipitating
event(s) and response(s) and the newly learned coping skills that
can be applied in the future. The crisis worker ensures that the fam-
ily is scheduled for meetings with, and committed to, any necessary,
ongoing community services.
Step 9: Follow-up
Crisis workers arrange for continuing contacts with families and
referral sources on predetermined dates or say “I’ll be contacting
you soon to see how you are doing”. This puts appropriate pressure
on families to continue to work on issues in a positive way.
(US Department of Health and Human Services 1994, x–xi).
Applying the Model
During the initial session with the Dewan family, the social worker iden-
tified changes to functioning in each of the areas specified by Myers et al.
(2014); these are discussed below.
Roles
Myer et al. (2014) suggest that the most visible change within a family in
crisis consists of the roles its members play. In a crisis, roles within fami-
lies become blurred or distorted and sometimes family members take on
the role that is not usually ‘assigned’ to them or is a role usually filled by a
person who is now absent. The unresolved crisis triggered by Mrs. Dewan’s
death five years earlier resulted in a change in family roles: Mr. Dewan
became the primary caregiver, a role that, though performed inconsis-
tently, was buttressed by Kamal’s taking on increasing responsibility for
the care of his siblings and this enabled the family to continue function-
ing. Changes in the roles of family members are an adaptive strategy that
enables families to restore the imbalance caused by a crisis (Gillespie and
Campbell 2011); however, the current crisis has led to Mr. Dewan all but
abandoning his parental responsibilities. As Mr. Dewan is now, in effect,
the absent family member, Kamal has had to assume the full care of the
family. The shift in roles in this new crisis is not adaptive; it has occurred
because the father is overwhelmed. Without intervention, this is likely to
trigger a chain of other problems: Kamal may run away from home, he
may take up drinking like his father or the children may be neglected. At
the very least, this new shift in roles is likely to cause conflicts (Rosenfeld
et al. 2005). Thus, as Myer et al. (2014) explain:
assessment of the nature of the changes to roles within the family is critical for
effective crisis intervention as it offers an understanding into one aspect of the
chaos and conflict that may be observed in a family system during a crisis (180).
Boundaries
The boundaries that exist within a family system serve an essential child-
rearing function: they help to regulate behaviours; they establish rules,
expectations and responsibilities; they provide the framework for intra-
family interactions and they set the parameters for routines, family chores,
family celebrations and so on. Boundaries are dynamic and permeable and
become established through complex patterns of communication based on
family relationships, needs and circumstances. Family boundaries can be
severely disrupted by periods of crisis and can be ‘made more permeable
or rigid depending on a family’s perception of the crisis and the manner in
which boundaries are used’ (Myer et al. 2014, 181). One of the key func-
tions of parenting is to establish boundaries for children, and in abandoning
his paternal role, Mr. Dewan has caused anxiety and insecurity, especially
for the two younger children. By focusing on re-establishing an effective
father role, the social worker can help the family to avoid the development
of dysfunctional relationship patterns (Brown and Manning 2009).
Communication
Boundaries and role expectations are transmitted within a family through

a complex array of communication methods. A hug for Nina because she
has tidied her bedroom is one way of communicating expectations about
the sharing of chores; parental disapproval expressed in a look or gesture
may be enough to remind little Tanik that he is not permitted to repeat
the swear word he has picked up from outside, and a sarcastic comment
to Kamal about his trousers hanging down can reinforce rules about
school uniform: these are all different examples of the myriad methods
of communication that help to maintain boundaries, rules and roles. In
a crisis, usual forms of communication can be drastically altered or trun-
cated (Tjersland et al. 2006) or, as evident from Mr. Dewan taking to his
bed, may be shut down altogether.
The shift in communication depends on unique and idiosyncratic family

characteristics, the family as well as the nature of the crisis. … For example,
a family’s previously established communication pattern influences the
nature of the changes in family communication during the crisis (Myer
et al. 2014, 181).
Although we do not know the pre-crisis communication patterns

in the Dewan family, this complete withdrawal is not an established
behaviour and therefore is an indication of how serious the crisis is
for Mr. Dewan. The closing down of communication will seriously
limit the family’s ability to adapt to the new situation and may set
up a chain of other difficulties. The children will often interpret a
parent’s emotional withdrawal in ways that generate anxiety. Tanik,
who may have insecure attachment issues related to the death of his
mother, could perceive this as a loss of his daddy; the boy has also
lost his playmate. Unable to understand this change in his father’s
behaviour, he may externalise his anxiety and present behavioural and
emotional difficulties. Nina, on the other hand, might associate her
father’s withdrawal with her disclosure of sexual abuse and this would
generate feelings of self-blame and guilt. Mr. Dewan, staying in bed,
may also trigger memories of her mother’s terminal illness and could
reactivate unresolved loss. With limited cognitive ability, Nina has

fewer psychological and linguistic tools to help her process and make
sense of what has happened; her enuresis, aggression towards Tanik
and problems at school are in danger of becoming worse. Kamal’s feel-
ings may fluctuate between sadness and anger; however, the longer the
lack of communication persists, the more likely that Kamal will begin
to feel resentful, anxious about the future and unable to cope himself.
Kamal may react in any one of a number of ways to these feelings,
including fleeing from the family situation completely. Re-establishing
healthy communication patterns can be a very effective way of helping
the family to regain a sense of equilibrium; indeed, this is the first step
towards problem solving (Hoff 2009).
Rules
Procedural rules are the guides and customs that enable families to
maintain a state of homeostasis (Myer et al. 2014). In periods of cri-
sis, the rules and processes may be abandoned, altered or disregarded.
Where this occurs as a consequence of the family’s healthy adaptation
to new circumstances, stability does not need to be threatened. In the
Dewan family, however, the deviation from family rules is a conse-
quence of a breakdown in the family system; it is not a coping strategy.
Kamal, as de facto head of the household, may decide to disregard the
usual rules about mealtimes, bedtimes, school attendance, hygiene and
behaviour or alternatively he may impose a new set of rules to help
him to manage. Any changes in the Dewan family rules that are not
part of the renegotiation process that healthy families engage in when
there is a problem event can generate feelings of confusion and inse-
curity for children.
Children are particularly vulnerable to changes in family processes. A child

may act out or rebel when previously stable expectations or rules are altered.
This rebelliousness has the potential to cause significant stress in the family
and precipitate an additional crisis in itself which complicates a family’s
ability to resolve the crisis (Myer et al. 2014, 182).
Goals
‘Family goals provide motivation for families to engage in positive inter-

actions and functional behaviors to achieve those goals’ (Myers et al.
2014, 182). The insecurity and uncertainty generated in times of crisis
can lead to an abandonment of long-term goals as people’s energies are
focused on getting through each day. Mr. Dewan may be consumed by
self-doubt in terms of his ability to provide for his family, and his drink-
ing and avoidance of work are possibly the first steps in fulfilling such
a prophecy. Ensuring his family’s material well-being is unlikely to be
perceived as a priority anymore and may even seem to be irrelevant given
what Nina has experienced. There is a real danger at this time that ‘family
goal setting may shift from being primarily a rational intellectual process
to an emotional process’ (Myer et al. 2014, 182). When Mr. Dewan sur-
faces from his immediate distress, there is a likelihood that his emotional
reactions will drive him to make shortsighted decisions that are coun-
terproductive; he may, for example, decide that Nina should move to
another school or he may decide to relocate his family again. This flight
response is understandable but is unlikely to provide his children with
the stability that they need. Crisis intervention work should include help-
ing the family to avoid making hasty, poorly thought-out decisions and
to hold on to the elements of family life that are predictable and secure
(Rosenfeld et al. 2005).
Values
Values function as the moral compass for a family and help its mem-
bers to regulate their own behaviours in line with shared beliefs, atti-
tudes and behaviours deemed to be good, healthy or appropriate. The
values transmitted within a family system influence how people treat
each other, how they relate to the external world and what personal
goals they set for themselves (Greenstone and Leviton 2002). Values
are often changed as a consequence of a crisis; these changes may be
minor or they may be quite significant. Assessing the extent to which
family values have been altered is an important source of information
for the social worker. A family which has strong religious beliefs and
which ceases attending the church or mosque, for example, may be an
indicator of incapacity to cope. Alternatively, such a change may indi-
cate a healthy adaptive strategy; a parent plunged into crisis because a
child has suddenly died and who responds by renouncing their faith
may find this helpful for the channelling of anger. However, this also
closes off a potential source of support and strength that has helped the
person cope with problems in the past, and can leave them isolated.
Changes to the value base of the family can often be picked up on by
assessing alterations in interactions and behaviours; the teenager who
starts truanting from school, the previously fastidious mother who now
remains all day in her night clothes, the father who refuses to get out
of bed to go to work in the morning or sustains his working routine
but no longer comes home for dinner with the family; these can all be
indications of a family struggling to cope. Within a family that holds
strong beliefs about the sanctity of childhood innocence and an abhor-
rence of child maltreatment, such as we assume of the Dewan family,
the sexual abuse Nina has been subjected to will be devastating. An
integral aspect of Mr. Dewan’s masculine identity is likely to be a belief
that paternal authority and wisdom position him as the protector of
his children. At an emotional level, we can expect him to have feelings
of rage, disbelief, denial, guilt and despair and his withdrawal from the
family shows that these feelings are internalised. He is unable to face
his daughter because he probably feels a great sense of failure that he
was unable to protect her; at the cognitive level, he may also be bat-
tling with imagining the details of the abuse. We must remember too
that values about sexual boundaries between adults and children have
been significantly altered by this crisis. At some point, as Mr. Dewan
begins to move on from his state of crisis, we can expect his feelings to
become externalised (although both internalisation and externalisation
features of distress can exist simultaneously); this is when his anger will
be directed towards others: the school, for example, may be criticised
for not doing more; the teacher may become a target for revenge; and
the police may be harangued about the pace of the investigation. Once
Mr. Dewan begins to gain some control over the situation, he will be
able to re-assert and possibly strengthen the family’s values.
In the social worker’s first session, he or she assesses that Mr. Dewan is
in a crisis state. Before the real work can begin, the social worker allows
and encourages the ventilation of emotions; anger, incoherence, crying,
repetition and internalisation and externalisation are all to be expected.
Through encouragement, the goals that Mr. Dewan sets focus on two
aspects of the family’s needs: his becoming the father that his children
need and improving the communication within the family. It is hoped
that improvements in these two areas will lead to the re-establishment of
boundaries, rules, goals and values. The social worker helps Mr. Dewan
to focus on what being a good father means and this leads to an early
recognition that urgent arrangements need to be put in place to improve
the day-to-day care of the children while he gets himself together. The
ecomap helps him to focus on the resources available to him; he asks his
mother to come and stay at the house for a few weeks. With the paternal
grandmother in the home, Kamal is released from his caregiving respon-
sibilities and Mr. Dewan has support with babysitting and managing the
younger children. However, Mr. Dewan is consumed with guilt and rage
about what has happened to Nina and it is clear that these feelings are a
constant threat to any progress. Mr. Dewan readily agrees to the sugges-
tion by the social worker that he should request a meeting involving the
school principal and the psychologist that worked with Nina in the past.
At this meeting, Mr. Dewan vents his anger about the school’s failure to
protect his daughter, but over the course of the meeting the conversation
shifts to how they can work together to support Nina through this. Mr.
Dewan is given advice by the psychologist about language and strate-
gies he can use when Nina acts out and how he can provide reassurance
that she is not at fault. The principal agrees to put in place additional
support measures, including an honest, child-appropriate explanation
for Mr. Johnston’s expulsion from the school. The psychologist offers to
support Mr. Dewan through the police investigation and court proceed-
ings and suggests that he think about whether Nina would benefit from
professional help herself. He accepts the help for himself but decides that
what Nina most needs is for the family to settle back into its usual daily
routines with minimum outside involvement. Mr. Dewan still feels ter-
rible about the abuse his daughter suffered but he begins to realise that
they can move on from this; he intends to use every opportunity he can
to let her know how proud he is of her. Another goal Mr. Dewan sets for
himself is to improve his communication with his children. He brings
the family together and explains that he has not been feeling well but is
much better now; he suggests that they begin to plan a family holiday
because they have all put up with a lot. He hopes that Nina will interpret
this as a sign that he is not angry with her. He also resumes his Saturday
playtimes with Tanik. In a conversation with Kamal, he apologises for
leaving his son to manage things and asks Kamal what changes he would
like to see. Kamal takes the opportunity to ask his father to get help with
his drinking problem and says that he is worried his father may lose his
job. In the next session with the social worker, Mr. Dewan agrees that
he will contact Alcoholics Anonymous; his ‘homework’ is to identify a
local branch of the organisation and make contact before their next ses-
sion. Mr. Dewan also decides to tell the human resources department in
his company that he needs their support; they agree that when the time
comes he will be able to take time off to attend court and they refer him
to the employee assistant programme in the event that he would like to
access counselling. It is now 6 weeks since Mr. Dewan has been working
with the social worker; during each session, Mr. Dewan sets his goals for
the next week and already he is beginning to feel more in control. He
can now plan for the time when his mother will return to her own home
but is anxious that the loss of her support will set them all back. His final
sessions with the social worker focus on how not to let this happen. In
the termination session, Mr. Dewan reflects on how much things have
improved, and although he does not believe that controlling his drinking
problem will be easy, he seems willing to seek and accept help if things
become too difficult again.
The Family Group Conference
In our scenario above, we have assumed that Mr. Dewan was responsive to
the crisis intervention approach used by the social worker, but what if he
had not been? What if, instead of agreeing to accept help, he had continued
to drink and to abdicate his parental responsibilities? At the stage we were
introduced to the family, Mr. Dewan’s daughter had been abused, he had
stopped providing care to his children, his eldest child Kamal was no longer
able to cope and the youngest child, Tanik, was potentially at risk of neglect.
On top of these concerns, the family was isolated from the extended family,
Mr. Dewan was in danger of losing his job, and the family’s livelihood was
threatened. Although Mr. Dewan has not physically harmed his children,
the situation is one that contains significant risks, especially for Tanik, who
is only five, and for Nina, who as a 13-year-old girl with a learning disabil-
ity and sexualised behaviour, is potentially vulnerable to further abuse. The
case will have been brought to the attention of the social services (via the
guidance officer or school social worker) because Nina was sexually abused
at school. As a potential child neglect case, an appropriate intervention
would be to conduct a family group conference.
Family group conferencing (FGC) is an evidence-informed family-based
intervention whose main objective is to give the family group (nuclear
and extended family as well as friends) responsibility for decision making
where the safety and well-being of children are a concern. The approach
originated in New Zealand in the late 1980s and early 1990s as a response
to agitation by Maori peoples against institutionalised racism and the
structural disadvantage that resulted in many children living in depriva-
tion and disproportionate numbers being taken into state care. These
concerns were confirmed by a damning report into services for Maori
children. The report called for a new system, one that would embrace
Maori customs, values and beliefs and that, crucially for all families,
would give them the authority for making decisions about their children.
Thus, the family group conference was introduced as the primary mecha-
nism for problem solving in cases of abuse and risk. The model acknowl-
edges that the authority for decision making in regard to children rests
with the family (in its widest sense), with the state (professionals) provid-
ing the support and resources for the family to fulfil its responsibilities.
The FGC model is progressive, participatory and inclusive. In the quar-
ter of a century since it was established, the FGC has been adopted in
many other countries and there now exists a strong body of evidence as
to its effectiveness and the conditions needed for optimal outcomes for
children. However, few jurisdictions have taken the steps adopted by the
New Zealand government and enshrined the model in law, establishing

this as the standard approach that must be used above all others.
The FGC model is premised on the empowerment of the family. It is a
practice that respects culture and family styles of child rearing while combat-
ting practices that may place children at risk. The approach uses ecological
systems theory in that children and their parents are understood as being
nested within a wider kinship network that has a history, unique strengths
and patterns of functioning that can be used to provide support and help.
As Pakura (2005) writes, ‘All families have strengths—it is rare for entire
family systems to be simultaneously in a state of crisis. Strengths are essential
elements in resolving concerns. Family criminality, drug abuse or violence
may limit options for the safe placement of children in families but do not
disqualify families from planning and committing to safe outcomes for their
children. Families know themselves best and are more likely to consent to
plans they develop themselves than those imposed by others’ (115).
In its original incarnation, the model was not envisaged to serve
as a restorative justice process; however, with its victim-centred ethos
and focus on family responsibility, it was quickly adopted both to
generate plans for the protection of children at risk of harm and to
involve families in restorative action aimed at addressing the behav-
iour of juvenile offenders. In New Zealand, the model has served as
an integral part of the child protective system and also as an integral
part of the juvenile justice since the early ’90s. In Australia, Canada,
the USA and several European countries, the model has also been
adopted as a restorative justice process (see Part 4 for more on the use
of the FGC in the criminal justice system).
The FGC model enables families to work within their own ‘cultural
and familial milieu’ (Pakura 2005, 114) and uses indigenous strengths
and therefore is highly appropriate for a Caribbean context. FGC
defines ‘family’ broadly to include people related by blood, includ-
ing the immediate family, extended family and people who have sig-
nificant relationships with the family or child. Fundamentally, FGC is
about empowering this broad kinship group to think about the poten-
tial sources of harm to children, to plan creatively for their children
and, through partnerships with professionals, to use their strengths
to resolve child welfare concerns. The FGC process would be appro-
priate in dealing with most cases of child abuse and neglect in the
Caribbean. We explore its potential to help the Dewan family, but two
other examples illustrate the varied types of cases that are appropriate
for this model of intervention.
Case Example 1:
Sharon, Moesha and Shem are all siblings between the ages of 5
and 12. They are frequently left alone at home, unsupervised, often
for days at a time. Each child has a different father, but no fathers
have ever presented at the home. The children’s mother is away for
extended periods of time and neighbours assume she is out looking
for work or working. In the meantime, older adolescent boys and
adult men have been seen visiting the house. Neighbours are con-
cerned that the children may be at risk of various abuses. They have
called child care services to perhaps remove the children to safety.
The child care authority would contact the children’s family net-
work, both immediate and extended, to give them the opportunity
in an FGC session to resolve this risky situation.
Case Example 2:
Ann-Marie, a 15-year-old girl, gave birth to a daughter two years
ago. Ann-Marie has slipped into a mild state of depression since,
and neighbours claim she has taken up a ‘promiscuous’ lifestyle,
often leaving her two-year-old daughter in the care of older cousins,
both male and female. Ann-Marie lives with her 31-year-old mother
and 48-year-old grandmother, both of whom work outside the
home. A total of five other children under age 16 also reside there.
Family members from a neighbouring village have contacted the
child care authority to ask their assistance in ‘bringing this family
under order, before very bad things happen that did not happen
already’. The child care authority now has the opportunity to help
this family, via the FGC model, to take up the abandoned sense of
responsibility which apparently permeates their household.
These are two examples of cases in which children are deemed at

risk of child sexual abuse, among other harms. In these cases, FGC
provides an opportunity for the families to resolve their own children’s
issues instead of having the children simply taken away by the state.
By placing the central focus of child protection issues into the hands
of families, families themselves are identified as having the ability and
responsibility to alleviate child protection concerns, with support from
professionals. The emphasis on family resiliency, strengths and ability
to problem-solve is a central tenet of Caribbean societies and values
and this is likely to appeal to families accessing or at risk of accessing
the child protection system.
The model operates on the strong presumption that the agencies that
have responsibility for child protection or juvenile justice should fol-
low the lead of the extended family rather than the other way around.
Extended families know their members best and usually are the best
sources of expertise on what should be done about their children and
what conditions are necessary to safeguard children’s well-being (Pakura
2005). Where families are considered to have failed children, it can be
very difficult for professionals to accept that they should have the power
to determine how best to protect them. However, it is important to
acknowledge that the state also fails children in their care but this does
not take away their legal mandate to ensure their protection; it is unfair
to demand a higher standard of infallibility from families. Professionals
can be reassured too that the process requires approval, resourcing and
monitoring of the plans that families put in place and the role of the
professional in accessing resources means that they become the enabler.
The FGC is based on established principles:
• The child and family have the right to participate in decisions that
affect them.
• Families have strengths and resources that they can draw on.
• Child safety and well-being are enhanced by strengthening families
and their networks of support and through shared responsibility for
child welfare.
• Through collaborative problem-solving, families can resolve issues and
develop plans that keep their children safe and well cared for.
• Solutions developed by the family are more likely than those imposed
by professionals to respect and preserve children’s bonds to their fami-
lies, communities and cultures.
• Families are more likely to respect and adhere to plans that they
develop than those imposed on them by professionals.
• To encourage trust and open dialogue, discussions that occur during
FGC are confidential, except where disclosure is required by law (e.g.,
necessary for the child’s safety).
(Knoke 2009, 1).
The FGC process has four phases: preparation, the actual meeting,
approving the plan and (later) reviewing the plan. A coordinator or facili-
tator (a skilled communicator with expertise in group work and mediation
strategies) coordinates and oversees the process. The role of coordinator
is crucial; this should be someone who is impartial and operates inde-
pendently from the professionals who have the authority to accept, reject
or request revisions to the family plan (child protection workers). The
coordinator works with the parents, other family members and also
the child to decide who should be invited to the FGC, what concerns
they may have about the meeting and any of the potential participants.
‘Preparation for the meeting also involves deciding on details of the fam-
ily meeting such as how family traditions and preferences will be built
into the process. For example, the meeting may include prayers, having
a meal together and/or other ceremonies or rituals that are important
to the family’ (Knoke 2009, 2). The coordinator prepares participants
about what to expect and what the objective of the FGC is. Families are
informed that participation is voluntary and they can leave at any point.
It is also the coordinator’s role to contact the professionals involved with
the family to make sure they are available to attend.
The FGC
‘Once the coordinator has reviewed the process and purpose of the meet-
ing, child welfare workers present to the family, community members and
professionals the issues related to the child’s care that have to be resolved or
decided in the FGC. Other service providers may also share information.
Family members are encouraged to ask questions. In the next phase of the
FGC, family members are given ‘private family time’ to discuss what they
heard and develop their own plan to meet the child’s needs. The family
is asked to identify resources and supports that are needed to effectively
implement their plan. In some jurisdictions, families are asked to develop
two plans; one is the plan to be implemented and the second is an alternate
that can be adopted if they have problems implementing the original plan.
No time limit is imposed on the family meeting which can last anywhere
from a few hours to a full day’ (Knoke 2009, 3).
In New Zealand, all professionals, including the coordinator, are
excluded from family time. In other countries, the FGC coordinator
remains with the family during private family time to facilitate discussion,
answer questions and help the family record the plan (Knoke 2009). Once
the plan is drawn up, professionals are invited to rejoin the meeting to
discuss the proposed plan, ask questions, make suggestions or ask for clari-
fication. They may be asked to commit to providing services to support
the family plan. The child welfare worker or child protection worker has
the responsibility for making sure that the proposed plan addresses con-
cerns about the physical and emotional safety of the child. In some coun-
tries, the child protection worker has the authority to approve the plan,
whereas others may require the approval of a manager or sometimes the
court before the plan is adopted. Additional meetings may be scheduled
to finalise the plan and make modifications. Once the plan is approved,
everyone who was at the conference is usually given a copy of the plan; this
will specify what everyone has agreed to do to support the plan. The child
protection worker (or other social worker) is usually responsible (together
with family members) for monitoring that the plan is implemented as
agreed and for organising a review meeting to see how well it is work-
ing. Plans usually cover a specified period of time (e.g., 6 months), and a
review is usually held before the end of the period to assess how well it has
worked and whether it should be extended (Knoke 2009).
Applied to the Dewan family, the family group conference would involve
Mr. Dewan, Kamal (it’s unlikely that the two younger children would be
involved in the meeting, although they may be present if child care can be
provided), the paternal grandmother and extended family members from
Mrs. Dewan’s side of the family (this may include grandparents, aunts and
uncles). Even though Mr. Dewan distanced himself from his wife’s family
after her death, they should still be invited unless this is not in the interests
of the children. Involving this wide group of people is important since,
regardless of Mr. Dewan’s feelings, the children have a right to contact
with both sets of grandparents. One can imagine the potential benefits
of bringing this rich source of support and ideas to bear in resolving the
family’s problems. For example, the paternal grandmother may suggest
going to stay with the family on alternate weekends so that Mr. Dewan
gets the opportunity for some time to himself; emboldened by the pres-
ence of supportive adults, Kamal may feel encouraged to ask his father to
commit to a 12-week Alcoholics Anonymous programme, and perhaps
one of the uncles present will offer to support Mr. Dewan in achieving
sobriety; Mrs. Dewan’s family may suggest that Nina stay with them dur-
ing school holidays so that they can rebuild a relationship with her and
at the same time provide respite support to her father. Mr. Dewan may
agree to his mother-in-law’s organising a babysitter three evenings a week
so that Kamal has this time to spend with his friends; Kamal may offer to
doing this two evenings a week until his father gets home from work; the
family may decide that Nina would benefit from individual therapy—this
would be one of the resources they could request from the professionals;
as the sex abuse case goes through court, the family may decide on a rota
of people to attend the proceedings with Mr. Dewan and so on.
No one can predict the results of the FGC planning process and at
this hypothetical level it is easy to bypass the negative or destructive
dynamics that often exist within families and which could potentially
derail the process. But the family members themselves will know this
better than anyone, and professionals need to trust them to manage their
own dynamics and relationships. The family will know who will be unre-
liable, who will be unsafe, whom they need to protect children from,
who really has the resources to help, whether granny’s health can really
withstand the demands of a 13-year-old and so on. This is knowledge
that professionals can only ever have a partial view of and the message to
children, that the family has come together to ensure they are properly
looked after and kept safe, could not be more affirming. The evidence on
FGC practice shows that families are able to produce effective, workable
child protection plans given the authority, space and resources to do so.
In several Caribbean countries, agencies are already engaged in family

conflict resolution as a part of their child protection mandate, and mov-
ing to the FGC model would be a way of systematising a programme
standard. From a policy perspective, the transitioning of the family group
conference into Caribbean child protection and restorative justice sys-
tems has the potential for cost reduction by decreasing the reliance on
state-initiated solutions. As we review the practice some 14 years after its
implementation in New Zealand, two important lessons ring out as par-
ticularly important for its adoption in the Caribbean: ring-fenced fund-
ing for convening family group conferences—better plans emerge when
family members are able to attend in significant numbers, and ensuring
that funds for convening conferences are protected may be key to the
implementation of the model in the region. The second lesson that seems
crucial is that the family group conference model requires a major ideo-
logical shift to the notion of family empowerment if it is to be effective
and this will require the re-conceptualisation of existing support systems
(Pakura 2005).
Conclusion
In Part 3 of this book, we explored some of the factors that increase vul-
nerability to sexual abuse for children with learning disabilities and have
argued for the full recognition of their rights and for consideration of
their communication needs and intellectual impairments in the delivery
of services. We make the point that unless professionals (social workers,
psychologists, teachers and health workers) have the training and skills
to work with disabled children, Caribbean governments cannot claim,
with any degree of confidence, that they are promoting the rights of
all children. Disabled children are exposed to the same forms of abuse
and exploitation as non-disabled children, but they are at increased risk
because of their dependence on adults (often for intimate, personal
care), may lack the vocabulary or means of expression to tell someone
about their abuse, are especially likely to be considered as lacking cred-
ibility by adults around them and have reduced access to information
and services.
Important information is provided in this section of the book about

what issues should be considered in assessing the needs of children with
learning disabilities, and we offer some practice examples of techniques
that can be used in therapy.
Nina’s story provided an excellent medium for exploring two interven-
tions which aim to empower families to provide better care and support
for children at risk of harm: crisis intervention and FGC. We discuss
the principles and key practice elements of these models which are both
underpinned by an extensive body of evidence as to their effectiveness
and are especially suitable for Caribbean contexts.
References
Ainsworth, M. D. S. & Bell, S. M. (1970). Attachment, exploration, and sepa-
ration: Illustrated by the behavior of one-year-olds in a strange situation.
Child Development, 41, 49–67.
Allington-Smith, P., Ball, R., & Haytor, R. (2002). Management of sexually
abused children with learning disabilities. Advances in Psychiatric Treatment, 8
(1) 66–72. http://apt.rcpsych.org/content/8/1/66. Accessed August 3, 2015.
Angelides, P., & Michaelidou, A. (2009). The deafening silence: Discussing chil-
dren’s drawings for understanding and addressing marginalization. Journal of
Early Childhood Research, 7(1), 27–45.
Bowlby, J. (1969). Attachment: Attachment and loss: Vol. 1, Loss. New York: Basic
Books.
Brown, S., & Manning, W. (2009). Family boundary ambiguity and the mea-
surement of family structure: The significance of cohabitation. Demography,
46, 85–102.
Case, C., & Dalley, T. (2002). Working with children in art therapy (1st ed.).
London: Tavistock/Routledge Publication.
Centers for Disease Control and Prevention (CDC). (2006). Improved national
prevalence estimates for 18 selected major birth defects–United States,
1999-2001. Morbidity and Mortality Weekly Report, 54 (51): 1301–1305,
www.ncbi.nlm.nih.gov/pubmed/16397457/. Accessed September 29, 2014.
Dickinson, J. J., Poole, D. A., & Bruck, M. (2005). Back to the future: A com-
ment on the use of anatomical dolls in forensic interviews. Journal of Forensic
Psychology Practice, 5(1), 63–74.
Edwards, L., & Crocker, S. (2007). Psychological processes in deaf children with
complex needs: An evidence-based practical guide. Great Britain: Jessica Kingsley
Publishers.
Faller, K. C. (2005). Anatomical dolls: Their use in assessment of children who
may have been sexually abused. Journal of Child Sexual Abuse, 14(3), 1–21.
Finkelhor, D., & Berliner, L. (1995). Research on the treatment of sexually
abused children: A review and recommendations. Journal of the American
Academy of Child and Adolescent Psychiatry, 34, 19–28.
Gauthier, L., Stollak, G., Mess, E., & Aronoff, J. (1996). Recall of childhood
neglect and physical abuse as differential predictors of current psychological
functioning. Child Abuse & Neglect, 20, 549–559.
Gilbert, R., Kemp, A., Thoburn, J., Sidebotham, P., Radford, L., Glaser, D.,
et al. (2009a). Recognising and responding to child maltreatment. The
Lancet, 373(9658), 167–180.
Gilbert, R., Widom, C. S., Browne, K., Fergusson, D., Webb, E., & Janson, S.
(2009b). Burden and consequences of child maltreatment in high-income
countries. The Lancet, 373(9657), 68–81.
Gillespie, D., & Campbell, F. (2011). Effect of stroke on family carers and fam-
ily relationships. Nursing Standard, 26, 39–46.
Goff, B. S., & Smith, D. B. (2005). Systemic traumatic stress: The couple adap-
tation to traumatic stress model. Journal of Marital and Family Therapy, 31,
145–157.
Greenstone, J. L., & Leviton, S. C. (2002). Elements of crisis intervention: Crises
and how to respond to them. Belmont, CA: Brooks/Cole.
Hahn, L. J., Fidler, D. J., Hepburn, S. L., & Rogers, S. J. (2013). Early intersub-
jective skills and the understanding of intentionality in young children with
down syndrome. Research in Developmental Disabilities, 34(12), 4455–4465.
Hoff, L. A. (2009). People in crisis: Clinical and diversity perspectives (6th ed.).
New York, NY: Routledge Press. http://www.nhslothian.scot.nhs.uk/Services/
A-Z/LearningDisabilities/CurrentReports/ChildProtectionNeeds
OfChildrenYoungPeople.pdf. Accessed October 1, 2014.
James, R. K., & Gilliland, B. E. (2013). Crisis intervention strategies (7th ed.).
Belmont, CA: Brooks/Cole, Cengage.
Jones, A. D. & Trotman Jemmott, E. (2009). Child sexual abuse in the Eastern
Caribbean. www.unicef.org/infobycountry/files/Child_Sexual_Abuse_in_the_
Eastern_Caribbean_Final_9_Nov.pdf. Accessed April 3, 2015.
Kendall-Tackett, K. A., Meyer-Williams, L., & Finkelhor, D. (1993). Impact of
sexual abuse on children: A review and synthesis of recent empirical studies.
Psychological Bulletin, 113, 164–180.
Knoke, D. (2009). Family group conferencing in child welfare, CECW information

sheet. Toronto: Centres of Excellence for Children’s Wellbeing. http://cwrp.
ca/sites/default/files/publications/en/FGC77E.pdf. Accessed August 6, 2015.
Kvam, M. H. (2004). Sexual abuse of deaf children. A retrospective analysis of
the prevalence and characteristics of childhood sexual abuse among deaf
adults in Norway. Child Abuse & Neglect, 28(3), 241–251.
Malchiodi, C. A. (Ed.) (2014a). Creative arts and play therapy: Creative interven-
tions with traumatized children (2nd ed.). New York: Guilford Press.
Malchiodi, C. A. (Ed.) (2014b). Creative interventions with traumatized children.
New York: Guildford Press.
Malchiodi, C. A. (2014c). Creative interventions and childhood trauma. In
C. A. Malchiodi (Ed.), Creative interventions with traumatized children
(pp. 3–21). New York: Guilford Press.
Myer, R. A., Williams, R. C., Haley, M., Brownfield, J. N., McNicols, K. B., &
Pribozie, N. (2014). Crisis intervention with families: Assessing changes in
family characteristics. The Family Journal, 22(2), 179–185.
Ney, P. G., Fung, T., & Wickett, A. R. (1994). The worst combinations of child
abuse and neglect. Child Abuse & Neglect, 18, 705–714.
Pakura, S. (2005). The Family Group Conference 14 Year Journey: Celebrating
the successes, learning the lessons, embracing the challenges, Paper from
‘Builiding Global Alliances for Restorative Practices and Family
Parad, H. J., & Parad, L. G. (Eds.) (1990). Crisis intervention book 2: The prac-
titioner’s sourcebook for brief therapy. Family Service America: Milwaukee 3/4.
Paul, R. (2007). Language disorders from infancy through adolescence: Assessment
and intervention. Philadelphia: Elsevier Health Sciences.
Poulin-Dubois, D., Brooker, I., & Chow, V. (2009). The developmental origins
of naïve psychology in infancy. Advances in Child Development and Behavior,
37, 55.
Rapoport, L. (1970). Crisis intervention as a mode of brief treatment. Theories
of social casework, 265–371.
Reiter, S., Bryen, D. N., & Shachar, I. (2007). Adolescents with intellectual dis-
abilities as victims of abuse. Journal of Intellectual Disabilities, 11(4),
371–387.
Roizen, N. J. (2007). Down syndrome. In M. L. Batshaw, L. Pellegrino, & N. J.
Roizen (Eds.), Children with disabilities (pp. 263–273). Baltimore: Brookes.
Rosenfeld, L. B., Caye, J. S., Avalon, O., & Lahad, M. (2005). When their
worlds falls apart: Helping families and children manage the effects of disasters.
Washington, DC: National Association of Social Workers Press.
Sagar, C. (2002). Working with cases of child sexual abuse. In C. Case &
T. Dalley (Eds.), Working with children in art therapy (pp. 89–114). London/
New York: Routledge.
Santen, B. (2014). Treating dissociation in traumatized children with body
maps. In C. A. Malchiodi (Ed.), Creative interventions with traumatized chil-
dren (2nd ed. pp. 126–149). New York: Guildford Press.
Stalker, K., Green Lister, P., Lerpiniere, J., & McArthur, K. (2010). Child protec-
tion and the needs and rights of disabled children and young people: A scoping
study. Scotland: University of Strathclyde.
Steinhardt, L. (1985). Freedom within boundaries: Body outline drawings in art
therapy with children. The Arts in Psychotherapy, 12(1), 25–34.
Sullivan, P. M., & Knutson, J. F. (2000). Maltreatment and disabilities: A
population-based epidemiological study. Child Abuse and Neglect, 24(10),
1257–1273.
Tjersland, O. A., Mossige, S., Gulbrandsen, W., Jensen, T. K., & Reichelt, S.
(2006). Helping families when child sexual abuse is suspected but not proven.
Child and Family Social Work, 11, 297–306.
Trevarthen, C., & Aitken, K. J. (2001). Infant intersubjectivity: Research, theory,
and clinical applications. Journal of child psychology and psychiatry, 42(1), 3–48.
US Department of Health and Human Services. (1994). Crisis intervention in
child abuse and neglect. Washington: US Department of Health and Human
Services, www.childwelfare.gov/pubs/usermanuals/crisis/index.cfm. Accessed
October 6, 2014.
Welsh, T. (2007). Child’s play: Anatomically correct dolls and embodiment.
Human Studies, 30(3), 255–267.
4
Working with Young People
with Harmful Sexual Behaviour
Mother-Son Incest; Restorative Justice for
Juvenile Sex Offenders; Treatment and
Rehabilitation: Individual, Group, Family and
Community-Based Approaches
Fig. 4.1 ‘Metamorphosis’ © Jaime Lee Loy (2008)

I began to navigate a visual landscape within the physicality of a typical

house structure. Here the house began to come alive to speak secrets of
abuse, the battle for space and territory, the negotiations of survival, and
the politics of the personal. … Spoons and forks, plates and flowers—they
become roaches, they become weapons. These images, these created spaces
generate an unfamiliar feel in a familiar space, they are simultaneously ugly
as they are beautiful (Lee Loy 2008, n.p.).
Introduction
The exploitation and subjugation of one gender by another (women are
more likely to be victims of exploitation than men) are deeply rooted in
historical practices, politics and cultural values concerning the roles each
should adopt in a society. These roles act as identifiers, defining what it
means to be a male and what it means to be a female in domestic, group and
community spaces, be it in the home, at work or at leisure. The subjugation
of women and maltreatment associated with these gendered roles are pre-
served by everyday actions, social expectations and traditions and are main-
tained by outmoded legislation. The enculturation of gender inequality thus
becomes intergenerational, and the values that contribute to gender-based
violence and the sexual abuse of children are passed down and across fami-
lies. In this part of the book, we examine the impact of a form of sexual
abuse that is little talked about—abuse by mothers. As will be shown, sexual
abuse of children by women is as likely to have its genesis in gender inequal-
ity and violence to women as is sexual abuse by men. We traverse a different
terrain from the other parts of the book, the abuse of a son by his mother,
the cyclical nature of intergenerational abuse and the factors that intersect to
create conditions of risk and vulnerability to children. Elsewhere (Jones
et al. 2014), we identify how these intersections place children at risk of
male perpetrators of abuse. In this part of the book, we explain that these
same conditions can mean that children are also at risk from women and
these same conditions can, in turn, mean that children who once were vic-
tims are now both victim and perpetrator—placing other children at risk of
abuse from them. These networks of sexual abuse are often described as
4 Working with Young People with Harmful Sexual Behaviour 141
intergenerational but we must remember that they also extend their reach
laterally across generations, across young people in a wide range of settings,
across peer groups and sibling groups too. Interlocking factors that perpetu-
ate child sexual abuse (CSA) in the Caribbean include the following:
Harmful sexual cultures (implicit social sanctioning).

Males with sexually abusive behaviours.
Females with complicit behaviours.
Officials with collusive (condoning) behaviours.
Lack of awareness of effects and consequences.
Lack of collective public/professional outrage.
Ineffective systems for reporting and responding to abuse.
Patriarchal values which place protecting male status and privilege
above protection of the child.
Disempowerment of children.
(Jones et al. 2014, 13–4).
Inter-personal violence is a global problem. Lisak and colleagues

(1996) offer some theoretical insight into its possible genesis through
a typology derived from a review of the literature. They argue that one
of the factors associated with male socialisation, which they call ‘emo-
tional constriction’ (Lisak et al. 1996, 723), when combined with early
trauma such as abuse, can result in the types of empathy deficits associ-
ated with male inter-personal aggression. These researchers construct a
model (Lisak et al. 1996, 724) which they describe as:
a vehicle by which this socialization may, in interaction with the emotional

legacy of abuse, inhibit some men’s capacity to respond empathetically, and
thereby increase their likelihood of committing aggressive acts (723).
In this part of the book, we meet Levi, a young man who has been
physically and sexually abused all of his life and whose behaviour as
an adolescent suggests that he may take this legacy of abuse with him
as he becomes a man. Levi was abused by his mother and by men,
boyfriends of his mother, some of whom as a very young boy he might

have seen as a surrogate father. We can only imagine the formative
experiences of these abusers, but it seems that whatever their own
childhood traumas may have been, their capacity for empathy was
diminished in the process, for they showed none to Levi. There is
little to suggest that Levi, as a young sexual offender himself, will have
empathy for his victim, and as Lisak and colleagues (1996) argue,
any treatment or interventions will need to focus on building empa-
thy. Levi raises a particular challenge for practitioners—your client
may be both victim and abuser. We speak to treating victims and we
speak to treating offenders, bearing in mind that Levi is simultane-
ously both; however, as we work towards healing and rehabilitation,
our aim is for him to regard himself holistically as a survivor of both
his abuse and abusing experiences. His case enables us to explore indi-
vidual and group treatment for juvenile sex offenders. We discuss the
benefits of developing restorative justice (RJ) approaches for young
people with harmful sexual behaviour and introduce the reader to
interventions that build family and community skills in supporting
young offenders. In this section of the book, we also discuss the fam-
ily group conference (FGC) model as an RJ approach.
Levi’s Story
Family History
Levi is a 17-year-old young person whose family of origin consists of his

mother only. He has never met his father, who abandoned his mother
when he found out she was pregnant with Levi. Levi’s mother (Jennifer)
was 18 years old when he was born, and his father was 27. Levi is an only
child, although he is close with two older male cousins on his mother’s
side (brothers, Kyle aged 19 and Kristian aged 22). From the age of 18
to the present, Jennifer has worked in the hotel industry, although owing
to fluctuations in the tourism sector this has not been a stable job. Her
job as a hotel maid and sometimes waitress meant that she often worked
night shifts. Her pay has been minimum wage, and it was sometimes
difficult to meet the basic needs of the household. There were many days
when Levi did not have enough food (or none at all) and wore tattered
clothing, until he was nine years old. Soon thereafter he began to culti-
vate relationships with two older male cousins who lived nearby and they
provided him with food, clothing and a supply of drugs and alcohol.
Jennifer and Levi lived in a small and dilapidated apartment complex in
an area known for crime and community violence, from his birth until
he left home at 15. The apartment consisted of one bedroom, a bathroom
and a small kitchen. He and his mother shared the bedroom; she slept on
the bed and he on a piece of foam on the floor. Jennifer has never had a
stable intimate relationship and has had many boyfriends. In addition to
being exposed from early childhood to pornography and being sexually
molested by his mother, Levi was sometimes locked in a cupboard when
his mother and her boyfriend were having sex. Levi was also physically
abused throughout his childhood by his mother and some of her boy-
friends. When he was eight years old, he was hospitalised with a broken
collar bone and injuries to his face, but this was never reported to child
protection agencies or the police. Jennifer was also subject to beatings by
her intimate partners, particularly when Levi was a child. Between the
ages of 15 and 17, Levi spent much his time on the streets and sometimes
was given pocket money and food by Mrs. Walsh, an elderly woman in
the village for whom he did odd jobs. Mrs. Walsh has been concerned
about Levi since he was a small child and has made several reports to
the social services about his neglect and ill treatment. Levi seems to have
close relationships with his aunt and two cousins, Kyle and Kristian. Kyle
and Kristian are well known as troublemakers in the village and seem to
have access to financial resources—it is suspected that they are involved
in selling drugs.
Presenting Problem
We meet Levi upon his conviction for sexual assault of a 13-year-old girl
when he is 17. As part of his sentence (a suspended sentence of four years
in prison), he has been placed in a juvenile detention centre and man-
dated to undertake initial treatment and assessment of his psycho-sexual
functioning by a psychotherapist. Depending upon the evaluation report,
the court is to decide whether Levi will have to serve an actual prison
Mother Father
No contact at all
Levi
17 yrs
Fig. 4.2 Levi’s genogram
sentence or whether he should participate in a group treatment and RJ

programme supervised by the probation department. This is a new initia-
tive by the government to divert young offenders away from prison.
Levi is experiencing severe withdrawal symptoms from his former
poly-substance abuse. Although he admits to the sexual assault, he is
detached, lacking remorse and far removed from the events and experi-
ences of his life. Levi’s mother first sexually abused him when he was
five; this started off with forcing him to watch pornography with her
and her boyfriends. Not long after this, his mother began fondling
him. Levi’s mother often left him in the care of her boyfriends while
she was at work and he was sexually abused by at least three of them.
This involved fondling and oral sex, and Levi remembers the acts but
is unable to give any detailed accounts of the specific timing of events
between five and 15 years old. The abuse by his mother’s boyfriends
stopped when he was 14; she continued to do so until he was 15, when
he left home. Levi’s memories are blurry and he says that his sexual
molestation seemed to go on forever. He cannot remember the names
or faces of the men who abused him and he says he wishes he could
forget all memories of his mother. Other than partaking in the treat-
ment sessions with the psychotherapist, Levi barely talks to anybody in

the detention centre and seems to be isolating himself further. He has,
however, become confrontational with some of the other young people
in the centre, and officials are concerned about his aggressive tenden-
cies and are considering having him placed in isolation. He has been
given a warning and since has become generally silent and brooding.
Maternal
grandmother–
lives some
distance away
Psychologist
Tanik 5 yrs old
Younger brother
Nina
13 yrs
Down Syndrome
and hearing
impaired
Kamal 15 years Father

old. Older Drinking
brother problem
Mr. Johnston
Special Needs Teacher and Other children at
School reportedly sexual school
abuser
Positive
Stressful
Tenuous
Arrows=energy flow Line thickness=intensity
Fig. 4.3 Levi’s ecomap

Chronology of Events Leading up to the Presenting Problem
Up until the age of five, Levi showed no marked problems with his
behaviour and seems to have met all of his physical, language and cog-
nitive developmental milestones. His performance in school between
the ages of five to nine was at least satisfactory. At the age of nine,
he began experimenting with alcohol and marijuana, which he got
in steady supply from his older cousins, and by the age of 12 he was
regularly high on both substances. Levi completed primary school
at age 11 and took his secondary entrance exams. He dropped out
of school before he turned 12 and has never tried to go back. Until
age nine, when he was in Standard 3, Levi performed on par with his
peers in all academic domains. There was a sharp decline in his aca-
demic performance from Standard 4, from which he never recovered.
His teachers at that time reported that Levi was shy and quiet, but
around Standard 4 he tended to be bossy, aggressive and destructive
to school property.
Levi sexually assaulted a 13-year-old girl at a nearby school when he
was 17. Levi was not the only one. Three of his friends were also involved
in the assault—two of the group went on to rape the girl (medical forensic
5–9
yrs 9–12 yrs 15–17 yrs
Hospitalised Completed Left
for primary home
1–5 broken at
school
years bones; 15 yrs; 17 yrs
but
No school sexually
marked performance failed abused Detention
problems satisfactory secondary form Centre for
exam 5–15 yrs Juvenile sex
offenders
1–5 yrs 9–12 yrs 12 yrs; 15–17 yrs

Neglected Experimented dropped spent lots
by with out of time
mother; school on
drugs streets;
food and and assaulted
clothing alcohol 13 yrs old
girl
Fig. 4.4 Levi’s timeline

examinations indicated that she was also penetrated with an object) while
Levi and another young man watched. Levi admits to sexually assaulting
the girl, although he says he did not partake in any other violations—he
simply watched. He gives no reason for his involvement but does admit
to it. Criminal proceedings were brought against Levi when he was 17
and he was convicted in that same year. Although this was his first con-
viction, Levi said that he had previously taken part in gang sexual viola-
tions against girls at school, twice when he was 16. These cases were never
officially reported.
Perspectives from the Literature
Gender-Specific Sexual Predatory Behaviours
Mothers and fathers can sexually abuse children, including their own. The
complexity of incest requires considerable skill in teasing out who is doing
what to whom. One of the authors recalls working with a family compris-
ing mother, father and six children aged 4 to 18 years. This was a religious
family that kept to themselves and functioned as a closed unit—the children
had no friends outside of the home and no one was allowed in. Behavioural
problems with several of the children had been noticed at school but were
not serious enough to warrant intervention, and in any event, the parents
refused help. The children missed school frequently, but just at the point
when official proceedings could be considered, they would reappear in
class, as though they had never been away. Their poor clothing and care
suggested borderline neglect, but there were no grounds for state action.
Abuse may never have come to light but for the 13-year-old girl running
away and declaring that ‘everyone was doing it to everyone’. She was refer-
ring to incest. An investigation proved inconclusive because no one would
talk, the young children had been threatened into silence and the two older
children, a boy of 18 and a girl of 16, mirrored the exact behaviours and
words of the parents. We did indeed believe that everyone was at it, but
intuitive knowledge is not enough, and without any evidence nothing could
be done, even when the 16-year-old daughter’s mysterious stomach disorder
proved to be a pregnancy. The 13-year-old was disowned by her family and
was placed in a children’s home; she said that her mother and father had sex
with them all, her elder brother and sister had sex with the younger children
and sometimes they would all climb into bed. She later recanted everything.
Although most sexual abuse is perpetrated by males, incest may
involve a complex network of adult–child and child–child sexual behav-
iours in which the sexual abuser can be anyone—a mother, son, daughter,
father, brother, sister. Rehabilitation in incest cases, where abuse has been
embedded in family relationships and has become part of the family’s
normative behaviours, requires that perpetrators be helped to reappraise
their whole schema on family life. Ward (2002) argues ‘one of my core
assumptions is that, in order to rehabilitate offenders, it is necessary to
instil in them the skills, knowledge, and resources to live different kinds
of lives’ (514). In the Caribbean, the task of rehabilitating sex offenders
requires new and well-researched intervention approaches if we are going
to change the lives of victim and abuser and stem the cycle of violence.
We discuss some of these approaches later; for now, we turn our attention
to the issues raised by Levi’s story.
Levi’s incestuous experience was at the hands of his primary caregiver,
his mother, the person to whom he looked for his secure attachment needs
and overall well-being and safety needs. In Levi’s formative years, there
was a monumental betrayal by his mother in failing to meet his physi-
cal and emotional needs, failing to protect him from the men she had
relationships with and in inflicting emotional, sexual and physical harm.
We can easily imagine that this laid the foundations for his drug abuse,
criminal activities, distorted views about females and violent tendencies.
Incest is generally regarded as a form of CSA that crosses particular
taboos, as evidenced by the legislation of various countries which prohibit
marriage between close family members. Early research by Russell (1986)
and, more recently, Stroebel and colleagues (2012) identifies some of the
effects of father–daughter incest (FDI).
Victims of FDI had more problematic scores on sexual satisfaction, sexual

partner intimacy and depression scales than controls. The sexual satisfac-
tion scores of FDI victims were also significantly more problematic than
those of victims of CSA-O (CSA by an adult male other than the father).
Furthermore, victims of FDI were significantly more likely than the con-
trols or the CSA-O group to endorse feeling like damaged goods, thinking
that they had suffered psychological injury, being distant from both par-
ents or distant from father and close to mother in high school and, at the
time of study participation, being angry or estranged from one or both
parents, having nightmares about adults whom they had sexual experiences
with as a child, having undergone psychological treatment for CSA, and
having had the listener react with horror and disgust when she (sic) tried to
open up with another person about her childhood sexual experience.
Victims of FDI (but not victims of CSA-O) were more likely than controls
to report negative reactions to disclosure about childhood sexual experi-
ences. Such experiences may represent one of the processes by which FDI
or other childhood sexual experiences can cause psychological harm to the
victim through the processes of shaming, suggesting that they had been
damaged by the childhood sexual experience, and rejection (Stroebel et al.
2012, 192).
The sexual abuse of daughters by their fathers is widely written about

and some cases even hit the headlines—worldwide attention was drawn
to this form of sexual abuse through the story of ‘the arrest and prosecu-
tion of Josef Fritzl of Austria, who held his daughter, Elisabeth Fritzl,
captive in a complex underneath his family home for 24 years’ (Salter
2013, 146). In comparison, the research on incestuous mothers is said
to be greatly under-reported, but research on prevalence and its trau-
matic effects on victims has increased over the past two to three decades
(Lawson 1993; Rudominer 2002). However, although ‘published reports
of the psychoanalytic treatment of children and adults who experienced
incest in childhood or adolescence has increased over the past twenty-five
years, … only a handful of authors have written detailed studies of cases
of mother-son incest’ (Rudominer 2002, 909). We confront mother-son
incest head-on by sharing Levi’s story, but we do so with some unease.
Stories of CSA by fathers are commonplace, but that is not the only
reason we report them. As four women writers, we find ourselves on the
right side of the gender fence on this topic; we ride our gendered steers
across the landscape of children’s rights affirmed as women by the won-
derful mothers that we all had. It is right and necessary and although
it is not easy (it is never easy), we are willing to confront the men who
harm their own children. But confronting women who abuse their sons
and daughters raises a whole set of other issues and makes us ques-
tion assumptions we all make about being female that run to our core.
Rudominer, a psychiatrist at the New York University Psychoanalytic
Institute, implies that resistance to acknowledging sexual abuse of chil-
dren by their mothers may be related to ‘countertransference reactions
that seem to be unique to incest cases’ (Rudominer 2002, 910). Below,
we present an extract from a report on mother-son incest, which by his
own admission he procrastinated in writing up for 35 years.
Mr. D was thirty-five years old and an unhappily married father of two when
a colleague referred him to me in December of 1978….Mr. D had had an
extremely traumatic childhood. He was abused by his mother verbally, physi-
cally, and sexually until he was eleven, when she died from complications of
gallbladder surgery… After his father’s death when he was fourteen, Mr. D
went to live with a very wealthy uncle for a short time, but he was sent off
once again to boarding school when he could not comply with his uncle’s
strict rules. The patient stated that there was never any real communication
between them, and that his uncle was a very cold man ... (910–1).
Rudominer’s case study is useful to our discussion of Levi because a num-

ber of general principles for practice might be gleaned from his analysis.
Rudominer reminds us, however, that ‘caution should be observed about
just how much can be generalised from a single analytic case study’ (926).
Several months of vis-à-vis psychotherapy gave me a growing awareness of

the underlying issues, and I decided that psychoanalysis, though risky, was
this man’s best chance of resolving his conflicts. At the time of that decision
I had no idea of the enormity of the abuse he had suffered throughout his
childhood. .... He reported images associated with particular phrases that
kept repeating in his mind: “Mommy, Mommy, don’t put me in the closet,”
and “Mommy, don’t touch my penis”. He had fragmented images of touch-
ing his mother’s breasts and vagina, and of his mother touching his penis
(912).
I feel that the slow, piecemeal nature of the uncovering of the somatic as
well as the repressed memories, and the presence of obsessive and coercive
doubting (in Kramer’s 1985 terminology) lends strong evidence that the
abuse actually occurred. In addition, aspects of Mr. D’s case show striking
similarities to the other case studies published on sexual abuse (926).
In later sessions, Mr. D recounts to his psychiatrist his memories of

abuse by two females: his mother and her friend:
It was now exactly three years into the analysis …, more graphic memories
began to emerge; these were extremely upsetting and disturbing to Mr. D.
“It seems unbelievable. Am I making it up? Can it be real that my mother
and her friend Mrs. C did things to me together? I remember going there
a lot. They tied me up”. He recalled them touching him, sticking things in
his rear end, and laughing. “I remember closing my eyes and making
believe I wasn’t there to shut it all out. I blocked a lot of it out…I was just
thinking how much I must have hated my mother.” I interpreted again
how frightened he was at re-experiencing that hatred and murderous rage
now in the analysis (Rudominer 2002, 919–20).
This rather full account from Rudominer’s report is included because

it demonstrates the level of violence, sexual objectification and humili-
ation to which a parent can subject a child. Other research on female
abusers from around the time that Rudominer began treating his patient
in 1978 reveal, should there be any doubt, that women may be as capable
of incest as men, both as initiators and as participants. Green and Kaplan
1994 (954, quoting Mayers 1983) found, in a study of female incest
offenders, that 77 % manifested ‘infantile or psychotic behaviour’ and
in a study by Faller (1987) ‘72.5 % of the 40 female sexual offenders
molested children within polyincestuous family situations, where there
were at least two perpetrators and two or more victims where a male
offender was usually the initiator of the sexual acts’ (Green and Kaplan
1994, 955 reporting on Faller 1987).
Levi’s long-standing sexual molestation and physical abuse at the hands
of his mother were reported to the authorities, according to an elderly neigh-
bour, but no action was taken. From Levi’s ‘tattered’ appearance, the school
was arguably well placed to raise concerns, of neglect at least. However,
raising such concerns to a child protection agency in the Caribbean would
not have been adequate to generate the kind of in-depth assessment of
risk and need that was necessary in this case. Propelled by children’s rights
activists and organisations such as UNICEF, the Caribbean is mainly at
the stage of getting the public to speak out on all forms of violence and, in
particular, sexual abuse against children (Reid et al. 2014), (www.unicef.
org/lac/Break_the_Silence–Introduction_.pdf.). Physical violence to chil-

dren, however, is still tolerated to a much greater extent in the Caribbean,
both in the home and at many schools, than in other countries where leg-
islation is stronger and enforced. Therefore, Jennifer’s physical maltreat-
ment of her son is unlikely to have generated the levels of concern that
might have led to someone intervening, and although her sexual abuse
would not have been condoned, this would not have been visible. We do
not know from the available case study information whether Jennifer was
physically or sexually abused (or both) as a child and, if so, by whom and
for how long. To what extent were Jennifer’s boyfriends both perpetrators
and initiators of her abusive actions towards her son? These are some of the
questions raised by cases such as Levi’s.
Messages from the Research About Mothers

Who Sexually Abuse
There are mixed accounts of mothers’ roles in the sexual abuse of their
children. Some of the early reports in the literature state that many non-
offending mothers often disbelieved their children’s disclosures about
abuse by fathers and others in the family, reacting by blaming, resent-
ing and rejecting their children (Herman 1981; Summit 1983; Jones
and Trotman Jemmott 2009). Denial, ambivalence and passivity were
responses attributed to mothers of daughters alleging incest in a study by
Zeanah and Zeanah (1989). However, in Crawford (1999), mothers were
reported as colluding directly or indirectly in the sexual abuse of their
children. Other studies, showed that a high percentage of non-offending
mothers (between 69 % and 78 %) believed their daughters’ disclosure
either in part or completely, regardless of whether the abuse was intra-
familial or outside of the family (Heriot 1996; Jinich and Litrownik
1999; Lovett 1995). As Elliott and Carnes (2001) conclude, from a liter-
ature review of studies spanning several years, even when mothers believe
their children’s allegations, this does not necessarily ensure supportive
or protective responses. Furthermore, mothers who exhibit ambivalence
about alleged abuse will still often take action to protect their children.
How a mother responds to the abuse disclosure of her child determines

that child’s ability to process the sexual trauma suffered and influences
the extent of psychological difficulties (Summit 1983).
A Caribbean study revealed that the reaction of mothers to CSA ranged
from disbelief to overprotection. In several instances, mothers used phys-
ical violence to constrain their daughters so that they would not be at
risk from predators (a hugely misplaced form of protection) (Jones and
Trotman Jemmott 2009):
Silence seemed to have acted as a powerful barrier with the survivors

describing their fears that should they tell anyone, a tidal wave of negative
repercussions would engulf them. Despite this, many survivors did tell
someone, usually their mother. However, of the respondents who reported
abuse to their mothers, in no single instance did the adult (survivor) feel
that they had been believed and supported (102).
Other interviewees, in attempting to protect their children, sometimes

repeated the physical abuse they had experienced themselves:
It was really a painful time. It still comes back to me. And every time I look
at my daughter I see the same whole thing again. Yes. Oh God. I beating
her if she come (sic) home late, or if she take (sic) too long getting from one
corner to the next corner. I calling her. I beating her if she don’t want to
hear me (sic). I still trying to let go my anger of men (105).
How can a therapeutic intervention make a difference in the emo-

tional and psychological functioning of boys who have suffered severe
abuse, like Levi? This is a real challenge in the Caribbean, where resources
are scarce and child protection and therapeutic services underdeveloped.
The research shows that one in six men has experienced some form of
sexual abuse before reaching his 18th birthday (Dube et al. 2005; Lisak
et al. 1996). There is no research specifically on male victims of CSA
in the Caribbean, but since the problem is generally under-recognised,
under-reported and under-treated (Holmes and Slap 1998), we can
assume that there is a considerable unmet need for services.
Recognising that Females Can Be Sexual

Offenders
The research on female sex offenders is less comprehensive than that of
male sexual offenders. Certain factors may be responsible for this: reports
of female perpetrators are fewer than those of men; professionals may
regard sexual offending by women as less harmful; and fewer women are
convicted of sexual assault. Saradjian (2006 in Ford 2006) explains:
despite at least a century of knowledge pointing to a significant number of

women engaging in sexually abusive behaviours towards children, it is still
a phenomenon that has not been sufficiently accepted. … Looking at the
gender of convicted sexual offenders against children, the very low percent-
age (1 % to 2 %) of these that are female could justify societal beliefs and
attitudes [i.e., that women rarely abuse children]… However, when the
research in relation to gender of the perpetrators alleged by adult survivors
of childhood sexual abuse is considered, much higher percentages are
found (between approximately 6 % and 60 %) depending on the popula-
tion surveyed (Saradjian 2006, ix–x).
As Green and Kaplan (1994) state, ‘the paucity of clinical studies of

female sexual offenders is in sharp contrast with their numbers’ (954),
but the situation is changing and an increasing number of studies explore
women’s violence. Our discussion focuses on the abuse of children by
women; nevertheless, it is instructive to point out that research has
increasingly included women’s sexually abusive behaviours towards men.
We can understand from this that violence is not a masculine or feminine
trait. It is not defined by gender; rather, it is an aspect of human behav-
iour that is present to a larger extent among men but that exists among
women too. Morczek (2014), in a review of When Women Sexually Abuse
Men: The Hidden Side of Rape, Stalking, Harassment, and Sexual Assault
(Cook and Hodo 2013), states:
One of the strong points of the authors juxtaposing the current rhetoric on
what many denote as a rape culture, to include men, is their argument that
much like women, adult men who are victimized are often met with
explicit skepticism, disbelief, and sometimes even jokes when telling their
stories … both genders are susceptible to societal glorification of the vio-

lence against them. Thus, it is not sexual violence toward one gender over
another that is particularly troubling, but rather that we culturally accept
both forms, just in contrary ways … (Morczek 2014, n.d.), http://clcj-
books.rutgers.edu/books/when-women-sexually-abuse-men.html.
Women and Sexual Abuse

As has been discussed, the sexual abuse of children by women is not a
new phenomenon; it has simply been little reported or researched in
the past. That this information has been ‘hidden’ from scrutiny is not
only because abuse by men is the far greater problem (in terms of prev-
alence) but because abuse by women flies in the face of their histori-
cal and socially constituted gender role of nurturance and protection
(Jones et al. 2014). A woman who sexually abuses her child is anath-
ema, a contradiction in terms, and represents a profound betrayal of
children’s trust that cuts deep into the psyche; we do not expect this
to happen. We are prepared for stories of harmful sexual abuse by
men; such stories are legion. There are even books we can use to warn
children about being ‘touched’ inappropriately by men and whom to
tell. But we do not have any warnings about mothers. Our familial and
cultural socialisation patterns may cause us to want to negate this real-
ity, but our professional training and values must kick in; we must take
the abuse of children by women every bit as seriously as abuse by men,
and we should recognise that abuse by mothers, given their primary
caregiving role in Caribbean societies, can cause extensive psychologi-
cal and emotional trauma to children. Even if Levi had disclosed his
abuse at the hands of his mother, action may not have been taken.
Adult inaction following a disclosure of sexual abuse by a child may
result from certain emotional states such as:
• Confusion—arising from cultural and other stereotypes about what

kinds of people sexually abuse children
• Dependency—economic, emotional and physical reliance on the per-
petrator that might be threatened if such concerns were investigated
• Self-doubt and minimisation of the harm (e.g., ‘I’m paranoid’, ‘What

if I’m wrong?’, ‘It’s none of my business’ or ‘the sexual act is not harm-
ful to the child’)
• Overwhelming feelings (fear, anger or shame) caused by just thinking
about the sexual abuse of children
• Fears of various consequences (e.g., of acknowledging betrayal by a
trusted and respected person, of being wrong or of being right)
(adapted from the 1in6 website (n.d.), www.1in6.org/men/get-information/

online-readings/others-who-were-involved-or-not/why-do-adults-fail-to-
protect-children-from-sexual-abuse-or-exploitation/).
These various emotional responses demonstrate how the emotional
safety of the self (see Part 1) can be disrupted by discovering that a child
has been abused, particularly when the abuser is the child’s mother or
when the abuser is someone you know and love too. Saradjian (2006)
explains further:
Cultural schema in any society that enable the majority of its citizens to
feel psychologically happy are often maintained by a process of shared min-
imization and denial. This is the means by which the long held “secret” of
the sexual abuse of children by women has been ignored. Should this
“secret” be explored and fully accepted then the seeming social security of
having women as “sexually safe” primary carers and protectors of our chil-
dren would be irretrievably damaged (Saradjian 2006, ix).
Women are held in positions of trust; their filial caregiving responsibilities

give them ready and unsupervised access to children and therefore there are
regular and ongoing opportunities to plan and disguise their offending. The
distorted values and impulses associated with sex offending are described by
Ó Ciardha and Ward (2013) as cognitive distortions—‘specific or general
beliefs/attitudes that violate commonly accepted norms of rationality, and
which have been shown to be associated with the onset and maintenance of
sexual offending’ (Ó Ciardha and Ward 2013, 4). These researchers acknowl-
edge some of the difficulties with the term cognitive distortion, suggesting
that it is vague or unwieldy or may be seen as meaningless. Nevertheless, they
explain that, to the practitioner, the term ‘refers to lists of statements that
reflect distorted views of the self, the world, and the victim’ (Ó Ciardha and
Ward 2013, 3). Professional terms and labels can contribute to stereotyp-
ing and pathologising clients and a critical approach to their use is impor-
tant. However, they are derived from theoretical frameworks that help us to
understand the causes and manifestations of harmful sexual behaviour. As a
tool for practitioners, professional terms enable the communication of shared
meanings and categories that can be helpful in determining the appropriate
treatment or intervention.
Theoretical Models to Assist Clinical/

Practitioner Interventions in Sexual Offending
To conclude this discussion, we look at some theoretical models for practitio-
ners’ consideration. Therapeutic intervention by professionals such as social
workers, psychiatrists, psychotherapists or psychologists can benefit from
the typology proposed by Lisak and colleagues (1996) (discussed earlier),
which helps us to look beyond the immediate violence to understanding its
possible antecedents. This typology nevertheless is incomplete and would
be strengthened by a greater understanding of the role of cognitive distor-
tions in sex-offending behaviour. Ó Ciardha and Ward (2013) reminded us
above that cognitive distortion reflects distorted views of self, others and the
world. There are models which can help us better understand some causes
and pathways in sex-offender thinking and cognitive development. Some
of these models have been used to treat both adult and young offenders
(Chu et al. 2015). Examples include the good lives model (GLM) and the
self-regulation model (SRM). The GLM focuses on rehabilitation, empha-
sising the promotion of the individuals’ personal goals and managing the
risk of potential future offending (Chu et al. 2015 citing Ward 2002). The
practitioner’s role is of great importance here as it can assist the offender in
fulfilling and achieving what is called their primary human goods, described
as ‘outcomes sought by individuals for their own sake and typically reflect
propensities evident in basic human needs’ (Ward 2002, 514). Within
the GLM, these primary goods are classed as ‘characteristics, experiences,
and/or states of mind that are valued by individuals, and will increase the
individual’s sense of fulfillment and happiness’ (Chu et al. 2015, 152, citing
Ward 2002). Ward describes primary goods in some detail:
There are three classes of primary goods derived from the facts of the body,
self, and social life, and the basic human needs associated with such facts. The
primary goods of the body include basic physiological needs for sex, food,
warmth, water, sleep, and the healthy functioning of the body as a whole.
The primary goods of the self are derived from the basic needs of autonomy,
relatedness, and competence. Each of these needs is associated with a cluster
of related primary goods. For example, relatedness can be further broken
down into goods of intimacy, understanding, empathy, support, sexual plea-
sure, sharing, etc. The primary goods of the social life include social support,
family life, meaningful work opportunities, and access to recreational activi-
ties. A conception of good lives should be based on these three classes of
primary goods and specify the forms that they will take in each individual’s
life plan. The possibility of constructing and translating such conceptions of
good lives into actions and concrete ways of living depends crucially on the
possession of internal and external conditions capabilities (Ward 2002, 519).
Ward contends that ‘the conception of a possible good life [GL] for
an offender … should take note of each offender’s capabilities, tempera-
ment, interests, skills, deep commitments (i.e., basic value system and
preferred ways of living in the world)’ (514). When all of this is distilled
by the practitioner working with young offenders such as Levi, at least
three importance issues emerge:
i. Gathering biographical information about the offender’s life is criti-

cal, but so is the autobiographical, getting to know and understand
the emotional and psychological states directly from the offender.
ii. It makes sound social and monetary sense to invest in young offenders.
iii. ‘Clinicians ought to explicitly construct a conception of good lives to
guide the rehabilitation of each offender’ (Ward 2002, 527).
Another model briefly shared here is the SRM. This stresses that indi-
viduals/offenders will act in ways to achieve a desired state or to avoid an
undesired one, according to the nature of their goal-directed behaviour.
The SRM also describes different offending routes or pathways, useful in
assisting the categorisation of offenders. These theorised pathways describe
two things: firstly, the nature of an offender’s goal-directed behaviour

defined in the model as approach vs. avoidant (author’s italics). The offend-
er’s approach goals are concerned with successfully achieving a goal while
seeking to minimise a particular situation or state. Secondly, the manner in
which the offender seeks to achieve his or her goal is through a passive vs.
active manner (author’s italics). A thorough familiarisation with these mod-
els can help the practitioner understand the self-regulatory styles of offend-
ers and help them to develop more appropriate strategies for self-regulation.
Both the GLM and the SRM can help us to appreciate the goal-directed
nature of offenders’ propensity for sexual offending, such as grooming, the
harbouring of harmful sexual intentions and the planning connected with
their execution (Chu et al. 2015). Later in this chapter, we discuss in much
more detail several other approaches for the rehabilitation of young sexual
offenders, in line with our systems and ecological framework.
Chu and colleagues (2015) identify evidence that suggests that dif-
ferent types of sexual offending are associated with different offending
pathways in adults. For example:
Avoidant pathway offenders tend to have sexual interest in children and are
also likely to engage in intrafamilial offending … whereas rapists and those
who sexually offend against male children tended to follow the Approach-
Explicit pathway (Chu et al. 2015, 154 citing Kingston et al. 2012 among
others).
These ideas are useful as we construct interventions and treatment

approaches for working with young people with harmful sexual behav-
iour, such as Levi. We turn our attention to this next.
Protecting Young Children from Abuse

and Neglect
Before we move forward, let us take a step back to when Levi was a
young child. There were numerous missed opportunities throughout
his childhood for social workers, teachers and health professionals to
take action that could have improved his life and protected him from
harm. But responsibility also lies with those in his community who may
have been aware of abuse but took no action. The small villages and
communities of the Caribbean are blighted by a paradox—‘everyone
knows your business’ and neighbours will ‘mind your business’, but
when it comes to the business of either domestic violence or child
abuse, people are reluctant to get involved. Discussing people’s busi-
ness oils the wheels of interaction; it functions as a social glue. There
can be little doubt that the people in Levi’s neighbourhood knew his
family’s business—his maltreatment and the behaviour of his mother
will have been the talk of the village, and as he grew up, his own behav-
iour will have become the focus of attention too. But there are strict
social rules at play here; talk of business is one thing, but intervening in
someone’s business without an invitation to do so crosses a barrier that
could not be more effective if it were an electric fence. Reporting abuse
to the authorities or challenging destructive behaviours that pertain to
someone else’s private life, though morally justified, may be considered
tantamount to breaching the social codes that bind people together.
Our observations come from being steeped in Caribbean societies, but
these are unscientific generalisations, and for sure there will be people
who do take action to speak out against abuse. In a community survey
of 859 adults to explore attitudes towards CSA in the Caribbean, most
people believed that both women and men could do more to protect
children from abuse in their communities:
Respondents were strongly of the view that women could take more
action to protect children (87.5 %, n = 752). They were also firmly of
the view that men could do more to stop other men from sexually abus-
ing children (83.2 %, n = 715) (Jones and Trotman Jemmott 2009, 92).
Within the Jones and Trotman Jemmott study, most respondents said
they would inform the police about CSA if they became aware of it in
their own families, yet when this was discussed in focus groups, it trans-
pired that even when abuse was widely known about, people felt it was
not ‘their business’ to report it or were concerned about causing trou-
ble. Consequently, there existed a kind of collusive silence, even as ‘the
business’ was widely talked about—powerful social codes disabled people
from taking action. Participants in the study were often fully aware of
child maltreatment in their communities and knew where the risks lay
for children, but doing something about it was another thing altogether:
‘Women could take more action to protect children

from men taking sexual advantage of them’
35, 4%
52, 6%
20, 2%
Agree
Disagree
Not sure
Missing
752, 88%
Fig. 4.5 Women could take more action to protect children

(Source: Jones and Trotman Jemmott 2009, 92)
‘Men could do more to stop other men from having

sex with children’
73, 8%
49, 6%
22, 3%
Agree
Disagree
Not sure
Missing
715, 83%
Fig. 4.6 Men could do more

(Source: Jones and Trotman Jemmott 2009, 92)
There was a father who was molesting his baby, and his sister told him that
he ‘must stop the foolishness’. They all knew about it. The whole thing was
disclosed when the baby was found to have gonorrhoea in its mouth. He
can’t think that he is doing anything wrong, when everyone knows and
nobody calls the police (Jones and Trotman Jemmott 2009, 21).
In another example, a 14-year-old girl reported to her local police sta-

tion that her stepfather had been sexually abusing her. When she got
home, news of this ‘social betrayal’ had reached before her. The whole
family was outraged; the abuse was one thing, but for a child to report
her father was not acceptable (clearly, the police officer thought so too).
Before she was thrown out of the family home, the girl was severely
beaten by her stepfather—a lesson in collusive silencing she would prob-
ably never forget.
How do we transform communities and villages into spaces where
people really do mind children’s business and make the protection and
support of all children a priority? This is a question for us all. As for
Levi, members of his wider family and of the community could have
and should have intervened—they failed him as a victim of abuse, but
as we discuss later, there are ways in which they can now support him as
he seeks to tackle the destructive behaviours that are a legacy of his past.
There are many key ‘moments’ when professionals might have identi-
fied Levi was a child at risk of abuse—the timeline of events highlights
the most obvious of these. One example is when Levi was hospitalised at
the age of eight because of physical abuse.
Levi was physically abused throughout his childhood by his mother and
some of her boyfriends. When he was eight years old, he was hospitalised
with a broken collar bone and injuries to his face, but this was never
reported to child protection agencies or the police. Jennifer was also subject
to beatings by her intimate partners, particularly when Levi was a child.
Although sexual abuse can be difficult to detect, a child who presents at

a hospital with a serious unexplained injury provides professionals with an
opportunity to undertake a needs assessment which can then reveal hidden
forms of abuse. Levi needed protection from neglect and abuse through-
out his childhood, not only to prevent harm to him as a young child but
also to prevent the onset of behavioural problems later. There is a growing
body of research to suggest that the influence of adverse childhood experi-
ences, including abusive and neglectful parenting, may have a detrimen-
tal impact on brain functioning that can contribute to later behavioural
problems (Mehta et al. 2013; Hanson et al. 2010; Bruce et al. 2009). Early
intervention can substantially reduce the likelihood of maltreatment and
may have helped to prevent Levi from spiralling into the vortex of trauma
he experienced and the onset of his own offending behaviour (Farrington
and Welsh 2007). There will have been a time before the neglect and abuse
began when Levi’s mother envisaged a better future for her son and may
have been amenable to receiving the support in caring for him that was so
clearly needed. Services to support young mothers, who may themselves
have experienced adverse childhood experiences, can facilitate the positive
attachment and parenting behaviours (see Part 1) that are important pro-
tective factors. Intervention and support services at an early point in Levi’s
life were this child’s right—it is indeed an incontrovertible right within
the UN Convention on the Rights of the Child (CRC) for a child to grow
up free from abuse, a right underlined by Caribbean governments through
the ratification of this Convention. No services for Levi and his mother
were provided, and the lack of effective inter-agency practice meant the
risks he faced were easily missed.
We cannot turn back the clock for Levi, but as there can be many
reasons why professionals and agencies fail to protect children even when
they have a legal duty to do so, there is need for a retrospective examina-
tion of what went wrong, and why, in cases of serious abuse and neglect,
such as his. These arrangements exist in many countries as part of the
legislative and policy framework for the protection of children, such as
the Serious Case Reviews that are held in the UK (HM Government
2010; Sidebotham et al. 2010). There are dangers of review processes
being used to blame and vilify individuals rather than identify the factors
that contribute to systemic and organisational failings. Furthermore, the
lessons from review processes often do not result in improving child pro-
tection and their focus on individual children means policy makers can
miss intersecting factors at the meso level that could contribute to wider
prevention strategies (Kuijvenhoven and Kortleven 2010). Also, system-
atic reviews add a layer of bureaucracy to overstretched workloads; they
can become an end in themselves rather than being regarded as the means
to an end (Rawlings et al. 2014) and they can consume professional and
agency resources that, in middle- and low-income countries, are thinly
stretched. Despite these limitations, reviewing cases of serious abuse and
neglect is necessary in order to learn lessons from failings and to improve
practice and organisational responses.
No country in the Caribbean has yet established a rigorous inter-

agency system for learning from cases of child maltreatment and therefore
there is no sense of a ‘culture of accountability’ which could demonstrate
the region’s commitment to a child’s right to grow up free of abuse. As
Trotman Jemmott, in response to the non-accidental death of 12-year-
old Shamar Weekes in Barbados on 14 May 2015, stated, ‘All profes-
sionals working with children should be empowered to act wisely from
a knowledgeable and accountable practice base’ (Nation News, Barbados
12 June 2015). Establishing strategic reviews in serious cases can help
on all three counts: they can empower workers, increase knowledge and
improve accountability. Such systems can sow divisions between pro-
fessional groups (Rawlings et al. 2014), but handled well, formal inter-
agency meetings which enable honest reflection can improve professional
collaboration (Crawford and Jones 1995). Agency cooperation in pro-
tecting children from abuse is built into the child protection plans of
Caribbean governments, but many barriers exist which prevent the trans-
lation of these policies into effective inter-professional practice (Jones
et al. 2014). In the absence of sound arrangements for working together,
workers most likely to confront abuse cases—police officers, social work-
ers, teachers and health workers—often hold unhelpful assumptions and
perceptions about each other’s roles and responsibilities and may invest
more in sustaining power differentials than in child protection (Hudson
2007).
For reasons already discussed, the establishment of procedures for
reviewing cases of serious abuse and where children have been failed by
professionals and agencies is not without some challenges. Therefore, we
do not argue for the wholesale adoption of systems that exist elsewhere
since this could result in replicating their weaknesses too. However, we
do argue for the creation of review processes relevant to the Caribbean.
These should be timely and bureaucratically minimal and seek to promote
accountability (rather than blame) and build inter-professional practice.
These processes should be tied into organisation monitoring systems to
ensure that changes needed are effected.
Making the Case: Interventions for Juvenile

Sex Offenders
We have read that Levi is mandated to receive treatment from a psycho-
therapist as part of his sentence with a view to his being prepared for
inclusion in a juvenile sex-offender treatment programme. At the time
of writing, however, we were not aware of any such programme in the
Caribbean, and our call is for professionals to create such a service in
their countries and to become the experts in this field of practice. Lack
of professional confidence, experience, training and inadequate resources
means that most young people with sexually harmful behaviour in the
Caribbean are left waiting for help. In an analysis of child protection
practice, policy and legislation, Jones et al. (2014) describe some of the
organisational factors that impede effective family support and child pro-
tection services in the Caribbean. Although several countries in the region
have good protocols for dealing with abuse, there are challenges to their
implementation. These include the lack of coordinated approaches and
accountability across key agencies, organisational and professional ambi-
guity about definitions of abuse, and ineffective monitoring and follow-
up. This is the context in which professionals work in the Caribbean, and
although we do not minimise the impact of these factors, practitioners
should work together to develop interventions for juvenile sex offenders.
We are not proponents of poorly thought-out programmes that have no
scientific basis or proven benefit, but we do argue for multi-agency teams
to come together to design, pilot and evaluate models appropriate to
the Caribbean. Interventions are needed for the treatment of those who
commit sexual offences and also for those who are their victims (see, for
example, the interventions proposed in Parts 1 and 2 of this book).
Professionals have always had to be resourceful and it is this resource-
fulness, skilfully applied, that is needed to support Levi, since apart from
his own resilience and strengths, the most important resource for change
available to him may be the psychologist, probation officer, prison wel-
fare officer or social worker reading this. In the next section, we present
the case for establishing treatment services for juvenile sex offenders as a
vital tool in the wider strategy to reduce and prevent sexual violence to
women and children in the region.
Making the Case for Providing Treatment

to Juvenile Sex Offenders and Young People
with Harmful Sexual Behaviour
It is well documented that sex offenders have often been victims of CSA
too and theirs is a crucial target audience to reach and rehabilitate. Most
children who have been abused do not go on to commit sexual offences
as adults, but paradoxically most people who do were themselves abused
as children and this is especially true if they have not received any help
to address trauma and the cognitive distortions that may arise from early
CSA (Veneziano et al. 2000). That Levi should have graduated from being
a victim to becoming a perpetrator is too familiar a script and, though
not inevitable, was made more likely because of the lack of early interven-
tions. One of the greatest problems with preventing sexual abuse is that
there is virtually no help available in the Caribbean if someone is con-
cerned about their own or other people’s sexual behaviours or attitudes.
Like CSA elsewhere, CSA in the Caribbean, when formally exposed,
generates great public anger, social stigma and vigilantism (McAlinden
2008). Families must either deny there is a problem or isolate the person
whose behaviour is a cause for concern. This is especially so in the vil-
lages of the Caribbean where it seems that everyone knows everyone else.
Together these factors mean that help-seeking behaviour is discouraged
rather than facilitated, and as governments in the region move towards
mandatory reporting, fear of retribution, prosecution and alienation
drives denial and leads to greater subterfuge in the commission of sex
crimes. That the only possibility of help should come through a mandate
of the courts means Levi can now access treatment. As a general approach
to reducing sexual violence, however, a criminal-justice-led response is
problematic for a number of reasons:
1. It requires a conviction, but as most sex crimes are unreported, this

means that help is not available for the large majority of people who
need it.
2. It is widely understood that sex-offender treatments are unlikely to be
effective unless there is an acknowledgement of a problem, a willingness
to address it and acceptance of responsibility. Enforced compliance

can undermine treatment.
3. Mandated treatments mean that the crime has been exposed—the per-
son is now in a situation where he is socially isolated, a potential target
for attacks and abuse, and consigned to the fringes of family and com-
munity. His most likely allies may be other sex offenders and he may
need to move to a new neighbourhood and bury his crimes. These are
the least desirable environmental conditions to support and sustain
behaviour change among sex offenders, and on the contrary, the risk of
re-offending is higher because of the lack of a positive support net-
work. The misuse of drugs and alcohol may also be increased in these
circumstances, contributing to the lowering of inhibitions and self-
control mechanisms that can help prevent recidivism.
The environment that we (the public, professionals, academics and

policy makers) have generated in response to sex crimes is such that we
have sabotaged one of the most important strategies to address the prob-
lem, the open acknowledgement of abuse by those who are a risk to oth-
ers and access to treatment and support before a crime is committed.
This problem does not apply only to the Caribbean and a letter in The
Psychologist raises this very issue with respect to the UK:
As I see it, the main stumbling block for unconvicted and would-be offend-
ers seeking psychological support lies in our mandatory reporting laws.
These laws bind social, medical and mental health professionals into com-
pulsorily contacting police if they believe that a crime has been committed
or is likely to be committed, superseding all confidentiality clauses. … it
becomes almost impossible to provide treatment to individuals of this
nature … It is clear that British society is currently failing the victims of
child abuse as well as the adults who may prey on them. Following the
arrests of 660 people for child pornography offences, Phil Gormley, deputy
director general of the National Crime Agency, called for a proactive
approach in developing ‘a range of interventions to prevent people offend-
ing … [and] to enable people to seek help to prevent their offending from
becoming even more serious’. Convicted offenders make up only the tip of
an iceberg, with vast numbers of those attracted to children remaining hid-
den throughout their lifetimes. Research … estimates that paedophilia
affects around 1 per cent of the global population, a figure suggesting

British society may currently contain 641,000 such individuals; more than
seven times the total capacity of British prisons (87,879). These figures
seem to be supported by Phil Gormley’s assertion that we cannot ‘simply
arrest our way out of this problem’ (Macleod 2015, n.p).
There is a growing international call for policy makers and profession-

als to lead the way in shifting responses to CSA away from anger and
reactive punitive approaches towards facilitating help-seeking behaviour
and accountability. Criminal justice systems are particularly limited in
responding to sex offences (McAlinden 2007; Jones et al. 2014) since
they can deal with only the very small percentage of offenders known
to the authorities, estimated at fewer than 5 % (Salter 2003). Several
Caribbean countries are introducing more punitive responses, and some,
mandatory reporting laws—the message intended by developments such
as these is that governments take the matter seriously and there can be no
impunity under the law. Unfortunately, these strategies can actually drive
the problem underground. Twelve out of 13 Caribbean Community
(CARICOM) countries state that they have mandatory reporting laws;
however, only two said the law was enforced, although the vast majority
reported that they had specific protocols and referring mechanisms in
place (UNICEF 2013). What this state of mandatory reporting in the
Caribbean shows us is that CSA is highly unlikely to be prosecuted and
therefore is highly unlikely to result in increased convictions and is highly
unlikely to bring about any change in the prevalence.
Improvements in critical services for victims and perpetrators remain
elusive. Indeed, it is likely that, as elsewhere, mandatory reporting laws lead
to a fear of consequences and actually prevent victims from disclosing abuse.
Although we accept that there are some sex offenders for whom heavy pen-
alties are warranted, any strategy which reduces capacity to detect, prevent
and treat the large numbers of people with harmful sexual behaviour in
our communities who may never be known to law enforcement officers
will be counterproductive in the long term. This is criminal justice policy
according to the iceberg approach: that is, policy directed towards the vis-
ible tip of the problem while neglecting the huge destructive force that lies
beneath. Resources are swallowed up by the cases we know about while
prevention strategies and support for victims who cannot or do not report,
and for perpetrators who are not detected, remain scant.
From the available literature, we can speculate that, generally, fewer
than 5 % of disclosures will result in a conviction, yet almost all child
protective resources (e.g., professional time and expertise, government
and agency requirements and procedures on tasks such as reporting,
forensic investigation, prosecution, risk registers, and surveillance) are
targeted towards this end of the problem.
What this means in terms of resource allocation is that although only
5 % of allegations result in a conviction, almost all of the criminal justice
and child protection resources for tackling CSA are directed towards the
small number of reported cases and the even smaller number of cases that
make it through the courts. In other words, child protection resources in
the Caribbean are consumed by responding to crimes that have already
been committed, leaving little for prevention and treatment services. An
alternative public health approach which facilitates help-seeking behaviour
can actually increase the number of disclosures and reporting of concerns
about CSA, including self-reporting (Macleod 2015). Adopting a proac-
tive non-judgemental approach to supporting those who want help may
be one of the most effective ways of reducing the prevalence of sexual
violence in the Caribbean. Regardless of how compelling these arguments
are, we must accept that, at this point in our history, Caribbean societies
are a long way from the open self-acknowledgement of risk behaviours,
and for now we must satisfy ourselves with agitating for treatment services
convicted Fewer than 5 percent of

cases- disclosures result in a conviction
consume yet almost all child protective
most
resources resources are targeted towards
this end of the problem, while the
95 percent of cases in which
non-
there are no convictions receive
convicted
cases - far less support.
receive
least …
Fig. 4.7 The distribution of child protection resources according to the

iceberg approach
to be available at the very least for those 5 % of offenders who do come to

the attention of the authorities.
Professional Concerns
There is likely to be some reluctance among professionals about creat-
ing interventions for those who commit sex offences. This is because it
is often believed that only those with the highest levels of expertise and
training have the skills necessary to run such programmes. We absolutely
get this point, but the reality is that there are so few people with train-
ing in this area of work in the Caribbean that solution-focused, rapid
capacity-building strategies are needed. Governments, agencies and pro-
fessionals in the region who are committed to preventing CSA should
prioritise the acquisition of postgraduate training in sexual disorder diag-
nostic and therapeutic skills for psychologists and social workers, but in
the interim the pooling of available skills and expertise is an excellent
stating point. Another reason why there may be reluctance to develop
treatment interventions for sex offenders is the fear that the stakes of
programme failure will be high; however, as we see from Levi’s case, the
stakes of not providing such services are far higher. Agencies may be con-
cerned that they will be overwhelmed by the request for services; this is
unlikely, but should potential offenders come seeking help, this would
be a major step forward in reducing the incidence of CSA. A further
issue of concern is the medicalisation of a problem implied by the term
‘treatment’. Sexual abuse of children is not a matter of illness or wellness
but is primarily about behaviour, values, power and disinhibited sexual
impulses. ‘Treatment’ implies a treatable medical condition, but sexual
attraction to children is not something that medical interventions can
address, and the most effective methods focus on cognitive and behav-
ioural changes. Where medical treatment is available, this refers primarily
to pharmacological approaches which use drugs to reduce sexual desire;
however, by themselves, these methods fail to tackle issues of control and
manipulation that are an integral part of many sex offences. Some critics
of sex-offender treatments suggest that the medicalisation of CSA allows
abusers to assert that they are sick and thus unable to help themselves.
We acknowledge these limitations, and although we are uneasy too, we
continue to use the term because (a) the notion of treatment requires a
positive, hopeful attitude; (b) if treatable, then CSA cannot be inevitable;
and (c) it confronts blame attribution and makes it clear that the target
of change should be the person with the problem, not the victim. Blame
attribution directed towards victims is a commonly reported problem
which not only compounds feelings of guilt and self-loathing among vic-
tims but also gets in the way of people with harmful sexual attitudes
taking responsibility for their actions. A benefit of the term ‘treatment’
is that it moves the discussion away from blame and retribution towards
hopeful transformation. Nevertheless, we are equally concerned about
the dangers of perpetuating perceptions about the dominance of indi-
vidual psychopathologies and notions of sexual deviancy that ‘treatment’
conjures up. As Letourneau and Borduin (2008, 290–1) point out:
Although the research literature reviewed … strongly indicates that sexu-

ally offending youths are influenced by multiple ecological systems, most
current treatments focus heavily on presumed psychosocial deficits in the
individual youth. ... Another problem with the predominant approaches to
treatment is the fact that many sexually offending youths desist from future
offending (even in the absence of intervention).
Letourneau and Borduin (2008) make the point that, even without
treatment, many young offenders would not present an ongoing risk for
children. This finding has been confirmed in other studies too; however,
none of this research has been conducted in Caribbean contexts in which
peer group norms reinforce gender-based violence as normative, as in
Levi’s case. By offering treatment to Levi, he may come to realise that
his harmful sexual impulses may be linked to his own experiences of
traumatic sexualisation, which can be identified through a psychological
rating scale (Sparta 2003, 226). Also, regardless of the causes of his sexual
thoughts, treatment approaches make clear that he is fully responsible for
learning to control them and not acting on them. Individual treatment
(which is discussed later) will not, by itself, address the social conditions
that promote and enable sexual violence—this needs attention too.
Clearly, there are challenges in setting up a sexual abuse treatment pro-

gramme for young people such as Levi, yet the policy, legislative, human
rights and professional mandates for doing so could not be stronger, as
we summarise below.
1. Juveniles are responsible for a significant number of sex crimes.

Although adults commit most CSA overall, up to a third of cases in the
UK are perpetrated by other children and adolescents (Erooga and
Masson 2006); in the USA, young people commit 20 % of all rapes and
50 % of all child molestations (Finkelhor et al. 2009; Koss et al. 2006).
There are no prevalence data for the Caribbean, but Jones and Trotman
Jemmott (2009) reported that sexual offending often begins in adoles-
cence, with transactional sex and coercive sex among young people
being common. Although many young offenders do not have paedo-
philic inclinations, where they do, these can persevere into adulthood
and programmes specifically targeted to help them can decrease the
likelihood of their going on to commit sexual crimes in adulthood.
Clearly there is a strong child protection mandate for providing treat-

ment services to people with harmful sexual behaviour, especially young
people.
2. Conceptualised as part of a public health approach to prevention,

interventions that target adolescents can reduce short- and long-term
health problems associated with CSA (e.g., unwanted pregnancy, HIV,
sexually transmitted infections, drug and alcohol misuse and mental
health problems).
Therefore, there is a strong public health mandate for providing services

to young people who have harmful sexual behaviour.
3. Sex-offender treatment programmes are an important component of

any comprehensive restorative justice (RJ) strategy. Based on the
recognition that imprisonment is not the only form of justice and, for
young people, may actually reinforce rather than reduce criminogenic
behaviour, Caribbean governments have pledged their commitment
to RJ, especially for youth. There are, however, no RJ juvenile pro-
grammes that address sexual offending in the region. Although experts
have increasingly advocated for a less punitive approach for juveniles,
public policy has moved largely in the opposite direction and courts
often apply the same sex-offender legislation used for adults with
costly consequences. For example, prison sentences may place the
young person at risk of physical and sexual trauma at the hands of
other prisoners (Abram 2004). Juvenile sex crimes are a serious prob-
lem; however, the prospect of interventions being effective in chang-
ing harmful sexual behaviours and attitudes is far greater with
adolescents than with adult offenders. The US National Center on
Sexual Behavior of Youth reports that only 5 % to 14 % of juvenile
sex offenders re-offend compared to approximately 40 % of adults
(NCSBY nd) and that young people with sexually harmful behaviour
are particularly responsive to treatment (especially multi-systemic
approaches). The aims of RJ in sex crimes are similar to those in other
offences (to make some form of reparation for the harm done to a
survivor/victim and, where appropriate, to their families/communi-
ties through offender acceptance of responsibility); however, for these
aims to be achieved, offenders must be able to access treatment and
rehabilitation programmes (McAlinden 2008).
There is a strong criminal justice mandate for providing treatment ser-

vices to juvenile sex offenders.
4. It is the case that only a small proportion of survivors of sexual vio-

lence ever see their abuser or rapist punished. There is also increasing
evidence that legal proceedings are often in conflict with the needs of
the victims and that the adversarial court process can be very trau-
matic. Fear of the courtroom and invasive questioning and examina-
tions, together with the implications for individuals and families of
protracted proceedings, especially where the abuser may continue to
live alongside or in the vicinity of the victim (common in small

societies like the Caribbean), discourages disclosure and reporting and
this in turn decreases the likelihood of perpetrators ever being con-
fronted with their crimes. In contrast, an effective RJ framework in
which the community has confidence and where there is clear evidence
of treatment and rehabilitation being offered to the sex offender can
encourage victims to report sex crimes. This offers a better safeguard
for families and communities than other measures such as sex-offender
registration and surveillance (Koss et al. 2006).
From a victim’s perspective, providing treatment services to juvenile

sex offenders as part of an RJ approach can help in overcoming the
effects of abuse (we discuss this in more detail later). Therefore, there is
a strong family/community mandate for providing services to juvenile
sex offenders.
5. Juveniles differ significantly from adult sex offenders (Przybylski

2014). Brain research shows that adolescents have less capacity than
adults to regulate emotions. Also, psychosocial development takes
place much more slowly than cognitive development and this impacts
judgement and impulsive behaviours (Przybylski, 2014).
‘the developmental differences between juveniles and adults that have been
identified through recent advances in neuroscience and developmental crimi-
nology are extensive and profound. Based on the scientific evidence, it is clear
that juveniles and adults differ in their cognitive capabilities, capacity for
self-management and regulation, susceptibility to social and peer pressure,
and other factors related to judgment, criminal intent, and the capacity to
regulate behaviour’ (Przybylski 2014, n.p., emphasis in original).
The parts of the brain linked to planning and foresight are not fully
developed even by late adolescence—this may help to explain why young
people often fail to consider the consequences of their actions (Przybylski
and Lobanov-Rostovsky 2014). The evidence is compelling—adolescents
with harmful sexual behaviour require developmentally appropriate
interventions that take into account contextual factors and their level of
maturation. Specifically designed therapeutic and supportive interventions

can help young people modify their thinking patterns and make the link
between emotion, behaviour and consequences.
There is a professional mandate for therapists (psychologists, counsel-

lors, psychotherapists and psychiatrists) to provide treatment services for
young people with harmful sexual behaviour.
6. With effective treatment and support, attitude and behaviour changes

concerning sexual violence to women and children can percolate fami-
lies, peer groups and communities. Educating children, young people
and the public about sexual harmful behaviours and facilitating com-
munity support of young offenders who are in treatment may help in
reducing sexual violence in society more widely.
There is a strong community mandate for providing treatment services

to juvenile sex offenders.
Collaboration, Partnerships and Systemic

Practice
These powerful mandates for action point to the role that agencies, pro-
fessionals, communities and organisations all need to play in treating and
supporting young people with harmful sexual behaviour. The first step
is to establish a multi-agency team that has an interest in the preven-
tion and treatment of CSA. In some countries, the establishment of such
groups is part of the formal child protection system and is a legal and pol-
icy requirement. In the UK, for example, Safeguarding Children Boards
(SCBs) (France et al. 2010) established within each local authority are
multidisciplinary groups charged with responsibility for improving child
protection within a locality. Unlike what we are proposing here, SCBs
do not establish services or deal with the treatment needs of abusers, but
they provide a good example of inter-agency collaboration. Creating part-
nerships between professionals and agencies breaks down organisational
barriers that sometimes get in the way of finding effective solutions to

problems. Pooling expertise and knowledge about what needs to be done,
by whom and how is the prerequisite for effective integrative practice for
young people with harmful sexual behaviours and attitudes.
It is important to acknowledge from the outset that no method will
be effective for all young people who display harmful sexual behaviour.
Juvenile sex offending is highly complex. For example, a review of cases
by Finkelhor et al. (2009) found that paedophilia (a fixed attraction to
young children) may not be the sole or even predominant motivation for
juvenile sex offences.
Finkelhor and colleagues also commented that it was more common
for younger teenagers than older teenagers to engage in illegal sexual acts
with younger children and further that:
to the extent that epidemiologically rarer events correspond to greater indi-

vidual deviancy, cases of older teenagers victimizing much younger chil-
dren might raise relatively more concern and pose higher future risk than
cases where younger teenagers victimize young children (Finkelhor et al.
2009, 9).
As Finkelhor and colleagues make clear, it is exceedingly difficult to

identify which young people who have displayed harmful sexual behav-
iour will continue to present risks for children in the future. Equally
clear is the fact that many juveniles may desist from further offending,
even without treatment. The research this information is based on is from
the income-rich, industrialised countries of the West. There is no pub-
lished research of juvenile sex offenders in the Caribbean, where sexual
and physical violence against women and girls is endemic. What research
has been carried out shows that some people become socialised to regard
sexual abuse as normal and in this sociocultural context, it may be more
likely for juveniles who have committed sex offences to continue doing
so. For this reason, it is important to ensure that all young people in the
Caribbean who present harmful sexual behaviour and are considered a
risk to children have access to treatment. In the next section, we describe
an individualised treatment approach and then move on to discuss a
potential model for group treatment of young people.
Working with Levi
Although we have changed his name and the details of his case in order to
protect his identity, Levi is a real person who actually received treatment.
Group treatment methods (which we go on to discuss) are particularly
important for working with sex offenders as the group functions as a
source of support and can help hold the offender accountable for destruc-
tive attitudes and behaviours. However, many young people will need
individualised treatment either before they can benefit from being part
of a group or as well as group treatment. Levi is withdrawn and seems
reluctant to engage with the idea of a formal treatment programme. His
demeanour suggests that he may be depressed and he is likely to be expe-
riencing drug withdrawal symptoms. He is also isolated and this, along-
side childhood traumas, can mean that he lacks the confidence to be able
to function in a group setting and may not have the psychological tools
to be able to benefit from group treatment as the first stage of interven-
tion. As a first step to helping Levi, he is provided with individual ther-
apy. In the description of the intervention that follows, the theoretical
underpinnings of the approach are explained and therapist’s reflections
enable us to explore the dynamics of the therapist-client relationship and
the ways in which anger, distress and hurt begin to surface.
Psychotherapy
When beginning work with a sex offender, a psychotherapist may expect
to experience the same flood of conflicting emotions as anyone would,
particularly if the therapist and offender reside in the same community
and particularly if the community is small. Therapists or social workers
may feel outrage, repulsion, fear and despair. Whether these emotions arise
naturally when one is placed in close proximity to a known predator or as
a result of cultural conditioning, we, as human beings, are susceptible to
the range of them. We would go so far as to say that one cannot not react
to this type of encounter, and it is essential for a therapist to acknowledge
this, going in (see Part 1, where this issue is discussed in more depth).
It is equivalently essential for a professional to take the next step,

once intruding fears have been identified and acknowledged. The next
step is for a therapist to ask him- or herself ‘Do I wholeheartedly believe
that this individual can be helped?’ and ‘Do I wholeheartedly believe
that I have the capacity to provide such help?’ If the answer to either of
these questions is ‘No’, then the professional should not become directly
involved in the case but should refer it to someone else. Similarly, as a
medical doctor in an emergency room does not stop to investigate the
moral character of the patients coming in for surgery, neither should a
psychotherapist harbour judgements in regard to her client. If hands or
hearts shake, either professional needs to put down their instruments and
refer the case to someone else with a steady nerve.
There are dictates guiding this orientation to life and work throughout
history. For those who take the Western Bible’s Ten Commandments to
heart, the one which extorts us to ‘Love Thy Neighbour’ refers not only
to the nice neighbours but to all of them. And on the opposite side of
the coin, the following poem by an Eastern philosopher, Chuang Tzu,
instructs in the Taoist method of refusing to disown, disapprove or judge
any task, except for the wholehearted resolve to simply ‘do’ it.
When an archer is shooting for fun,

He has all his skill.
If he shoots for a brass buckle,
He is already nervous.
If he shoots for a prize of gold,
He goes blind
Or sees two targets.
He is out of his mind.
His skill has not changed,
But the prize divides him.
He cares.
He thinks more of winning
Than of shooting.
And the need to win
Drains him of power.
—Chuang Tzu
http://theunboundedspirit.com/inspirational-taoist-quotes-and-stories-by-
chuang-tzu/.
Meeting Levi
The practice of psychotherapy includes an ethical responsibility to hold
every client’s basic human rights at the heart of all encounters and this
responsibility extends to all details of engagement, including such appar-
ently mundane issues as location, placement of objects within the clinical
space, and proximity of the body of the therapist to the body of the client.
In the clinic where Levi first met with the therapist, the setup was similar
to most clinics in the Caribbean, in which the therapist lodges him- or her-
self behind a desk while the client is kept at a distance opposite, generally
on a much less comfortable chair. Levi reacted negatively to this display of
spatial power the moment he walked in the door. Readers will see how his
intuitive reactions to space, power and feeling interrogated or trapped were
crucial to the design of programmes for Levi’s rehabilitation later on.
Levi had met with this therapist once before, when he first entered the
system after being charged with sexual assault. This next encounter was
for the specific purpose of taking a more detailed history as a prelude
to designing a treatment plan or, rather, for the purpose of determining
whether Levi was a good fit with the state’s proposed group programme
for juvenile offenders or would need a different or additional approach.
Although this case describes Levi’s reality, both the process and outcomes
might well apply to other clients of similar circumstance.
So, prior to developing a treatment plan to which this client might be
responsive (lessening the risk of treatment dropout) and as a means of
assessing his capacity for rehabilitation, we reviewed Levi’s general fam-
ily history, his criminal history, and psychological background. That is,
we reviewed how the world saw Levi and his place in it. We then began
the process of determining how Levi saw himself. Having been con-
victed for the sexual assault of a girl and with a well-known background
of violent actions and substance abuse behind him, was he remorseful,
horrified at the kind of man he had become, and desperate to change?
(This is, of course, the option that psychotherapists hope for, as an ‘eas-
ier’ path of rehabilitation could then be administered.) Was he angry at
the adults who raised him and blameful of their part in the sculpting
of his character? In Levi’s case, it seemed he could not care less about
either position. Not only would Levi resist all attempts at treatment, at
developing rapport with the therapist, or at answering the most basic of

questions (‘Do you know who Barack Obama is?’, ‘What is the month
of your birth?’), but he actively resisted the room in which we sat and his
‘behind the desk’ designation, which appeared to symbolise an infringe-
ment upon his very right to draw breath and live.
An Insight into Levi’s Stance

with the Therapist
Levi’s background was firmly steeped in gendered notions of power and
control. He was used to gender-based domination: men who dominated
women, mothers who dominated their sons, or people in positions of
greater power belittling people in positions of lesser power. His entire
orientation towards life spun from a paradigm of ‘dominate, or be domi-
nated’, so he chose the option that would never see him dominated or
victimised again. To be specific, Levi had seen men dominate women,
and he had been raised to think this was normal. Levi had also seen
women dominate and abuse men, which he had been raised to think was
abnormal and degenerate. Add to this Levi’s sexual abuse at the hands
of his mother, and we had a prescription for automatic distrust, if not
open hatred, of his female therapist. Levi would rather die than trust her,
rather suffocate than answer even one of her probings. At the heart of his
resistance to the female therapist and her intention to make friends with
his mind lay a deep fear of self-disintegration. Having been caught at
his game, having faced the judge and made to understand that he might
be locked away for more years than he could bear because his ‘normal’
behaviours had been found heinous, Levi’s central equilibrium was fast
eroding; his internal barometers of self and safety, blasted sky high. Nor
was this the first time that Levi had felt himself explode internally. In an
article titled ‘Can losing everything be a blessing?’, Christina McDowell
speaks of her millionaire father’s being charged with fraud and sent to jail
in America, leaving her suddenly penniless and emotionally broken. The
reality of self-disintegration was no more potent for her than for Levi, or
anyone, when all of the strings of one’s bow come undone.
All the things I thought defined me, all the things I thought kept me safe,
had been ripped out from underneath me. My identity was quickly unrav-
elling. I was losing who I was and wondering who I would become
(McDowell 2015, 1).
Self-fragmentation often occurs subconsciously in the face of chronic

danger. When children experience fragmentation anxiety, it is the parent
or caregiver who helps the child regulate their psychophysiological state.
In the case of children who have been abused by their parent, a psycho-
therapist may then step in to help keep fearful psychological states at bay
and help the child return to emotional equilibrium, from which point he
can go on to develop his own potential. In Levi’s case, danger has been his
daily bread. By the time of his coming into therapy, he had struggled to
make sense of his world and developed his own self-soothing framework
in extremely maladaptive ways.
In less good circumstances, the (abused) child will be compelled to incor-

porate the mother’s desire as an internalized structure around which to
organize the self—or will organize around an idealized abuser or indeed
around any available perceived source of strength. This inner structure will
then be opposed to the child’s authentic potential. The work of psycho-
analysis involves undoing this alien parasitic structure, thereby releasing
the unknown true self. However, such work brings the threat of fragmenta-
tion and may result in great anxiety (Mollon, n.d.), www.selfpsychology-
psychoanalysis.org/mollon.shtml.
At this stage of Levi’s arrest and mandated appearance in the thera-

pist’s office, he could only regard the female therapist as an opponent,
and from somewhere deep within his flesh and bones, he needed to not
be absorbed and swallowed up by her. None of this is unexpected. Panic
over self-fragmentation, or fear of introjection by an all-consuming (m)
other, is one of the symptoms of complex post-traumatic stress disorder
(PTSD), another one being resistance to treatment. ‘PTSD related to
chronic and repeated forms of trauma (e.g., childhood abuse, domestic
violence, being a witness of genocide) is associated with a more complex
constellation of symptoms that can be especially resistant to treatment’
(Jackson et al. 2010, 76).
Sessions with Levi
The first session was spent in attempts to conduct intake, encouraging
the client to openly and frankly offer his narrative, in his own words and
on his own terms. But Levi’s steely silence, angry glares, and defensive
posturing yielded nothing. That is, they yielded nothing verbal. His posi-
tion, nevertheless, provided the therapist with a very good understanding
of where work needed to begin. Similarly, in the second session, very
few words were spoken. The therapist allowed Levi to sit in his silence
while she quietly described what the next few weeks of treatment might
bring. A period of 6 weeks had been requested for this phase of pre-
treatment. The therapist provided a clear, unambiguous explanation of
the process of therapy in brief, calm terms, herself leaving lots of silent
spaces throughout the hour. This was a method for accustoming Levi to
the space, her non-threatening presence, and (she hoped) a sense of non-
judgemental compassion, or the unconditional positive regard of which
Carl Rogers speaks. This second session also ended the way it began, with
murderous stares coming from the client. At the sound of the alarm bell
(a gentle gong) which he now understood signalled the end of session,
Levi knocked over his chair in his hurry to leave. Session three was pre-
cisely of the same format; nothing could be rushed.
Bessel Van der Kolk is clear that taking trauma histories should involve
less talk and more natural emergence of a narrative.
When people get close to re-experiencing their trauma, they get so upset
they can no longer speak …Their entire bodies respond again as if they
were being molested again—heart pounding, muscles tensing—they seem
literally to take leave of their senses—unable to distinguish now from then
(Wylie n.d., 4).
As psychotherapists, we need to take histories in ways that do not re-

traumatise our clients. We need to pay attention to whether our need for
a full interrogation is not more to satisfy our own curiosity about the cli-
ent’s past than it is about providing them with the help they need.
By the fourth hour of contact, the therapist introduced a psychologi-
cal measure called a Thematic Apperception Test (TAT). The TAT was
developed by the Harvard Psychological Clinic in 1935 and is a pro-

jective identification measure intended to evaluate a person’s patterns of
thoughts and attitudes.
The instrument comprises a set of cards that portray human figures in a

variety of ambiguous settings and situations. The client is then asked to tell
a story about each card while the therapist takes note of their responses.
Although discussing art cards may seem more appropriate to a child or
youth clientele or to a clientele that has voluntarily suspended disbelief to
engage in what may seem a child’s game of fantasy, note that the Thematic
Apperception Test [TAT] is also used for forensic purposes with clients
who have committed violent crimes, including incarcerated violent
offenders.
The TAT is often administered to individuals as part of a battery, or
group, of tests intended to evaluate personality. It is considered effective in
eliciting information about a person’s view of the world and his or her
attitudes toward the self and others. As people taking the TAT proceed
through the various story cards…they reveal their expectations of relation-
ships with peers, parents, or other authority figures, subordinates, and pos-
sible romantic partners. In addition to assessing the content of the stories
that the subject is telling, the examiner evaluates the subject’s manner,
vocal tone, posture, hesitations, and other signs of an emotional response
to a particular story picture
(Encyclopedia of Mental Disorders n.d.).
A Breakthrough!
Not surprisingly, Levi let no stories escape his lips for the first four full
sessions. If any images reminded him of his substantially abusive past,
he avoided displaying his feelings in favour of a hostile façade. And then,
towards the end of the second hour of TAT (session 5), there was a sud-
den break in Levi’s armour, followed by the somatisation of extreme,
profound despair. The therapist had slowly turned over a new card, this
one showing a tropical storm in full blast, with a male figure struggling
against the elements, grasping a small boy in his arms. Note that the
original TAT cards, developed in America decades ago, contain many

images that are not necessarily appropriate to a Caribbean clientele. That
is, the images are of Caucasians, in urban scenes, snowy landscapes, and
so on. This therapist took the initiative to source and insert other images
more closely representative of the demographic in which she worked, as
many professionals around the world have done. It was, nevertheless, a
dramatic surprise to see Levi react so intensely to this card; he came per-
ilously close to a full psychotic break. Hardly ambiguous by the thera-
pist’s own interpretation/projection, the image nevertheless triggered the
fragmentation of all the psychic pieces Levi had fought so hard to hold
together.
Levi’s face sagged, his tightly pursed lips wobbled, he let out one
wail. In just that instant, his control fell clean away and tears poured
like a tsunami from his eyes. Simultaneous with his mind cracking,
Levi’s body went into hyper-arousal crisis as emotion worked his last
nerves.
Emotional reaction is not a simple action, it reverberates throughout our

physical selves. When we cry tears of emotion, happiness or sadness, much
more than tear ducts become involved. Medical researchers are finding that
almost every physical process is affected—blood chemistry, skin color and
muscle reflex, to name a few (Singer 2001, 21).
Levi leaned into the cards, now turning them over himself, racing
from image to image and yelling at what he found. The words he spoke
were barely English, instead being the names of various Caribbean dei-
ties of malicious intention, and of the female gender. ‘La Diablesse!’ he
shouted, ‘Liggarou!’, ‘Yemalla!’ As he returned to the image of the hur-
ricane, jabbing at it and yelling ‘Yemalla!’ (Yemaja, goddess of the ocean
who is implacable when angry), the therapist intervened for the first
time, stilling the turning of the cards and asking what this one meant.
It was her first direct question to Levi in five sessions, and now he was
ready to answer.
Levi Telling his Story

Levi disclosed (rather, he let escape) that the first time he was raped was
during the tropical hurricane that devastated his home and village in
2005. Added to the pandemonium of national disaster, witnessing the sky
fall and his modest apartment building coming apart like matchsticks,
Levi was sodomised in front of his mother and family while a male
neighbour in the next yard screamed curses at the skies, calling on the
goddess of the seas and moons to stop doing her dirty work. It was
obviously at that very moment that Levi internalised a fundamental
belief that women were terrible and immanently capable of perform-
ing unspeakable tortures, that God himself was feminine and she was
wicked in epic proportion.
It was well that the therapist saw fit not to get up and offer Levi any
solace from a physical point of view. As he spontaneously fell into a
full re-experiencing of his five-year-old rape in front of a distracted and
unhelpful mother, any approach on the part of a female authority figure,
no matter how well intended, would likely have been met with aggressive
self- defence.
Clinically dysfunctional adolescents are instantaneously flooded with power-

ful anxiety, rage and fear. Given their volatility and histories of victimization,
such youth are distrustful, guarded, fearful, and acutely sensitive to adult–
child power issues in the therapeutic alliance (Jennings et al. 2013, 18).
Levi was certainly one of these ‘clinically dysfunctional’ youths, but

several layers below he was also an individual who had experienced disas-
ter trauma and never received help.
Right after any disaster you will experience a period of acute shock, which
usually lasts from 10 days to 2 weeks. How you deal with acute shock is crucial
… your approach will result in either mental paralysis or mental recuperation.
Failing to deal appropriately with the acute shock can lead to ongoing nega-
tive preoccupations, which can become chronic (Singer 2001, 3).
In the case of children, it ought not to be how they deal with disaster,
but how the adults responsible for their protection help them process it.
But Levi never had any such thing as adults who attended to his protec-
tion needs, and adding insult to injury during the storm, he also suffered
the torture of sodomy. Thus, his chronic negative preoccupations and
behaviours can come as no surprise.
It was another hour of intense, draining session time before Levi pulled
out of his breakdown and could prepare to leave. In an unfortunately
comedic aside, the police guard who had escorted Levi from the juvenile
centre to the therapist’s office had heard that one blood curdling wail and
jumped into action. Forbidden to enter the therapy room or even to knock
on the door under any circumstances, he had climbed up to the window
on a pile of cement blocks and was doing his level best to force open the
glass louvres and make sure the doctor was safe inside. The therapist could
see his frantic scrabbling and it was all she could do to stop herself from
commanding loudly ‘Get the hell away from there, man!’ Instead, she
caught the guard’s eye and willed herself to transmit an aura of composed
well-being. Should Levi have seen the guard and imagined himself under
surveillance at this most vulnerable moment, the sliver of trust which had
just manifested out of the therapeutic fire would have been lost for good.
Regarding use of the TAT, or art cards, as a projective identification
device, particularly with a convicted sex offender, art therapy as a disci-
pline has historically been used among this demographic. Sgroi (1988),
citing Harter, describes how various forms of art (graphics, dance and
movement, drama, music, poetry, literature, photography and play) facil-
itate the assessment and treatment of sexual offenders against children.
He has suggested a three-stage process in developing the ability to accept a

multiplicity of feelings associated with a given individual or circumstance.
This theoretical concept is most useful both in establishing the level of
developmental arrest in sexual offenders and in planning therapeutic inter-
ventions using the expressive therapies (https://www.ncjrs.gov/App/
Publications/abstract.aspx?ID=118382).
Harter uses art cards, photo cards, drawings and collage, among several
other techniques.
The use of art therapy is explored more comprehensively in Part 6,

focusing more on art as a healing modality for victims of sexual assault.
Ironically, we are at the point in this case where we understand completely
how Levi is himself a victim as well as a perpetrator of sexual violence.
Helping Levi Draw Breath

Levi’s legs shook as he was re-living the traumas that were loosened by
the art cards. They shook so hard that his chair rattled where he sat. Levi
was somatising a frantic need to get away, and even as he realised he
should not actually get up and flee the therapist’s office, his nervous sys-
tem recalled the many instances in which he needed to run away, could
not, and was trapped and violated. This memory further intensified the
somatising process, and Levi spun in a terrifying loop of hurt, anguish
and complete existential despair.
Trauma throws one’s functioning mentality into waves of repetitive think-

ing about what happened and how dangerous it was…emotional shock
keeps the mental treadmill churning…analysing the periods of preoccu-
pied thinking only reinforces their strength and prolongs the process of
recuperation (Singer 2001, 27).
Remember that at the start of psychotherapy with Levi, the psycho-

therapist was tasked with developing a treatment plan for a sex offender—
that is, a rehabilitative package which would take into account why Levi
had become dangerous—and prescribing a behaviour change programme
that he would likely adhere to. Instead, five sessions later, what organi-
cally emerged was a profound need for Levi’s own healing. No attempts
at building empathy for others could possibly work while Levi needed so
much empathy for himself. Empathy was a concept he had never heard
of, experienced or contemplated in his wildest dreams. He would have to
learn it first, by receiving it first, before any further psycho-social work
stood a chance of success.
Levi’s associations with malfeasant feminine deities are also significant
to his psycho-spiritual healing. In the Caribbean world view, room is
certainly left for the possibility of a spirit world, alongside a belief system
that generally claims a monotheistic God. Everyone knows the stories
to which Levi alluded, of La Diablesse, Loup Garoup and so on. Most
make allowances for the ‘other world’, along with prophetic dreams and
visions. But from a purely psychological point of view, without initi-
ating dialogue on whether the spirit world is myth or reality, and cer-
tainly without suggesting that God is a ‘mind-created projection’ (Tacey
2013, 125), Levi is nevertheless not relating to a spirit world with either
informed or intuitive knowledge. Rather, in much the same way that the
TAT (or art therapy) encourages an individual to examine their troubling
emotions by observing them from a safe distance, as though outside of
their own body, so too does Levi deny the unbearable reality of what
loved and trusted family members have done to him (and what he has
done to others) by projecting blame onto an external spirit being, which
he can hate and curse at without repercussion.
even the high intellectualism of the Renaissance, to say nothing of the

modes of mind in ancient Egypt and Greece and of contemporary Japan,
allowed for the animation of things, recognizing a subjectivity in animals,
plants, wells, springs, trees and rocks (Tacey 2013, 125).
‘As Jung announced in 1929, the gods have become diseases’ (Tacey
2013, 126). Scapegoating is a similar notion. Scapegoating is a ‘condi-
tioned response that involves blaming one’s misfortune on an outside
agency or person’ (Singer 2001, 27); as long as we can blame others (the
gods included), we do not have to assume responsibility ourselves. More
complex yet, in the mind of a small child like Levi whose survival (of
whatever sort) depends entirely upon his mother, he cannot afford to see
her through a fallible lens. If he did, it would mean he was consigned
lock, stock and barrel to the care of the gods, which he had come to
believe were randomly punitive. Levi would need to project anger and
blame onto a scapegoat (the gods) and transfer his yearnings for love
back onto his human caregiver (Mother) while deep inside himself his
repressed confusion and conflicted understandings would slowly fester
and morph into the neurotic states manifesting in the clinic today.
The danger to Levi was that he could never come to terms with what
was rattling around in his own psyche, and so bring it under manage-
ment, as long as he attributed all negative influences in his life to the
whims of gods and spirits who held all the responsibility and all of the
blame for wrongdoing. But this level of discussion would not be able to
take place until Levi was soothed and stable enough to take in a word. As
it was, Levi was having difficulty even drawing breath.
Regarding the self-fragmentation mentioned before, Levi’s belief in
wicked feminine deities was a part of the framework which kept him
glued. If the entire world were relentlessly bad, he might think, then it
would be normal for him to have bad feelings, too. But if the world were
benevolent and the gods kind, why was he the only demonic force, the
only one suffused with a sense of personal badness? ‘What is wrong with
me, me alone?’ he might ask, and this single demoralising question would
be much too much to bear. Levi was much safer in a world where evil acts
committed by destructive spirits were the natural legacy to mankind, so
he held firmly to that.
Getting the Plan Right for Levi

The first phase of his treatment plan was finally formed. The one male
yoga instructor with credentials to teach and work with vulnerable com-
munities on the island was found, and he was brought into service to co-
facilitate a series of mindfulness-based stress reduction (MBSR) exercises
for Levi. Mindfulness-based approaches have been common in main-
stream Western psychotherapy since the 1990s (Jennings et al. 2013, 17)
but are much less well accepted in the Caribbean. Perhaps it is because
mindfulness practices have their origin in Zen Buddhism, and à propos
our earlier conversation about the Christian Caribbean giving a nod of
understanding or tolerance to folklore which includes gods and spirits
of African persuasion, they seem much less likely to accept a worldview
that is Oriental. This psychotherapist has, in fact, been refused space for
art therapy and yoga practice in a church cathedral, being told in no
uncertain terms by the attending priest ‘yoga is the Devil’. Nevertheless,
the central instruments of mindfulness, meditation and yoga have been
incorporated in numerous branches of cognitive-behaviour therapy,

either in whole or in part (Jennings et al. 2013, 17).
In Levi’s case, mindfulness was selected as a therapy for stress reduc-
tion, as brought into psychology by Fitz Perls in 1969 and into medical
practice via Kabatt-Zinn in 1979 and by Kurtz in the 1990s. Dr. George
Engel, of the University of Rochester Medical School, is another major
voice articulating the importance of psychological and social factors in
health and disease and in taking a systems perspective that views the
patient as a whole person (Kabatt-Zinn 1990). Instilling MBSR tech-
niques as an integral part of the treatment protocol for hospital ward
patients suffering from chronic pain, anxiety, major depression, conges-
tive heart failure or terminal cancer, Dr. Engel and associates were able to
track real health benefits in the following specific areas:
1. Optimism—a way of explaining the causes of “bad” events

2. Self-efficacy—confidence in your ability to grow
3. Psychological hardiness—the willingness to ask yourself hard ques-
tions about where your life is going and how it may be enriched by
your choices
4. Sense of coherence—the ability to continuously restore balance in
response to continual disruption
(Kabatt-Zinn 1990, 199–204).
As well as MBSR techniques positively impacting these psychological

characteristics for overall health benefit, they have been applied specifi-
cally to mainstream psychotherapy, inclusive of treatment protocols for
adolescent sex offenders: ‘the application of mindfulness to adolescents,
… and its recognized value with sexually abusive teenagers is (now)
emerging’ (Apsche and DiMeo 2010, 2012). Furthermore, Jennings et al.
(2013) comment:
While there may be mindfulness elements in traditional CBT and other

forms of psychotherapy, the explicit effort to integrate mindfulness and
acceptance into traditional CBT has clearly revolutionized the field and
spawned the so-called third wave of cognitive behavioural therapies (Baer
2006). Among other therapies, these include, in published chronology,

Mindfulness Based Stress Reduction (Kabat-Zinn, 1982); Acceptance and
Commitment Therapy (Zettle and Hayes 1986); Dialectical Behaviour
Therapy (Lineman 1993); Mindfulness-Based Cognitive Therapy (Teasdale
et al. 1995); and Mode Deactivation Therapy (MDT) in 2002 (Apsche
et al. 2002)…In particular, MDT uses direct training in mindfulness skills as
a major intervention in the process of deactivating the adolescent’s ingrained
maladaptive “mode” responses (i.e., emotional deregulation). Given the
resistance and reactivity of severely dysfunctional adolescents, Apsche and
Jennings (2013) developed a diverse “toolkit” of non-threatening ways of
teaching mindfulness skills, including breathing exercises, guided imagery
meditation, visual concentration tasks, nature walks, sensory explorations,
and intentionally fun exercises that incorporate sports and adventure to
engage youth. The diversity of tools offers more ways of engaging youth and
gives them the autonomy of choosing mindfulness exercises that they prefer.
Since the mindfulness exercises are relaxing in nature, they do not trigger
the emotional disruptions and oppositional reactivity of “modes”. Moreover,
the mindfulness exercises typically do not involve traditional “talking” ther-
apy, which can often be experienced as aversive, intrusive, boring, or upset-
ting for teen clients (Jennings et al. 2013, 17–8).
Many of these elements would comprise the curriculum that Levi

would follow in the psycho-educational group programme for juvenile
offenders to which he would later be referred. However, in preparation
for his group participation, Levi needed a full course of individual psy-
chotherapy first. In order to prescribe as non-threatening an incubator as
possible, the male yoga teacher would provide gentle, supportive, mas-
culine guidance and modelling. Under his guidance, Levi would learn to
breathe, stretch and release the tensions and traumas that had settled into
his very cellular structure over the course of a lifetime. The sessions would
take place in a private studio, far removed from the hustle and din of a
public city clinic. Three weeks in, the same psychotherapist would come
to the studio following yoga sessions, to re-introduce talk therapy based
on the MBSR methodology. Finally, after a total of 12 sessions, Levi was
ready to contemplate a healthy new beginning and was released to join
his community of peers in the rehabilitation programme.
Restorative Justice for Sexual Offences

As of this writing, juvenile justice reform and the introduction of effective
RJ programmes are matters of priority for the Caribbean. Indeed, there
is growing acknowledgement that current criminal justice arrangements
for juveniles fall far short of the children’s rights obligations to which gov-
ernments in the region have signed up. Even in countries where there are
restorative approaches to juvenile offending, these do not include treat-
ment and rehabilitation for harmful sexual behaviour—acted upon, our
proposals go a long way to filling this gap.
It is overstating the case to suggest that Levi is fortunate, but there was
never a more likely time for juvenile sex offenders to be able to access
the kind of help that they need. RJ in crimes such as CSA and domestic
violence is contentious, and before we describe the interventions that can
make a difference, there is need to discuss some of the issues.
RJ is a re-integrative approach to sex-offender rehabilitation that can
increase offender accountability by encouraging more victims and offend-
ers to come forward. It encompasses a range of methods which can be tar-
geted at individuals, groups, families or communities. Examples include
victim-offender dialogue, family group conferencing, community/school
conferencing, peace-making circles, reparative boards, victim services,
community service, restitution programmes, re-integration services,
healing/support circles and mediation. Here, we are concerned primarily
with the circles of support and the FGC model. One of the contempo-
rary debates in RJ discourse is whether RJ should be integrated into the
formal criminal justice system or should lie outside of it; some scholars
argue that RJ principles are incompatible with a retributive framework
(McAlinden 2008). As Levi’s case indicates, in the Caribbean, RJ is likely
to be established, not least for operational reasons, within the existing
criminal justice framework. RJ approaches require that the young per-
son has already accepted responsibility for an offence and are therefore
not aimed at establishing guilt. Some critics of RJ argue that it is not
appropriate for sexual, partner and family violence cases, yet there are
many examples where it has been used in such instances. The African phi-
losophy of humanity and community encapsulated by the term ‘ubuntu’
was the cornerstone of the RJ approach in the Truth and Reconciliation
Commissions of South Africa (Villa Vincenzo 1999). Furthermore, RJ

approaches were used following the genocide in Rwanda (Drumbl 2000)
and the civil war in Sierra Leone, both instances in which rape was used
as a weapon of war. RJ is also increasingly being considered in homi-
cide cases in the USA, where mediation between victims’ families and
offenders is offered as one of a range of measures (Mills 2003 in Hannem
2011). These approaches can provide a safe and controlled space for con-
fronting the dynamics of abuse, and depending upon the severity of the
crime and the wishes of those involved, bringing together both parties
can promote acceptance of the harm done and give the victim or family
an opportunity to express its full impact. Being able to participate in a
process that holds the offender accountable for his actions is argued to
hold more potential for victim recovery than court proceedings, which in
Caribbean courts are not always victim-sensitive and can compound the
harm already done.
Nevertheless, there remains considerable controversy about the use of
RJ in sex-offence cases. Part of the difficulty is that ‘restorative’ implies
being able to make things right, but a sex offender can never restore what
he has taken from the person he abused; the crime may affect the victim
for the rest of his or her life—self-esteem, relationships, families, commu-
nities, mental well-being, physical health and the ability to study, work or
have pleasure—these facets of human experience can all be impacted by
sexual violence in a way that does not occur with other types of crimes.
There is little that an offender can do to restore equilibrium or to help
the victim overcome these effects of his crime. Family group conferencing
is one of a range of graduated responses that are provided to juvenile sex
offenders under the umbrella of RJ, but it is important to note that for
victims the process has not always had the benefits the model seems to
promise. An early evaluation of one project reported:
Despite the significance attached to FGC as a means of addressing the

needs of victims of crime, the evaluation found: a higher than expected
dissatisfaction by victims with conference outcomes—the victims were the
least satisfied of conference participants; a surprising number of victims
reported that they felt worse as a consequence of having participated in a
family group conference; concerns about reconciling offender’s needs and
victim’s interests in the one forum; and a tension between family and
victim participation in decision-making and maintaining tariff equity.
Other problems of a more general nature included: the absence of due
process; the poor provision of adequate and accessible services to young
people and their families; a failure to engage young people in the decision-
making process; family group conferences remained European in their ori-
entation and were unresponsive to cultural differences …; the difficulty of
reconciling offender’s needs with the objective of holding them account-
able; and the tension between empowering offenders and their families in
a system which is ultimately aimed at control (Maxwell 1993, 119–24).
Another issue concerns the nature of the crime. Sexual offences are not
like other crimes. They reflect the abuse of power, often male power and
control over females. The sex offender often minimises the consequences
of his behaviour and may blame the victim or trivialise the impact of
his violence. Many sex offenders have little empathy for their victims
(Leibrich et al. 1995), and since ignoring their victim’s protests and pain
may have been a prime feature in reinforcing his sense of domination,
these factors can raise serious doubts about the capacity of the offender to
accept the consequences of his crime. Poorly conducted, an FGC can be
seen as providing another space for the offender to re-victimise the victim
(Daly and Stubbs 2006). And there are huge dilemmas about whether
to involve child victims in FGCs if they have to face the person who
abused them. Because of these concerns, many jurisdictions that have
embraced RJ do not extend its provisions to sex offences, and therefore
empirical evidence as to its efficacy and value is limited. However, one
of the most extensive studies (Daly 2006), which reviewed nearly 400
cases of youth sexual assault in which the FGC was instituted as part of
a restorative process, shows that the model has significant benefits. Daly’s
work, almost a decade later than Maxwell’s, contradicted his findings and
found that:
contrary to the concerns raised by critics of conferencing, from a victim’s

advocacy perspective, the conference process may be less victimizing than
the court process and its penalty regime may produce more effective out-
comes (Daly 2006, 334).
McAlinden (2005) agrees and suggests that sex offences are particularly
suitable for a restorative approach because the concept of re-integrative
shaming that underpins RJ reaffirms the offender’s membership among
law-abiding sections of their community—a direct contrast to stigma-
tisation and alienation which can contribute to recidivism. McAlinden
points out that partnerships between communities and agencies who
together can provide restorative support and treatment networks for
offenders may be the best chance societies have in reducing sexual vio-
lence (McAlinden 2005).
The work of Daly and McAlinden provides compelling arguments in
favour of RJ for sex crimes:
1. The prospect of enabling victims of sexual violence to have a voice in

the justice process, to be able to ask questions and seek answers
2. To make the offender aware of the impact of his actions
3. To give victims a role in deciding what should be done
4. The failings of traditional justice in preventing further sex crimes
Involving sexually abused children in an FGC which is part of a restor-

ative approach for a juvenile offender requires careful judgement that
must take into account the age and understanding of the child. Skilful
handling of the FGC, in which the child is given information in an
appropriate way, is effectively supported and through innovative and
creative strategies feels able to participate in the proceedings, can be an
empowering experience. The open acknowledgement of the crime against
the child and the fact that adults have rallied around to ‘deal’ with the
offender and support the child signal a message that she was right to tell.
We are proponents of RJ for juvenile sex offenders (and adults too) for all
the reasons outlined, but it is essential for the offender to participate in a
sex-offender treatment programme as well as participate in family group
conferencing, and involvement in a circle of support can provide another
measure by which the offender can be held to account for his actions.
The RJ strategy we recommend for young sex offenders in the Caribbean
is based on an ecological systems approach to understanding their needs
and creates synergies around rehabilitation, treatment and support.
An Ecological Systems Approach

to Understanding the Needs of Juvenile Sex
Offenders
Although Levi has needs that are specific to him, in the discussion that fol-
lows he stands as proxy for juvenile sex offenders more generally, and his story
used to illustrate the potential application of the interventions described.
There are differences between young people who commit sex offences
and adults who do so. Understanding juvenile sex offenders requires that
we take account of the impact of the family, wider environmental factors
and past experiences of abuse (Finkelhor et al. 2009).
Research is demonstrating that there are important developmental, moti-

vational, and behavioral differences between juvenile and adult sexual
offenders and also that juveniles who commit sexual offenses are influenced
by multiple ecological systems (Letourneau and Borduin 2008). Hence,
therapeutic interventions that are designed specifically for adolescents and
children with sexual behavior problems are clearly needed. Moreover, treat-
ment approaches that are developmentally appropriate; that take motiva-
tional and behavioral diversity into account; and that focus on family, peer,
and other contextual correlates of sexually abusive behavior in youth,
rather than focusing on individual psychological deficits alone, are likely to
be most effective (Przybylski 2014, n.p.).
Dealing with co-related forms of abuse, the role of family and peers
and the social values and attitudes that create the environment for abuse
to flourish requires a systems approach to analysis. In book two of this
three-book series, we introduced the reader to a systems model for under-
standing the drivers and determinants of CSA.
In the diagram below, the issues highlighted in the boxes refer primarily
to changes needed at the meso or macro level in order to prevent CSA as a
societal problem. However, the focus of action could equally be an individual
or family; the crucial point is that in addressing the sexual abuse of children
and the harmful sexual behaviour of adolescents and adults, there is a need to
adopt a systems strategy so as to tackle the wider factors that sustain abuse. In
placing Levi at the centre of the systems model, we can redraw the diagram
A Systems Model for Understanding the Social

Drivers and Determinants of Abuse
Gender Lack of Lack of
socialisation, awareness of collective
Officials who by gender inequality the seriousness outrage and
and gender- of effects Ineffective systems,
in action, denial and community laws and policies
evasion are collusive based violence action
Male privilege,
Women who are reputation & status
disempowered and placed above child
complicit for various protection
reasons
Men and youth with sexually Social

harmful attitudes and construction of
behaviours childhood
Environment:cultural sanctioning of Child Children’s

sex ‘trading’, social acceptance, disempowerment
consumerism,poverty,community Sexual and status
violence Abuse
Fig. 4.8 A systems model for understanding CSA

(Source: Jones et al. 2014)
to highlight the complex needs that juvenile sex offenders often have and
demonstrate the importance of designing services around them.
Levi’s story reveals that he experienced layers of abuse and neglect over
time from a very young age. Added to this are problems of drug abuse,
sexual offending behaviour, social isolation, homelessness, distorted sex-
ual values, negative views about females and induction to violence and
dropping out of school, all problems that have characterised his middle
and teenage years. His experiences are unique to him but many of these
factors come up time and again in the histories of juvenile sex offenders.
Providing appropriate help requires not only that a multi (inter)-profes-
sional approach be adopted but that systems strategy be used to engage
with the sub-systems which have contributed to his present situation.
The chrono-system reminds us that it is not only the sum or interaction
of systems that influenced the trajectory of Levi’s life but also the effects
of abuse over time—the chronology of abuse. It also reminds us that
there are no ready solutions to young people’s unresolved traumas and
SCHOOL SYSTEM ORGANISATIONAL SYSTEMS

Early positive signs, school a place of early Family support, child protection and health
stability, failure to pick up abuse, agencies not engaged at all – Ephraim never
subsequent decline in performance received help as a victim of abuse or child in
need
WIDER FAMILY/COMMUNITY SYSTEM VALUES SYSTEM
Some support but also introduced to drugs and Distorted sexual values/boundaries, negative
alcohol – now addicted, youth sub-culture views about females, role of men understood
characterized by gender-based violence as dominant, uncaring, violent, non-
accountable
FAMILY SYSTEM
CRIMINAL JUSTICE SYSTEM
Single parent/only child, extreme
poverty and neglect, abandoned by Involved in drug offences
father and abused by mother for years and now is a sex-
offender, has a custodial
sentence
INDIVIDUAL SYSTEM
Impacted by long-term exposure to CHRONO-SYSTEM
neglect, sexual and physical abuse, Accumulated effect of extreme
social network which reinforces adverse childhood experiences
criminal/violent behaviours, over time, learned mistrust and
childhood needs not met (material or socialised induction to violence
emotional), withdrawn, low self- and male domination as a frame
regard, socially isolated, homeless
for own identity
Fig. 4.9 Levi’s situational analysis using a systems approach
that they are likely to need help over a prolonged period. Like many of
his peers, Levi has drawn on repertoires of sexual and physical violence
from which to build his own identity and which have been reinforced
by the social networks in which he circulates (one of the sub-systems of
which he is part is a youth sub-system, through which he has become a
drug user. Also, one of his sexual offences was committed with a group of
teenage boys), but he is a victim of violence too and the effects of this are
writ large upon his emotional and behavioural development. Regardless,
Levi is now characterised primarily by that most stigmatising of labels—
he is a sex offender—and the main route through which help can be
provided at this stage in his life is the criminal justice system.
In the systems model, there are four types of intervention that make
up the menu from which individual treatment and support plans for
juvenile sex offenders can be developed:
1. The SORT Project (treatment)

2. Circles of support and accountability (CoSAs) (community support)
3. Family group conferencing (family strengthening; see Part 2)
4. Organisational support (agencies that can address additional needs such
as education and employment, substance misuse and homelessness).
Next, we turn our attention to discussing treatment and community

support.
The SORT Project (Sexual Offence Rehabilitation

and Treatment Project for Caribbean Youth)
Pivotal to our understanding of the nature of the juvenile sex offender,
and the nature of their sex offences in a Caribbean context, is the
2009 UNICEF study on Child Sexual Abuse in the Eastern Caribbean
(Jones and Trotman Jemmott 2009). The population of young offenders
we identify as a priority for help are those falling into the incest perpetra-
tor and acquaintance rapist category or cognitive sexual aggressor category
(Hall et al. 1993). Defining these target groups lends to the definition of a
proposed Caribbean-contexted model of treatment which suggests a psy-
chotherapy model that combines relapse prevention, milieu therapy, sports
therapy, sexual education, value clarification, family systems integration,
victim empathy and cognitive-behavioural therapy. And given that young
people who commit sexual offences have a higher than normal probability
of having themselves been sexually, physically or emotionally abused dur-
ing childhood, it will be important for the programme to address these
childhood precursors of personality development and later sex offending
as well as other factors which might lead to adult offending.
The treatment programme we propose we have named the SORT Project
(Sexual Offence Rehabilitation and Treatment Project for Caribbean
youth). The project would aim to address several sub-systems crucial in
treating sexual offenders (see Levi’s systems diagram): the individual sys-
tem, the values system, the family system, the criminal justice system and
the chrono system. The conceptual framework is multisystemic therapy
(MST) (Letourneau and Borduin, 2008) and seeks to minimise anti-social
behaviour by working with families on the understanding that family rela-
tions and social bonds mitigate against criminal behaviour and may play
a stronger role in preventing crime than legal sanctions. MST typically
focuses on improving family relationships and encouraging teenagers’
involvement in activities outside of the treatment programme as well as
healthy friendships. Two small controlled studies with juveniles who com-
mitted sex offences suggest that MST reduces recidivism more effectively
than individual psychotherapy. To strengthen the role of the family in

sustaining behaviour change, the FGC model which was described earlier
should be established as an integral component of the project. The treat-
ment approach would be based on behaviour therapy, which shows the
highest potential for success and includes relapse prevention, which helps
the offender see the big picture and not the immediate gratification gained
from acting on sexual impulses. The programme shows the offender how
he can avoid problem situations from the outset and the skills he learns can
help him maintain these changes throughout his life (Pithers et al. 1988).
The objective of the SORT Project would be to help young people
understand and reframe destructive sexual thoughts, attitudes and
behaviours in regard to women and children; to learn strategies for self-
regulation, inhibition and control; to understand the impact of early child-
hood experiences on current functioning; and to improve victim empathy.
Later, we discuss a community-based model that can help young people
access a network of support persons to help prevent relapse and recidivism.
The overall aim would be the rehabilitation and re-integration of juvenile
sex offenders into society and the prevention of further sexual offences.
The model proposed is similar to Prevention Project Dunkelfeld (PPD)
(https://www.dont-offend.org/), which has grown into a network of 10
treatment centres across Germany. Our hope is to see a SORT interven-
tion established in each Caribbean country to create a regional system for
the prevention of CSA by ‘accepting, training and re-integrating possible
offenders into the functional fabric of society’ (PPD, n.d.). The SORT
Project should be a free confidential service available to young people who
have been convicted of an offence and also to those who have not offended
but are concerned about their sexual impulses. It would not be appropri-
ate for young people who have committed offences but have not been
through the criminal justice system, because the mandatory reporting laws
that exist in some countries would be in conflict with the project’s confi-
dentiality policy. The project would comprise seven components:
1. Media campaign
2. Telephone helpline (initial screening)
3. Clinical interview
4. Psychometric assessment
5. Treatment programme
6. FGC
7. Post-test and follow-up
The treatment component of the project would be a weekly 2- to

3-hour group programme over the course of 16 weeks for young men aged
16–25 years as its primary target population. The programme would be a
self-change programme to help juvenile offenders understand themselves
and their patterns of offending and to practice better alternatives in order
to lead productive, fulfilling and offence-free lives. The treatment meth-
ods would use individuals’ strengths and aspirations and draw on the rich
tapestry of Caribbean culture, music, theatre, literature and other forms
of creative expression (see Part 6 for more on the use of art as therapy).
The programme design would be grounded in adolescent developmental
theory and would make use of psycho-social theories such as:
• Cognitive behaviour theory

• Attachment theory and relationally based theories
• Social learning theory
• Theory of motivational interviewing and the cycle of change
• Role play and psychodrama
• Experiential-based approached addressing unresolved trauma and
loss
• Mentalisation-based therapy
• Self-regulation model of relapse prevention
• Narrative therapy
• Systems theory
• Sport therapy
Possible Areas of Focus

FGCs should ideally be held at two points in the intervention: before and
after participation in the treatment programme. For young people who
are part of an RJ plan, the first FGC should be organised in line with RJ
objectives and be centred on the needs of the victim. The first FGC should
Table 4.1 Possible areas of focus in rehabilitation and treatment

Pre-programme Programme Post-programme
Assessment Reasoning and rehabilitation New ways of living
(modifying anti-social
habits, impulse control,
enhancing coping skills)
Motivation and Understanding traumatic Lifestyle change
preparation sexualisation (nature of the
sexual assault: degree of
force, humiliating features of
the assault, intrusiveness of
the acts and prior or expected
relationship between
offender and victim)
Understanding of Understanding rape trauma Networks of
and responsibility syndrome (fear and full- support/
for offending blown phobias, flashbacks, accountability
behaviour obsessive rumination,
elevated emotional
responding, disturbances in
sexual functioning and
deteriorating daily
functioning)
Relationships, Exploring distorted attitudes, Reflection and
attachment styles beliefs and perceptions based self-evaluation
and resolving loss in the maladaptive schemas
and trauma of the juvenile offender
Self-management Identifying risk-promoting Risk management
and inter-personal and risk-reducing
skills behaviours, emotional states
that raise or lower risk and
ways of thinking that allow
or curtail progress along the
offence pathway
Sexuality, sexual Emotional and behavioural Emotional and
interests and regulation problems behavioural
attitudes regulation
Gender-based Empathy enhancement Follow-up
attitudes (identifying negative evaluation
consequences to victims of
the perpetrators’ behaviour)
The proximal factors The distal or enduring Help-seeking
triggering child personality problems present behaviour Risk
molestation in the juvenile offender management
(preconditions)
(continued)
Table 4.1 (continued)

Pre-programme Programme Post-programme
Victim characteristics Affective dysregulation. Engagement as an
Understanding traumatic agent of change
sexualisation (nature of the for others
sexual assault: degree of
force, humiliating features
of the assault, intrusiveness
of the acts and prior or
expected relationship
between offender and
victim)
Family support Emotional liability Sustaining
behaviour change
Risk management Reasoning and rehabilitation Recognising
planning (modifying anti-social triggers and
habits, impulse control and help-seeking
enhancing coping skills) behaviour
also aim for the family to work with professionals and the young person
to come up with a plan to help with other needs, such as homelessness,
unemployment and drug misuse. The second FGC should be focused on
family plans to help the young person sustain behaviour change. Next, we
discuss the FGC as part of an RJ strategy for juvenile sex offenders.
The Family Group Conference as a Restorative

Justice Intervention
When we discussed the history, principles and implementation of the
FGC model in Part 3 of this book, we presented it as a means of empow-
ering families to put in place effective child protection plans for their chil-
dren. Now we discuss the model as an RJ intervention. Though similar
principles apply, the FGC, when used as an RJ intervention, is grounded
in the theory of ‘reintegrative shaming’ of offenders Daly (2002). The RJ
FGC should be inclusive. In addition to involving Levi, a major effort
should be made to include those family members who are considered
appropriate, including extended family members. From the genogram,
we are under the impression that Levi does not have an extensive family
network, but this should not be taken at face value. Some sensitive inves-
tigation within his village and community may unearth people who have
perhaps been on the periphery of his life but are willing to get involved
to help him. It may also be appropriate to invite a member of his CoSA
to participate. An early decision will need to be made about whether to
involve Levi’s mother. Although she has been responsible for some of his
early childhood experiences of abuse, her support of him at this stage in
his life may help her make some reparation too. She has many questions
to answer, but Levi may need to keep his distance from her for his own
sake. This, however, is a decision Levi should make in consultation with
the FGC coordinator. It may be helpful to invite Levi’s aunt (the mother
of the cousins who introduced him to drugs). The reason for this is that
she may know where the dangers lie in the wider family in terms of peer
pressure and drug-use relapse. The purpose of this FGC is twofold; firstly,
to help the family come up with a plan to support Levi with his treatment
and to address problems such as his drug abuse, homelessness and need
for education/employment. The second objective of the FGC is to hold
Levi accountable for his harmful sexual behaviour and come up with a
plan of reparation. In an RJ context, victims and their supporters are
invited. For child victims, careful consideration is needed about how best
they can be involved; however, adults should not assume that children
are best left out of the proceedings. This really depends upon the child’s
wishes and the age and level of understanding of the child—but remem-
ber, the child is the victim and this is her opportunity for justice; exclud-
ing her may further disempower her. As this is a restorative measure, a
lawyer/advocate for the offender is usually invited, as is a representative
of the police department, who serves as the prosecutor. Facilitator roles
are broadly and loosely defined and include mediation (MacLeod 1995).
The entire group is expected to come to a consensus on the outcome for
the case, not just on a restitution agreement, and to keep in mind that the
purposes of the FGC are the following:
1. To hold the offender accountable

2. To ensure that the offender is fully aware and accepts the consequences
of his crime
3. To empower the victim and give her the opportunity to have her ques-
tions answered
4. To facilitate consensus-based plans for reparation

5. To enable discourse between two sets of legitimate interests
6. To level out power imbalances
7. To ensure that family members commit to supporting the plans
8. To ensure that professionals and agencies commit to supporting the
plans and provide the necessary resources for their implementation.
In addition to needing access to the SORT Project and family group

conferencing, juvenile sex offenders need access to a community-based
support programme such as a circle of support. The intervention we
describe next could be offered to a young person either as a stand-alone
rehabilitation and re-integration project or as a supportive intervention
alongside treatment.
Circles of Support
The most established programme for sex-offender rehabilitation is the
CoSA model developed in Canada in the late 1990s. This is not strictly a
restorative approach to sexual crimes since, rather than being developed
as a custodial diversion measure, it was developed for offenders who have
served custodial sentences but who may present an ongoing risk to chil-
dren on their release (Wilson et al. 2002). In other countries where CoSAs
have been introduced (such as the UK, where trials have been ongoing
for over a decade) (http://www.circles-uk.org.uk/), there have been some
impressive results: ‘Since 2007, at 14 locations around the country, it has
quietly produced an 83 % reduction in reoffending rates among the sex
offenders it takes on’ (Guardian, March 2015). Positive results have also
been reported in Canada, where there has been a 60–70 % reduction in
projected recidivism since the introduction of the scheme (Wilson et al.
2007; Wilson and Prinzo 2002). Circles of support aid the re-integration
of the offender, and although they are not a community surveillance
mechanism as the offender is accountable to a wider group for any lapses
in his behaviour, they do provide a measure of reassurance to the public
and especially to victims of sex crimes.
We believe that establishing the circles of support as a restorative mea-

sure for juvenile sex offenders is particularly valuable for the Caribbean
context because the scheme has the potential for building community
capacity for preventive action regarding CSA. For young people like Levi,
who have very little family support to call upon or who come from frac-
tured families, a circle of support can act as a de facto family and reduce
isolation and social stigma which can contribute to re-offending. We rec-
ognise that since many young people with harmful sexual behaviour do
not go on to develop a ‘career’ in sexual offending, the imposition of a
model such as this could be seen as highly invasive in terms of personal
liberties or at least might be regarded as an unnecessary use of resources:
clinical data point to variability in risk for future sex offending as an adult.
Multiple short- and long-term clinical follow up studies of juvenile sex
offenders consistently demonstrate that a large majority (about 85–95 per-
cent) of sex-offending youth have no arrests or reports for future sex crimes
(Finkelhor et al. 2009, 3).
Therefore, we are not advocating the wide-scale use of the CoSA pro-
gramme where there is no evidence of need. However, for young people
steeped in personal histories of sexual violence and operating in youth
sub-cultures where gender-based violence may be viewed as normative
or as a marker of masculine identity, there is need for an approach which
galvanises positive influences. The wider benefits for Caribbean societ-
ies include the possibilities the model holds for helping young people
and men and women to develop counter-hegemonic views that challenge
norms associating masculinity with sexual prowess and control (Jones
et al. 2014). Levi has been part of a group of young men involved in
gang-related sexual offending, and finding ways to challenge group norms
that sanction violence against women and girls is crucial for Caribbean
countries, where it is very prevalent. Circles of support, though focused
on holding the offender accountable for their behaviours, can help to
percolate views about healthy masculine behaviours within communi-
ties more generally. Also, there are many men’s and women’s organisa-
tions and activists in the Caribbean committed to ending gender-based
violence—a ready pool of men and women with positive attitudes and
values and who may be willing to participate in making circles of support

work. So how do they work?
A CoSA is a network of four or five especially trained volunteers
brought together under professional supervision (a coordinator, often a
probation officer) to provide guidance and rehabilitative support for a
sex offender. Volunteers undergo an interview and 3-day training course
and are made aware of the person’s offence history, triggers or risk fac-
tors, patterns of drug or alcohol use and any mental or sexual disorders
(in Canada, access is given to the offender’s clinical and criminal records)
and conditions of release and any court orders in place. Pivotal to the suc-
cess of CoSA seems to be the role of the coordinator (Wilson et al. 2007),
clarity about roles and expectation, good quality training for volunteers
and clear lines of communication. There are some useful resources avail-
able to help agencies in the Caribbean to develop and implement the
model (see, for example, http://www.circles-uk.org.uk/resources, Nellis
2009, and the 2014 evaluation report of the pilot CoSA programmes
implemented in the UK; Thomas et al. 2014).
In an attempt to avoid stigmatising labels, the offender is referred
to as the ‘core member’. Each member of the circle signs an agreement
which details what assistance he or she will offer, and the core member
makes a commitment to interacting with the members of the group in
regular meetings, to seek their advice, to participate in treatment pro-
grammes, to comply with court orders and to desist from any harmful
sexual behaviour. In Canada, where the model originated, the CoSA
scheme is specifically targeted at sex offenders who are considered the
most dangerous to society. These are men who have come to the end
of their sentences but for whom re-integration into society is extremely
challenging and the risk of re-offending high (Stirpe, Wilson & Long
2001). Simply replicating the model for sex offenders released from
Caribbean prisons would in itself be extremely beneficial to prevent
CSA, but our innovation is to adapt the model as an RJ and preven-
tive measure specifically for young offenders. When young people who
are socially isolated, like Levi, have been subject to years of sexual and
physical violence themselves and live amidst community dynamics in
which ‘everyone knows your business’ (a feature of small island popula-
tions) and which feeds social stigma, the environmental conditions exist
for him to continue engaging in destructive behaviour—to others or

himself or most likely both. Gender-based violence in the Caribbean,
as elsewhere, is reinforced through cultural sub-norms which generate
high levels of tolerance for the sexual objectification of women and girls.
The CoSA provides a new cultural sub-norm for Levi. Furthermore, the
focus on accountability, as emphasised in the title of the scheme, indi-
cates that the members of the circle will hold him accountable for his
actions in the community (Hannem and Petrunik 2007).
In addition to assuming the befriending role, members of the circle
will assist Levi in making decisions about potentially risky behaviours
and situations. For example, he would be expected to discuss everyday
dilemmas within his circle—questions such as ‘all my friends sit around
smoking weed—I feel out of the group if I don’t take a pull, but if I do,
I’m breaching my conditions, what should I do?’; ‘There’s a girl in my
neighbourhood, she’s real hot. I know she likes me; I want to ask her on
a date but I’m not sure how old she is. Should I tell her about what I’ve
done?’; ‘I’ve been sent some porn pictures of a girl in my village by one
of my friends, I’ve deleted them but what can I do to stop them—if I
get caught with them, I’m sure I’ll be back in court’. Some of these are
relatively common situations for young adolescent males, but for Levi,
who does not have a clear sense of sexual boundaries and has been con-
victed of a sexual offence, they are potential risk situations for fantasising
(a common trigger for sex offending) and further victimisation (Hannem
and Petrunik 2007). Drug and alcohol use may lower Levi’s inhibitions
and undermine his self-regulating behaviour and his circle may decide
to report this to the authorities, especially if it constitutes a breach of
release conditions. If Levi engages in any behaviour that that may lead to
harm or sexual victimisation of another person, CoSA operational policy
requires that this be reported to the authorities (Heise et al. 2000). The
caring relationships that can be created within a CoSA provide a sense of
acceptance and permission to discuss fears and confront behaviours that
would not be possible otherwise. An example, drawn from an evaluation
of the scheme in Canada, demonstrates this well:
a core member was challenged at length during a circle meeting about his
minimization of the harm of child pornography; this resulted in the core
member withdrawing into himself and refusing to speak for the remainder
of the meeting … the volunteers persisted in emphasising how much they
valued the core member and wanted him to live a good life in the com-
munity, while clearly expressing the harm of child pornography to its vic-
tims and the community. The meeting ended with the core member
apologizing for his sullen behaviour and finding himself enveloped in a
“group hug”. Several weeks later, the same core member called an emer-
gency meeting of his circle, inviting the COSA coordinator to reveal that
he had been viewing child pornography on the Internet—in Canada, pos-
session of child pornography and accessing child pornography are criminal
offences. … The core member told the volunteers that he was no longer in
possession of the images and was determined to stop accessing them, plac-
ing his circle in the difficult position of deciding whether to report his
actions to the police. … The circle decided not to report the core member
provided that he would surrender his computer to be searched for inap-
propriate material, cancel his Internet service, and agree that the circle
could request to inspect his computer at any time, without notice. Any
failure to comply with this agreement or the discovery of further use of
child pornography would be grounds to contact the police (Heise et al.
2000, 281).
Circles of support do not ignore the harm that CSA causes (and they
do not allow offenders to minimise the harm either); they cannot change a
person’s sexual desires but they can help someone learn how to identify the
risk factors and triggers that could cause them to act on those impulses.
In our treatment plan for Levi, the plan would probably begin with
setting up the circle of support, followed by an FGC—this is because
Levi does not have a strong family system and members of the CoSA
could participate in the FGC if he needed their support. Within the
CoSA, Levi would have contact with a nominated person from the circle
each day in the initial phase of his treatment programme as this is a
high-risk stage, and all members of the circle would meet together once
a week. The CoSA would continue for as long as Levi was considered to
present a risk in the community (McAlinden 2005). We would anticipate

that it would continue at least as long as the treatment programme.
Conclusion
In this part of the book, we introduced you to Levi as a means of explor-
ing how different forms of child maltreatment often occur together. We
identify how, in societies in which physical punishment of children is
accepted, it can be hard to distinguish discipline from abuse and physical
abuse may go undetected. In Levi’s story, his mother is one of his abus-
ers, although she is not the only one and, as it turns out, was not the first
to sexually abuse him. We make no apologies for Levi’s mother; that she
was a single parent living in extreme poverty and subject to domestic vio-
lence herself does not in any way explain the violations and neglect she
subjected her son to. As we discussed in more depth in our second book
on CSA in the Caribbean (Jones et al. 2014), women who abuse have
often internalised so completely their subjugation to men’s wishes that
they might do anything expected of them, even to the extent of facilitat-
ing or participating in the abuse of their own or others’ children. But, as
we also make clear and as is supported by the literature discussed earlier,
women do not need to be spurred on by men to commit sexual vio-
lence, or for that matter any form of violence; they do not need to have
experienced oppression at the hands of a man in order to become the
oppressor. Violence is neither masculine nor feminine, or else it is both.
We contend that although sexual violence is in large part committed by
men, it is behaviour that women are capable of too. FDI is common but
is no less traumatic an experience for that fact. Mother-son incest, on
the other hand, is not common or commonly reported. As an aspect of
gender-based violence that is under-researched, we know far less about its
effects. The question arises then, is abuse by a mother any different from
abuse at the hands of a father? We think it is. As we see from Levi’s case,
the social construction of motherhood as nurturing, protective, primary
attachment figure juxtaposed against a reality in which a child’s mother
permits and commits gross acts of sexual violence against him is beyond
belief—so beyond belief, that any suspicions she was sexually abusing
him would have been suppressed; this would have been to utter the unut-
terable. In a land of taboos, this is the taboo of them all. Mothers simply
do not sexually abuse their children or watch as they are sodomised. Levi
would not have told anyway; he will have been aware from an early age of
the limits of his believability and power as a child, but even if he had been
able to speak out, he would have found us all conspirators in disbelief.
We have all bought in to motherhood so completely that we find it dif-
ficult to ask questions about the propensity and possibilities of women’s
sexual violence against their children. We cannot separate out the harm-
ful effects on Levi of the sexual abuse that men inflicted upon him from
those arising out of abuse perpetrated by his mother, but we also think
mother-son incest differs in the impact it has had on his capacity to feel
empathy for the victims of his own sexual crimes.
We have covered many issues in this part of the book:
• The importance of early detection and intervention in cases of abuse

and neglect
• The importance of conducting reviews in serious cases so that lessons
can be learned to improve practice
• The role of multi-agency teams and inter-professional practice
• The value of RJ for juvenile sex offenders
• The dynamics of the psychotherapeutic relationship and the power of
psychotherapy in helping victims and perpetrators to unlock the hurt
that is the cause of their behaviour
• The potential for rehabilitation offered by establishing group treat-
ment programmes for juveniles
• Circles of support as a community, strengths-based intervention to
build positive networks to sustain behaviour change
• Family group conferencing as a family, strengths-based intervention in
cases of sexual abuse, both to serve as an RJ method and to promote
family responsibility for the support of young people
• The importance of adopting an ecological systems approach informed
by intersectional analysis as a basis for designing interventions
Working with young people with harmful sexual behaviour is challeng-

ing work as the practitioner is constantly reminded of the trauma that the
young person has inflicted on another. But it is hopeful work, for there
is strong evidence that interventions at this stage can prevent adolescents
from going on to commit further sexual offences in adulthood. We do

not know the long-term outcome for Levi, but as we have shown, there
are many ways in which we can help him. There is a Levi in your neigh-
bourhood, practice, school, children’s home, Church or possibly in your
family; we hope we have given you the courage to see beyond assump-
tions about motherhood and to ask the questions that need to be asked,
for this is the first step to helping them.
References
Bruce, J., Fisher, P. A., Pears, K. C., & Levine, S. (2009). Morning cortisol levels
in preschool-aged foster children: Differential effects of maltreatment type.
Developmental Psychobiology, 51, 14–23.
Crawford, A., & Jones, M. (1995). Inter-agency co-operation and community-
based crime pevention. British Journal of Criminology, 35(1), 17–35.
Daly, K. (2002). Sexual assault and restorative justice. In H. Strang &
J. Braithwaite (Eds.), Restorative justice and family violence. Melbourne:
Cambridge University Press.
Daly, K., & Stubbs, J. (2006). Feminist engagement with restorative justice.
Theoretical Criminology, 10, 9–28.
Drumbl, M. (2000). Sclerosis retributive justice and the rwandan genocide.
Punishment and Society, 2(3), 287–308.
Encyclopedia of Mental Disorders. (n.d.). Thematic apperception test. http://www.
minddisorders.com/Py-Z/Thematic-Apperception-Test.html#ixzz3hNf9v8E2.
Accessed August 2, 2015.
Erooga, M., & Masson, H. (2006). Children and young people with sexually
harmful or abusive behaviours. In Children and young people who sexually
abuse others: Current developments and practice responses (pp. 3–17). London:
Routledge.
Faller, K. C. (2005). Anatomical dolls: Their use in assessment of children who
may have been sexually abused. Journal of Child Sexual Abuse, 14(3), 1–21.
Farrington, D. P., & Welsh, B. C. (2007). Saving children from a life of crime, early
risk factors and effective interventions. New York: Oxford University Press.
Finkelhor, D., Ormrod, R., & Chaffin, M. (2009). Juveniles who commit sex
offenses against minors. Juvenile Justice Bulletin. Washington, DC: US
Department of Justice, Office of Justice Programs, Office of Juvenile Justice
and Delinquency Prevention. www.ncjfcj.org/sites/deault/files/juvenilewho-

commitsexoffenses_0.pdf. Accessed July 27, 2015.
France, A., Munro, E., & Waring, A. (2010). The evaluation of arrangements for
effective operation of the new Local Safeguarding Children Boards in England-
final report. Loughborough University and Department for Children, Schools
and Families: Centre for Research in Social Policy (CRSP) and Centre for
Child and Family Research (CCFR). www.gov.uk/government/uploads/
system/uploads/attachment_data/file/219610/DCSF-RBX-10-03.pdf.
Accessed July 2, 2015.
Ford, H. (2006). Women who sexually abuse children. John Wiley & Sons
Gilbert, R., Kemp, A., Thoburn, J., Sidebotham, P., Radford, L., Glaser, D.,
et al. (2009a). Recognising and responding to child maltreatment. The
Lancet, 373(9658), 167–180.
Gilbert, R., Widom, C. S., Browne, K., Fergusson, D., Webb, E., & Janson, S.
(2009b). Burden and consequences of child maltreatment in high-income
countries. The Lancet, 373(9657), 68–81.
Gillespie, D., & Campbell, F. (2011). Effect of stroke on family carers and fam-
ily relationships. Nursing Standard, 26, 39–46.
Hall, G. C. N., Shondrick, D. D., & Hirschman, R. (1993). Conceptually
derived treatments for sexual aggressors. Professional Psychology: Research and
Practice, 24(1), 62.
Hannem, S. (2011). Experiences in reconciling risk management and restorative
justice: How circles of support and accountability work restoratively in the
risk society. International Journal of Offender Therapy and Comparative
Criminology, 57(3), 269–288.
Hannem, S., & Petrunik, M. (2007). Circles of support and accountability: A
community justice initiative for the reintegration of high risk sex offenders.
Contemporary Justice Review, 10(2), 153–171.
Hanson, J. L., Chung, M. K., Avants, B. B., Shirtcliff, E. A., Gee, J. C.,
Davidson, R. J., et al. (2010). Early stress is associated with alterations in the
orbitofrontal cortex: A tensor-based morphometry investigation of brain
structure and behavioral risk. Journal of Neuroscience, 30, 7466–7472.
Heise, E., Horne, L., Kirkegaard, H., Nigh, H., Derry, I., & Yantzi, M. (2000).
Community reintegration project: Circles of Support and Accountability. Ottawa:
Correctional Service Canada.
HM Government. (2010). Working together to safeguard children: A guide to
inter-agency working to safeguard and promote the welfare of children. London:
Department for Children, Schools and Families, DCSF-00305-2010.
Hudson, B. (2007). Pessimism and optimism in inter-professional working: The

sedgefield integrated team. Journal of Interprofessional Care, 21(1), 3–15.
Jackson, C., Nissenson, K., & Cloitre, M. (2010). Treatment for complex
PTSD. In D. Sookman & R. L. Leahy (Eds.), Treatment resistant anxiety dis-
orders: Resolving impasses to symptom remission. New York: Taylor & Francis,
Routledge Group.
Jennings, J. L., Apsche, J. A., Blossom, P., & Bayles, C. (2013). Using mindful-
ness in the treatment of adolescent sexual abusers: Contributing common
factor or a primary modality? The International Journal of Behavioral
Consultation and Therapy, 8, 3–4.
Jones, A. D. & Trotman Jemmott, E. (2009). Child sexual abuse in the Eastern
Caribbean. www.unicef.org/infobycountry/files/Child_Sexual_Abuse_in_
the_Eastern_Caribbean_Final_9_Nov.pdf. Accessed April 3, 2015.
Koss, M. P., Bachar, K., & Hopkins, C. Q. (2006). Disposition and treatment
of juvenile sex offenders from the perspective of restorative justice. The
Juvenile Sex Offender, 336–357.
Kuijvenhoven, T., & Kortleven, W. J. (2010). Inquiries into fatal child abuse in
The Netherlands: A source of improvement? British Journal of Social Work,
40(4) (special issue on risk and social work), 1152–1173.
Leibrich, J., Paulin, J., & Ransom, R. (1995). Hitting home: Men speak about
abuse of women partner. Wellington: Department of Justice and AGB McNair.
Letourneau, E. J., & Borduin, C. M. (2008). The effective treatment of juveniles
who sexually offend: An ethical imperative. Ethics and Behavior, 18, 286–306.
Macleod, B. A. (2015). Ben Aaron MacLeod’s letter – Tackling child sexual
abuse – a lesson from Germany?. The Psychologist, 28, 02–07. http://thepsy-
chologist.bps.org.uk/volume-28/january-2015/tackling-child-sexual-abuse-
lesson-germany. Accessed July 25, 2015.
MacLeod, L. (1995). Family group conferencing: A community-based model
for stopping family violence. In M. Valverde, L. MacLeod, & K. Johnson
(Eds.), Wife assault and the Canadian criminal justice system: Issues and policies
(pp. 198–204). Toronto: Centre of Criminology, University of Toronto.
Maxwell, G. (1993). Family decision-making in youth justice: The New Zealand
model. In L. Atkinson & S. Gerrull (Eds.), National conference on juvenile
justice (pp. 113–126). Canberra: Australian Institute of Criminology.
McAlinden, A. (2005). The use of shame in the reintegration of sex offenders.
British Journal of Criminology, 45, 373–394.
McAlinden, A. (2007). The shaming of sexual offenders: Risk, retribution and rein-
tegration. Oxford: Hart Publishing.
McAlinden, A. (2008). Restorative justice as a response to sexual offending–

Addressing the failings of current punitive approaches. Sexual Offender
Treatment, 3(1), 1–12.
McDowell, C. (2015). Can losing everything be a blessing?. Porter Asks. http://
christinamcdowell.com/Porter%20Asks%20(1).pdf. Accessed August 4, 2015.
Mehta, D., Klengel, T., Conneely, K. N., Smith, A. K., Altmann, A., Pace, T. W.,
et al. (2013). Childhood maltreatment is associated with distinct genomic and
epigenetic profiles in posttraumatic stress disorder. Proceedings of the National
Academy of Sciences of the United States of America, 110, 8302–8307.
Mollon, P. (n.d.). Releasing the unknown self in self psychology psychoanalysis. www.
selfpsychologypsychoanalysis.org/mollon.shtml. Accessed August 10, 2015.
Pithers, W. D., Kashima, K. M., Cumming, G. F., Beal, L. S., & Buell, M. M.
(1988). Relapse prevention of sexual aggression. Annals of the New York
Academy of Sciences, 528(1), 244–260.
Prevention Project Dunkelfeld. (n.d.). Do you like children in ways you shouldn’t?
www.dont-offend.org/. Accessed June 20, 2015.
Przybylski, R. (2014). Effectiveness of treatment for Juveniles who sexually offend.
Sex Offender Management Assessment and Planning Initiative. Washington: US
Department of Justice, Office of Justice Programs, www.smart.gov/SOMAPI/
pdfs/SOMAPI_Full%20Report.pdf. Accessed July 25, 2015.
Przybylski, R. & Lobanov-Rostovsky, C. (2014). Unique considerations regard-
ing juveniles who commit sexual offenses. Sex Offender Management
Assessment and Planning Initiative. Washington: US Department of Justice,
Office of Justice Programs, www.smart.gov/SOMAPI/pdfs/SOMAPI_
Full%20Report.pdf. Accessed July 25, 2015.
Rawlings, A., Paliokosta, P., Maisey, D., Johnson, J., Capstick, J., & Jones, R.
(2014). Study to investigate the barriers to learning from Serious Case Reviews
(SCRs) and identify ways of overcoming these barriers (Project report).
Manchester, UK: Department for Education, 112, ISBN 9781781053980.
http://eprints.kingston.ac.uk/28092/. Accessed 2 July 2015.
Sagar, C. (2002). Working with cases of child sexual abuse. In C. Case &
T. Dalley (Eds.), Working with children in art therapy (pp. 89–114). London/
New York: Routledge.
Salter, M. (2013). Grace’s Story Prolonged Incestuous Abuse From Childhood
into Adulthood Violence against women, 1077801213476459
Santen, B. (2014). Treating dissociation in traumatized children with body
maps. In C. A. Malchiodi (Ed.), Creative interventions with traumatized chil-
dren (2nd ed.pp. 126–149). New York: Guildford Press.
Sgroi, S. (2008). Vulnerable populations (Vol. 2) Simon and Schuster.
Sidebotham, P. (2012). What do serious case reviews achieve? Archives of Disease

in Childhood, 97(3), 189–192.
Sidebotham, P., Brandon, M., Powell, C., Solebo, C., Koistenen, J., & Ellis, C.
(2010). Learning from serious case reviews: Report of a research study of learning
lessons nationally from serious case reviews. London: Department for Education,
DFE-RR037.
Sparta, S. N. (2003). Assessment of childhood trauma. In I. B. Weiner (Ed.),
Handbook of psychology, forensic psychology. Hoboken, NJ: Wiley.
Stalker, K., Green Lister, P., Lerpiniere, J., & McArthur, K. (2010). Child protec-
tion and the needs and rights of disabled children and young people: A scoping
study. Scotland: University of Strathclyde.
Stalker, K., & McArthur, K. (2012). Child abuse, child protection and disabled
children: A review of recent research. Child Abuse Review, 21(1), 24–40.
Stanford, P. (2015). Their crimes provoke repulsion but it is our duty to rehabili-
tate sex offenders. UK Guardian, March 1. http://www.theguardian.com/
society/2015/mar/01/sex-offenders-rehabilitation. Accessed July 24, 2015.
Steinhardt, L. (1985). Freedom within boundaries: Body outline drawings in art
therapy with children. The Arts in Psychotherapy, 12(1), 25–34.
Stirpe, T. S., Wilson, R. J., & Long, C. (2001). Goal attainment scaling with sexual
offenders: A measure of clinical impact at posttreatment and at community
follow-up. Sexual Abuse: A Journal of Research and Treatment, 13(2), 65–77.
Summit, Roland. “The Child Sexual Abuse Accommodation Syndrome.”
Rennefeld Birgitta (2013)
Tacey, D. (2013). The darkening spirit: Jung, spirituality, religion. New York, NY:
Routledge.
Thomas, T., Thompson, D. & Karstedt, K. (2014). Assessing the impact of circles
of support and accountability on the reintegration of adults convicted of sexual
offences in the community. Centre for Criminal Justice Studies, School of Law,
University of Leeds. http://www.law.leeds.ac.uk/assets/files/research/ccjs/
CoSA/CoSA-Full-Report.pdfc. Accessed July 28, 2015.
UNICEF. (2013). Government of Eastern Caribbean/UNICEF CPAP one and
half year review 2012-2013: Child protection. http://www.unicef.org/eastern-
caribbean/Child_Protection_review.pdf. Accessed July 12, 2015.
Veneziano, C., Veneziano, L., & LeGrand, S. (2000). The relationship between
adolescent sex offender behaviors and victim characteristics with prior vic-
timization. Journal of Interpersonal Violence, 15(4), 363–374.
Villa Vincenzo, C. (1999). A different kind of justice: The South African truth
and reconciliation commission. Contemporary Justice Review, 1, 403–428.
Wilson, R., & Prinzo, M. (2002). Circles of support: A restorative justice initia-
tive. Journal of Psychology and Human Sexuality, 13(3), 59–77.
Wilson, R., Huculak, B., & McWhinnie, A. J. (2002). Restorative justice inno-
vations in Canada. Behavioral Sciences and the Law, 20, 363–380.
Wilson, R., Picheca, J., & Prinzo, M. (2007). Evaluating the effectiveness of
professionally-facilitated volunteerism in the community-based management
of high-risk sexual offenders: Part one – effects on participants and stakehold-
ers. The Howard Journal of Criminal Justice, 46(3), 289–302.
Wylie, M. S. (n.d.). The Limits of Talk. Bessel van der Kolk wants to Transform
the Treatment of Trauma. In Psychotherapy Networker: The Magazine for
Today’s Helping Professional. www.traumacenter.org/products/pdf_files/net-
Zeanah, C. H., & Zeanah, P. D. (1989). Intergenerational transmission of mal-
treatment: Insights from attachment theory and research. Psychiatry, 52(2),
177–196.
5
Interventions with Children
in Residential Care
Improving Residential Childcare Practice:
Nurturance Care; Attachment, Separation and
Loss; Narrative Therapy; Family Reunification;
Life Story Work
Fig. 5.1 ‘Conversation Piece’ © Jaime Lee Loy 2008

‘Conversation Piece’ … was constructed from a second-hand book found

in a garage sale … one of those stereotypical novels housewives supposedly
read, filling their heads with fantasy and daydream. The plot involved a
wealthy European female who visited an untouched island to pursue a
torrid love affair with an indigenous male. Her furious fiancé follows her to
wage war on the islanders. In ‘Conversation piece’ this type of book that
deceptively creates fantasies that promote myths about relationships and
desire, is being interrogated alongside the domestic space—another facili-
tator of myth and idealism. Stripping the book sentence by sentence, I
pasted excerpts that referred to a physical war to create a psychological one.
Key sentences were used to totally cover a plate, which was then installed
in my studio on a table, which was set with cutlery and wine glasses (Lee
Loy 2008, n.p.).
Introduction
In this section, our aim is to build knowledge and practice skills for
working with children in residential care. We begin by highlighting
important commitments to improving residential care and family-based
alternatives that Caribbean governments have signed up to. We describe
the current state of residential care services for children in the Caribbean,
articulate what is meant by good quality care and provide practice exam-
ples which can be easily replicated. We acknowledge that residential child
care in the Caribbean faces many challenges (Lim Ah Ken 2007; Sogren
and Jones 2015), and we have been careful to ensure that the practices
we describe can be implemented within current constraints while at the
same time contribute to improving children’s quality of life. This is a
book about child sexual abuse, and in this section we focus on the sexu-
alised behaviours presented by Anton and Oriana, siblings living in a
children’s home and our fourth case study. We look at the underlying
factors that have contributed to their behaviour and how caregivers and
practitioners should respond. We then discuss what these overall factors
signify for residential child-care practice in general and suggest a model
of nurturance care that can be adopted with relative ease by residential
facilities in the Caribbean.
5 Interventions with Children in Residential Care 221
Anton and Oriana’s Story

Family History
Anton (male) and Oriana (female) are siblings born on the 23 December
2005 and 16 November 2006, respectively. When Oriana was 10 months
of age, the children were placed in residential care, a place called ‘The
Home’, built by the Anglican Church to house 50 children. The chil-
dren’s mother, Charlene, a mixed-race Caribbean woman, was born in
1980. She suffered a life of physical and sexual abuse from age seven,
and with an education interrupted because of truancy and with little or
no family support, she found it impossible to find and keep a job after
officially completing her secondary education at age 16. She lived with
her mother, Elaine, with whom she had a very conflictual and detached
relationship. She never knew her father, who allegedly was a much older
man who engaged her teenage mother in commercial sexual exploitation.
After leaving school, Charlene drifted into prostitution and drug addic-
tion aided by a series of exploitative boyfriends. By the age of 21, she had
given birth to four children. They were all removed from her care within
months of their birth and placed in alternative care with extended family
members. Her children are two sons, dates of birth 1996 and 1998, and
two daughters in 2000 and 2001. When Anton and Oriana were born
in 2005 and 2006, they were allowed to stay with their mother (then
age 26) through the supportive intervention of a senior social worker.
Nonetheless, Charlene drifted back into prostitution before Oriana’s
first birthday. She also continued to misuse drugs (alcohol, marijuana
and crack cocaine). With a shortage of foster homes and extended fam-
ily unable to help further, Anton and Oriana were placed in a children’s
home. Charlene occasionally sees her oldest two children as they live
close by but has no contact with her other children and has never visited
Anton and Oriana.
Mother abused as a child

Cut Off- No relationship
Mother
26 Fathers
1996 1998 2000 2001 Anton Oriana

2005 2006
Kinship Foster Care
Fig. 5.2 Anton and Oriana’s genogram
Presenting Problem
Extended family members had been unable to take the children and in
the absence of a suitable foster home, there had been no choice but to
place Anton and Oriana in an institution. When they were placed, they
were among the youngest children in a home caring for 42 other chil-
dren. The physical standards of care they received were far better than in
the short period when they had lived with their mother, but the rotation
of caregivers on a shift system meant that there was no stable maternal
figure with whom they could bond. Anton and Oriana grew healthy and
met all of their early developmental milestones. They were very bright
children and learned to read ahead of other children in their age group.
They were generally undemanding but did not join in with the other
children’s games, preferring to stay together in a corner of the garden.
Oriana tended to cry easily and Anton was her protector—pushing away
the bigger children who teased her. He was tall and strong for his age;
although there was only a year between them, she was tiny and timid and
seemed much younger. They were exceptionally close and did absolutely
everything together. Although they had separate beds, they always slept
together—Anton would leave his bed in the night and go in search of his
sister.
When Anton was five, caregivers moved him to the boys’ dormitory.
Up to this point, he and his sister had both slept in the nursery, but at
age five, children were moved on—these were the rules. Oriana struggled
greatly to settle without her brother and she would cry for him until
caregivers lost patience and threatened her with a beating. Anton would
often awaken at night too—he would then sneak back to the nursery to
be with his sister. The children were punished but persisted; eventually
locks were placed on the dormitory door preventing Anton from leaving.
He began to seek comfort from the other boys, climbing into their beds
to cuddle up to them. Some months later, one of the boys said that Anton
had climbed into his bed and started playing with his “willy”. Soon other
boys made similar complaints. Anton was alienated, and when the older
boys in the home found out, he was taunted with homophobic names
and often hit by them. In turn, Anton became aggressive with boys who
were smaller than him, and anyone who told about his climbing into
their beds was subject to being bitten, punched or pinched. Soon all
the children avoided him and his only playmate was Oriana. Staff often
joined in with the name-calling, and Anton began to withdraw from
contact with adults too. He began to lose weight and became introverted.
His behaviour became more, not less, sexualised, though and he would
often sit and rock by himself, crying and masturbating.
Separated from Anton and

each other in Oriana found in
Home for first 'sexual' activities
time at 4 yrs of with each other
Born 2005/2006 age at age 5 & 6
Placed in Another boy

Residential Care complained of
at 1 yr and 10 unwelcomed
months of age; 'tactile' contact
always in each by
other's comapny 6 yr old Anton
in the Home
from thereon
Fig. 5.3 Anton and Oriana’s timeline

Before we move into discussing an intervention for working with

Anton, we explore some of the issues that impact residential care in the
Caribbean more generally and the importance of improving the knowl-
edge, skills and practices of caregivers.
Setting the Context: Residential Child Care

in the Caribbean
With the exception of juvenile correctional facilities and some homes for
children with special needs, many children’s homes in the Caribbean are
not owned by the state, but by faith-based organisations, private individu-
als or non-governmental organisations, and although some receive gov-
ernment subventions, many do not. Residential child care represents a
huge cost for local authorities in the West because Western governments
have a legal and financial obligation to children who cannot be cared for
by their parents. In the Caribbean, however, the full costs of caring for
children in residential homes are not usually borne by governments, and
even when homes receive a subvention, their survival is often dependent
upon charities and goodwill donations. Consequently, Caribbean govern-
ments are not fully aware of the true financial costs of placing a child in a
children’s home from infancy through to adulthood, and therefore there
is no economic imperative to invest in alternatives to institutional care.
Furthermore, in the absence of effective child protection and early child-
hood family support interventions, many Caribbean and Latin American
countries use institutional care, not as a measure of last resort, but as
the default position for responding to the needs of vulnerable children
(UNICEF 2012).
In a 2014 call to end the placement of children under the age of three in
residential care, endorsed at the 35th CARICOM1 Heads of Government
Conference, the prime minister of Grenada, Dr. Keith Mitchell, stated:
1
The Caribbean Community (CARICOM) was established in 1973 and comprises all of the inde-
pendent states and dependencies of the Caribbean, with the exception of Cuba. CARICOM’s
objective is to promote regional integration in the Caribbean through economic cooperation, for-
eign policy co-ordination among independent member states, development of common services
and co-operation in health, education, culture, communication and industrial relations.
It is our responsibility at this time to ensure that we take action to end the
residential institutionalization of children in the 0–3 year cohort. It is
imperative that we take the necessary reform measures which aim to pre-
vent further institutionalized care, and the onus is on us to work assidu-
ously to return children within that age group from residential care to the
family or family-based environments (UNICEF 2014).
Mitchell’s plea is underlined by the UN Guidelines on Alternative Care

of Children (www.unicef.org/protection/alternative_care_Guidelines-
English.pdf ), which call on governments to redouble their efforts and
commitment towards the protection of children without parental care
and particularly to end the placement of children under three years old
in residential institutions. There are sound developmental reasons why
such young children should not be institutionalised. One obvious one is
that this age group depends more completely (than their older peers) on
a responsive primary caregiver for their ultimate safety and well-being.
During this stage, physical and neurophysiological maturation is rapid
and heavily influenced by the attachment patterns the child forms with
a primary caregiver. Institutional care often provides poor opportunities
for secure attachment and this is due to, among other things, a varied
and changing number of caregivers who have to attend to the care needs
of many children, some of whom may have been severely abused and
neglected. Infants need stable and secure emotional bonding experiences
with a caring and loving adult but are highly unlikely to experience this
consistently in an institution.
We know that, universally, babies begin to develop an emotional attach-
ment to their primary caregiver by about six months of age, the time at
which they are showing a clear discriminatory preference for one person
over the other. From this stage to approximately three years of age—the
longest stage of attachment—infants and young children form strong
attachments with primary caregivers. Bowlby (1958, 1973) introduced
the term attachment to refer specifically to the ‘secure base’ definition of
this infant–adult bond. This is most often with a mother (or someone
who ‘mothers’ the child) and is usually in a domestic family environment.
However, in some cultures, including the Caribbean, another family mem-
ber or an older sibling may very well be the primary caregiver. The theory
of attachment with a responsive, available caregiver as the primary source

of security in infancy is applicable across cultural contexts (Waters and
Cummings 2000). We discuss this later in relation to Anton and Oriana.
The Extent of the Problem

In the case of Anton and Oriana, there was clearly an awareness that the
placement of these infants in a children’s home was not in their best inter-
ests, but the lack of a more appropriate placement (in kinship, foster or
adoptive care) reflects the extent of the problem that Mitchell highlighted.
A Caribbean study of institutionalised children reported that 30 (70 %)
out of 43 residential homes surveyed in Trinidad and Tobago were caring
for children who were five years of age or younger; of the total of 1229
children cared for in the 43 homes, 12.4 % were in the birth to five age
group (Sogren and Jones 2015). The Organization of Eastern Caribbean
States2 (OECS) study of 2002 found that 17 % of the 310 children in
the study who were living in children’s home were under five (Trotman
Stoby 2002). The institutionalisation of very young children is part of
a wider picture that shows an over-reliance on children’s homes to solve
problems of child neglect and abuse—an estimated 240,000 children and
adolescents in Latin America and the Caribbean are said to be living in
institutions (UNICEF 2014).
2
‘The OECS is a nine-member grouping comprising the States of Antigua and Barbuda,
Commonwealth of Dominica, Grenada, Montserrat, St Kitts and Nevis, St Lucia and St Vincent
and the Grenadines. Anguilla and the British Virgin Islands are associate members of the OECS.
[A Revised Treaty signed on June 18th, 2010 OECS] … establishes the OECS economic union,
making possible the creation of a single financial and economic space within which goods, people
and capital move freely, monetary and fiscal policies are harmonised and countries continue to
adopt a common approach to trade, health, education and environment, as well as to the develop-
ment of such critical sectors as agriculture, tourism and energy’. See more at http://www.oecs.org/
about-the-oecs/who-we-are#sthash.Bg85L7oo.dpuf.
Why Children Come into Care

In the OECS study (Trotman Stoby 2002), the top ten reasons for
admission to residential care were neglect, caregiver’s inability to cope
emotionally, delinquent behaviours of children, caregiver’s inability to
cope financially, abandonment, physical abuse, no available caregivers,
criminal behaviour of child, sexual abuse (including incest), and death
of parent. Neglect and abandonment, two of the most common reasons
cited, were primarily the result of parental inability to cope and finan-
cial difficulties and point to the cumulative effect of intersecting factors.
Sogren and Jones (2015) confirm this:
The reasons for children being in care were complex and multifaceted.
Death of a parent, homelessness, the need for special care and being
‘beyond control’ were the most frequently recorded reasons for being in
care. However, for 24.4 % (n = 288) of children, no specific reason was
recorded. Interviews revealed that this was because these children had
been exposed to multiple harms and complex situations that did not fit
into a single category. These experiences included harsh and violent
treatment at the hands of parents, exposure to illegal and harmful
activities, parents who abused drugs, orphanhood due to AIDS, incest
and abuse (Sogren and Jones 2015, 103).
These childhood experiences point to the importance of early family

support interventions. In a CARICOM study which explored the circum-
stances of children without parental care in ten countries (Lim Ah Ken
2007), a strong case was made for increased understanding of the factors
and related causes which make children vulnerable and which then increase
their likelihood of coming into the child protection system. Lim Ah Ken
(2007) gives a detailed list of vulnerability factors, including reasons such as
‘child ran away to join friends, be on the street or join a gang’; ‘parent is an
alcoholic or drug addict’; ‘lack of Government understanding of child pro-
tection issues, translating into lack of commitment to support social sectors
and parental rehabilitation and support’ (Lim Ah Ken 2007, 11–12).
So, children come into care for a range of reasons—in Anton and
Oriana’s case, the state intervened because of parental abandonment and
because there were no relatives to provide care for them. But is institu-
tional care necessarily bad for children? We discuss this next.
Is Institutional Care Necessarily Bad

for Children?
For most infants, in homes where there are inadequate resources to meet
children’s individual attachment and emotional needs, the answer is probably.
Research shows that ‘exposure to an institution or similarly depriving envi-
ronment for some unknown minimum duration during the first 2 years of life
is associated with higher Child Behaviour Checklist (CBCL) problem scores’
(Dozier et al. 2012, 1). Dozier et al. reviewed a number of studies, including
a randomised clinical trial, and concluded that institutional care does have
adverse effects on the development of young children. Furthermore, there
is now widespread evidence that young children placed in foster or adoptive
families have better physical, emotional, educational and mental health out-
comes, compared with those who have grown up in institutions.
The emotional and cognitive harm caused by long-term institutionalised

care of young children includes ‘physical and brain growth deficiencies;
cognitive problems; speech and language delays; sensory integration diffi-
culties as well as social and behavioural disorders’ (UNICEF 2006, 7).
The lack of physical and emotional contact that is a feature of life for
children in institutions, especially in large homes, contributes to the devel-
opmental delays which they experience and which can impact them in
later life—‘A general rule is that for every three months that a young child
resides in an institution, 1 month of development is lost’ (UNICEF 2006,
7). Young children in residential care are also more likely to experience
physical harm and sexual abuse. It is important to point out at this junc-
ture that legislation does exist for non-residential care in many islands (e.g.,
Jamaica’s Early Childhood Act (2005) and Early Childhood Regulations
(2005) for children under the age of six). Clearly, Caribbean governments
are beginning to acknowledge their obligations under the Convention
on the Rights of the Child (CRC) to prevent institutionalisation of
children wherever possible. However, in the absence of legislation regulating

institutional care and investment in good foster, adoptive and kinship care
arrangements, little is likely to change. Anton and Oriana’s situation illus-
trates this point well. Although these children could not have remained in
the care of their mother and it was clear that institutional care was not the
preferred option, there was little choice.
Is Residential Care Bad for Older Children?
Not necessarily. For some children who have experienced abuse, neglect
or ill treatment at the hands of their parents, placement in a children’s
home can provide valuable respite from the emotional intensity, expecta-
tions and anxiety that can come with family life. However, for residential
care to enable children to thrive and achieve their potential, the expe-
rience needs to be one in which they are protected from abuse within
the institution too. The too-ready use of physical punishment and verbal
abuse against Anton and Oriana by their caregivers was not an accept-
able way to treat children in care, but we suspect it might be common
in some homes. There is need also to pay special attention to the risk of
sexual abuse. The World Report on Violence against Children reports
that children in institutions are almost four times more likely to be sub-
ject to sexual abuse than those in family-based care (UNICEF 2006).
Children are at risk of harmful sexual behaviours not only by adults but
also by other children. This is not only a risk in homes in the Caribbean,
it also happens in countries where there is modern and updated residen-
tial care legislation, standards of care protocols and staff training. We can
predict however, that where there is a lack of trained staff and where there
are institutional cultures in which children’s rights are not protected, the
risks of child abuse by peers and staff are increased:
A variety of research designs and of definitions of sexual abuse obscures the

prevalence of sexual abuse in residential care. Sexual abuse by peers is often
overlooked, while this accounts for almost half of the known cases. Histories
of sexual abuse prior to placement, group dynamics, institutional culture
and insufficient knowledge of professionals on how to address issues of
sexuality, appear to be crucial factors in peer abuse. Gender also plays a
significant role: most, though not all, victims are females, most, though not
all, perpetrators are males. Instead of understanding sexual abuse as a phe-
nomenon related to individual characteristics, it is important to address
both institutional factors (culture) and group dynamics in order to provide
children in residential homes with the care they need (Timmerman and
Schreuder 2014, 715).
Good quality residential care that meets children’s cognitive, emo-

tional and developmental needs can be very therapeutic for many chil-
dren. In the Caribbean study reported in Sogren and Jones (2015), there
were several examples found where homes far exceeded the care children
had received in their families. For some children in this study, care repre-
sented stability, freedom from domestic violence and abuse, good health
and physical care and access to educational opportunity that they had
not had with their families. Interestingly, Sogren and Jones report that
although staff numbers matter, the attitudes, values and skills of staff
matter more:
There were many homes with very small staff numbers that appeared to be
providing a better standard of care than some homes where there were
more staff members, and variances among the homes in terms of resources,
size of home, and staffing levels did not always translate into major differ-
ences in the general standard of care or outcomes for children. This is not
to underestimate the importance of the issue of adequate staffing, and we
are particularly mindful that where there were relatively few caregivers,
children would have limited opportunity to disclose any experiences of
abuse or neglect since there might simply be no one to whom they could
tell their stories (Sogren and Jones 2015, 110).
Even where there are good standards of practice, it is the case that too
many children remain in residential care for far too long, sometimes until
they reach adulthood when they are then discharged into society, often
without being prepared for the transition to independence (Lim ah Ken
2007; Sogren and Jones 2015).
Improving Residential Care for Children

For children’s homes to consistently meet the conditions for good quality
care, there are several critical issues that need attention:
1. A proper funding base—the standard of care in many homes is con-

tingent upon goodwill and charity.
2. Many homes are unlicensed and operate in a vacuum characterised
by a lack of regulation and a lack of effective monitoring systems.
3. Staff are often untrained and poorly paid.
4. Staff-to-child ratios are not conducive to meeting children’s indi-
vidual needs.
5. Children’s needs are not routinely assessed or reviewed, and long-
term planning is often absent.
6. Children are sometimes placed by parents or relatives, without for-
mal assessment and approval of agencies with child protection
responsibilities.
7. Re-integration, rehabilitation and family contact support are often
non-existent.
8. There is a lack of effective data-gathering systems on children’s
progress and needs.
9. The large size of some homes (some homes care for 30–50 children,
and in one study a home for 185 children was reported). This is a
legacy of colonial rule when the concept of large institutions was
imported by the religious organisations that founded them.
10. The absence of effective legislation and mandated standards of care
11. The need for young care leavers to be properly prepared and sup-
ported in their transition to independent living. One pilot pro-
gramme in Trinidad and Tobago (Cambridge 2012) demonstrates
the positive benefits of effective leaving care preparation, but this
approach has yet to be adopted more widely.
12. An over-reliance on volunteers
Training
One of the most valuable interventions a social worker, psychologist or

psychotherapist can offer to children in residential care is to provide regu-
lar training workshops for caregivers and a consultative service to enable
caregivers to discuss children’s behaviour. Training on almost any topic is
likely to be welcome, but a good starting point, especially in homes where
there are very young children, is to provide some training on attach-
ment and nurturance. In one Caribbean study of residential care which
examined the training needs of 143 caregivers in children’s homes, the
most urgent training needs identified out of a possible 37 topics were the
effects of trauma and crisis and attachment and loss. Eighty-four percent
(n = 120) of respondents stated these as the most pressing need, exceeded
only by training on children’s mental health, which was identified by
86 % (n = 123) of staff, as can be seen in the table below:
Table 5.1 Self-reported training needs of caregivers in children’s institutions

(source: Jones and Sogren 2004, 39)
Not
Training needs Yes No sure %
Child care law 107 29 7 74.8
Children’s rights 112 27 4 78.3
Child development 90 50 3 63
Needs of children (psycho-social, educational, 99 41 3 69
physical and so on)
Dealing with challenging behaviour 119 22 2 83
Discipline 92 51 0 64.3
Children’s health 95 48 0 66.4
HIV/AIDS and sexually transmitted diseases 106 35 2 74
Childhood sexuality 105 34 4 73.4
Effects of trauma and crisis 120 23 0 84
Attachment and loss 120 23 0 84
Child abuse and neglect 112 30 1 78.3
Interpersonal relationships 92 48 3 64.3
Child mental health 123 17 3 86
Intimate care for physically challenged 89 53 1 62.2
children
Children with disabilities 116 26 1 81
Nutrition 91 50 2 63.6
Drug and alcohol abuse 112 31 0 78.3
Parenting skills in residential work 75 64 4 52.4
(continued)

Not
Training needs Yes No sure %
Communication skills 99 41 3 69
Assessment skills 112 29 2 78.3
Care across the age span 87 56 0 60.8
Leaving care and after care 113 29 1 79
Working in partnership with parents and 99 43 1 69.2
families
Problem solving 90 50 3 63
Anger management 81 59 3 56.6
Self-awareness 70 69 4 49
Evaluation skills 84 56 3 58.7
Conflict resolution 71 61 6 51.4
Stress management 93 48 2 65
Supervisory skills 52 71 6 40.3
Working with other professionals 70 57 8 52
Shift handovers 29 100 3 22
Team building 56 77 5 40.6
Record keeping 51 83 5 36.7
Care planning 92 42 5 66.2
Policy, procedures and care standards 51 81 6 37
What is clear is that caregivers cannot develop the strategies and skills
for meeting the needs of children with complex needs if they do not have
access to underpinning knowledge or the time to provide the nurturing
care that children need. In addition to the information in this book,
there are numerous resources available on the internet that can help. Two
sources of information that are based specifically on residential care in
the Caribbean are the Jones and Sogren report ‘A Study of Children’s
Homes in Trinidad and Tobago’ (2004), which includes model curricula
for training caregivers, and the review of research from the region by Lim
Ah Ken (2007), which offers valuable recommendations for improving
practice. Maginn and Cameron (2013) point out that there is a need for
caregivers to gain ‘the knowledge and skills to understand and respond
appropriately to the emotional, behavioural and attainment difficulties
that are exhibited by the children in their care’ (48). They advocate regu-
lar child-focused consultations with qualified professionals: a psycholo-
gist, social worker or psychotherapist and a programme of training in
nurturing care. We discuss the concept of nurturance-based care next.
Nurturance-Based Care
In many children’s homes, difficulties with children’s behaviour are

addressed by drawing on the caregiver’s personal experiences of parent-
ing, social norms on childrearing, a caregiver’s best guess about what
to do at the time, recollections of what tips or training they may have
picked up or, most probably, a combination of all of these. Residential
care is very much geared to managing problems and containing children
rather than focusing on their developmental needs. Where theoretical
approaches are consciously used to underpin practice, these are likely to
draw primarily on cognitive behavioural techniques. Although these can
be very useful, they require children to possess the psychological machin-
ery to be able to process adult expectations and respond accordingly.
However, children with unresolved attachment and loss issues may have
an impairment of brain functioning which affects the frontal cortex and
which makes it difficult for them to benefit from behavioural approaches
(Perry and Hambrick 2008). There is growing evidence however, that
adopting a philosophy of care which is based on a nurturance model and
which recognises that the attachment relationship is the main context
for developing emotional regulation may be more effective, especially
for children overcoming the effects of maltreatment, loss, trauma and
abandonment (2011).
Looked after children benefit from developing secure attachments with

their caregivers and interventions should support the development of these.
… Successful placements are more likely when carers are able to respond
to children at their emotional age rather than their chronological one.
Interventions with children should aim to address developmental brain
impairment by providing care that can build fundamental brain capacities.
For looked after children this will mean less use of verbal techniques and a
greater concentration on physical, sensory and emotional ways of working
(Furnival 2011, 1).
A consistent theme in the research on effective residential child-care

practice that makes use of these theories is the importance of the care-
giver’s capacity to do the following:
1. Demonstrate authentic emotional warmth (Maginn and Cameron

2013)
2. Be reflective—reflecting on the child’s behaviour in order to better
understand the child’s thoughts, feelings and needs
3. Be consistent and establish routines that are based on the needs of chil-
dren (not only the management or containment of behaviour). For
example, for children with impaired attachment, it can be helpful to
draw up a detailed plan (covering day and night) which is tailored to
their needs and which is adhered to by all caregivers. This would be dif-
ficult to implement in many Caribbean institutions at present because
of the structural problems we have outlined, but it is important that
practice standards not be set by prevailing conditions but by the imper-
atives to improve children’s lives to which we are committed
4. Understand the importance of nurturance and be able to apply this in
their daily care of children. For example, for Anton and Oriana, who
seek comfort from other children to help them manage internal
stresses, being cradled and comforted by a caregiver can alleviate the
need for this behaviour (Perry and Hambrick 2008).
5. Help children develop positive resilience by building protective factors
into their caregiving role and within the home that can buffer, moder-
ate and protect children from vulnerabilities (Norman 2000).
Children in institutional care are very resilient—they have to be; as

survivors of stressful events and trauma, they have to learn how to cope.
Sogren and Jones (2015) found strong evidence of resilience in their
research on children in residential care in Trinidad and Tobago, manifest
primarily through children’s achievements:
maintenance of consistently high academic standards and outstanding

performance in national examinations. … Linked to academic successes,
the caregivers noted the children’s advancement in social, interpersonal
and self-care skills. … This was reported as a significant feat for children
who had been deemed by society as being “beyond rehabilitation”, as
noted by one home manager, children defied this assignation and devel-
oped healthily—intellectually, socially, and emotionally (Sogren and Jones
2015, 106).
But not all resilient behaviours indicate positive adaptation. For exam-
ple, dissociation is a common psychological defence children use to pro-
tect themselves from emotional hurt and in that sense it demonstrates
inner resilience, but it can lead to dissociative disorders in later life or
become pathological in that it can contribute to impulse behaviours that
may have negative consequences (Brown et al. 2012). Using a ‘positive
psychology’ approach, identifying and building on children’s strengths
and positive attributes, residential caregivers can help children develop
positive resilience factors. Newman and Blackburn (2002) describe resil-
ient children as those who display the following:
• An optimistic outlook. Children who can articulate an optimistic

future for themselves, who have concrete goals and who believe that
initiative and effort pay off are more likely to do well in school and
avoid trouble during adolescence.
• Self-efficacy. Children who feel competent and have an internal
locus of control more often succeed in the face of challenges, fre-
quently because they are more persistent in working towards their
goals.
• Self-discipline. Children who can delay gratification and control their
impulses are more likely to resist temptation and peer-pressure when
the peer group becomes so important in middle childhood and
adolescence.
• Problem-solving skills. Children who are reflective and can think flex-
ibly and abstractly about problems, such as ‘what if ’ questions, are
more resilient, likely because they can sort through choices and better
evaluate their decisions.
Resilience links to nurturance care in that these characteristics are

more likely to be developed when children have sustained nurturing
relationships with adults (e.g., a caregiver, parent, relative, teacher
or youth worker) and live in a nurturing environment. A nurturing
environment is one that provides appropriate structures and bound-
aries, generates a sense of belonging and gives children purpose and
direction.
Pillars of Parenting: A Model of Nurturance Care
Jones and Waul (2005) argued that the over-professionalisation of the

caregiver role could undermine the nurturing environment and that
there was a need to re-insert the concept of parenting into residential
work. Cameron and Maginn agree: ‘no other word captures the long-
term responsibilities of raising children so completely as parenting’
(2013, 49). Cameron and Maginn have produced a model of residential
care that encapsulates this philosophy and emphasises the importance of
caregivers being able to tune in to children’s needs even when faced with
difficult behaviour. Called ‘Pillars of Parenting’ (Cameron and Maginn
2008), the core of the model is the establishment of authentic warmth
between adults and children; however theories of resiliency and positive
psychology are also used (Maginn and Cameron 2013). Maginn and
Cameron make the point that although caregivers are in a sense ‘pro-
fessional parents’, parenting vulnerable children should not be a mat-
ter of trial and error but requires thoughtful application of knowledge
and skills. Eight pillars of parenting are described: primary care and pro-
tection, making close relationships, positive self-perception, emotional
competence, self-management skills, resilience, a sense of belonging and
personal and social responsibility. For each of the pillars, there is a menu
of parenting activities. Caregivers, in consultation with psychologists and
social workers, determine what pillars most closely align to a child’s needs
at any given stage of development and agree on activities that can help
caregivers fulfil their parenting responsibilities. The pillars of parenting
apply throughout childhood, but the meanings for children and the par-
enting tasks will differ depending upon the age of the child; experiences
of trauma, loss and rejection; and the child’s attributes and strengths. The
table below (adapted from Cameron and Maginn 2008, 51) provides
examples of simple behaviours caregivers can use to create nurturance.
Cameron and Maginn’s model is a simple technique for caregivers to
help children manage the effects of trauma and loss, but it can also be
used by caregivers to produce working care plans that are child-centred and
that involve the minimum of bureaucracy. (For further information on the
Pillars of Parenting model, visit www.pillarsofparenting.co.uk/index.html.)
Table 5.2 Adapted from ‘A summary of the pillars of parenting and some of the
staff behaviours and tasks which support these’ (© Seán Cameron and Colin
Maginn 2008 in Cameron and Maginn 2013, 51)
Examples of support
Pillars of parenting What this means for the child required from care staff
Primary care and Sensitivity to a child’s basicTuning in to a child’s fears
protection needs shows the child that and offering a reassuring
we care and that they are word or hug
important. Being aware of potential
Education is included here risks and dangers
because in our complex yet allowing the child to
world knowledge and skills take modest risks
are essential to survival. Ensuring that children
attend school and taking
an interest in their
progress
Making close Secure attachment appears Encouraging the child to
relationships to act as a buffer against explore new things/
risks and to operate as a opportunities
protective mechanism. Engaging in play activities
with the child
Tuning in to the child’s
perspective of the world
Positive To allow the child to develop Celebrating the child’s
self- perception a positive self-image developmental advances
Positive and negative Recognising and
statements have a powerful rewarding good
impact on self-perceptions. behaviour
Recognising and valuing
new skills as these are
acquired
Emotional This ability underpins the Maintaining your adult
competence successful development of role during any conflicts
relationships outside the with the child
family and may moderate Explaining why you want
susceptibility to and the child to do
propensity for later mental something
health. Teaching the language of
emotion
(continued)

Examples of support
Pillars of parenting What this means for the child required from care staff
Self-management Self-management is the Guiding and setting limits
skills insulation which prevents for behaviour
inappropriate behaviour Employing positive
when enticing or compelling psychological control
outside factors try strategies
to intrude. Revising rules and
expectations as the child
or young person grows
up
Resilience Resilient individuals seem Ensuring stability and
to be able to understand continuity in care
what has happened to them Promoting friendships
in life (insight), develop with pupils doing well at
understanding of others school
(empathy) and experience Encouraging of high levels
a quality of life that is often of intrinsic motivation
denied to others who have and an internal locus of
suffered negative life control
experiences (achievement).
A sense of belonging Research and theory in Providing ‘good
relationships have beginnings’ in the foster
established human beings or children’s home
as ‘fundamentally, Personalising bedroom
extensively social’ and accommodation
highlighted the need to Facilitating family contact
belong. Maintaining child’s
cultural, language,
religious and ethnic
identities
Personal and social Essentially, personal and social Modelling considerate
responsibility responsibility means being behaviour to other staff
able to co-ordinate one’s members as well as
own perspective with the children
help of others and Encouraging children to
developing personal views ‘assume positive intent’
of fairness and reciprocity. Helping children to
recognise ‘stranger
danger’ from helpful
adult behaviour
Creating a nurturance-based approach to residential care in the Caribbean

does not necessarily require the adoption of models developed from other
contexts. (But where these models are relevant and can be adapted to local
realities, then why not do so?) However, it does mean using knowledge
about the profound significance to children’s emotional well-being of
attachment, loss and rejection and generating practices that build positive
resilience and are attuned to children’s needs (Rose 2010). In the UK, as in
many countries in the west, children’s homes are subject to strict govern-
ment regulation, monitoring and inspection procedures. We looked at the
‘outstanding’ grading of one children’s home, with which the authors are
familiar, to see what lessons there might be for homes in the Caribbean.
This children’s home had achieved the highest possible grading (out-
standing) in all nine quality standards measured, some of which are
reproduced here.
• From their initial starting points, educational attainment and achieve-

ment have excelled.
• A range of specialist services work hand in hand with the children’s
home and provide young people with additional support, information
and guidance.
• Relationships between young people and staff are remarkable. Staff
genuinely want young people to achieve. Staff work extremely hard to
support them to make progress.
• Relationships between families and the children’s home are excellent.
As such, contact arrangements have progressed and include the most
appropriate support.
• The interior decor of the home is of a very high standard and excep-
tionally well maintained. The home commissioned an artist to work
with young people to develop a piece of art (on an exterior wall) that
represents their home. Young people are proud of their home.
• Young people say “This is the best place I have ever lived. I love it
here”.
(Ofsted Inspection Report, June 2015, file:///C:/Users/staff/Downloads/

SC479776__1.PDF).
It is not unusual for children’s homes in the Caribbean and Latin America
and, indeed, in many middle- and low-income countries to be caring for
10 times the numbers of children generally found in UK institutions. (The
home to which the inspection report above refers cares for only five chil-
dren—albeit children with extremely challenging behaviours.) Therefore,
making direct comparisons in terms of what can be achieved is not pos-
sible, nor particularly helpful. However, as mentioned earlier, Sogren and
Jones (2015), reporting on a study of institutions in one Caribbean coun-
try, identified some homes where standards such as those described above
were being achieved, even with a larger number of children. So what then,
are the universal common denominators for achieving the best outcomes
for children? We think the list below sums these up.
1. Well-structured management and staffing arrangements

2. Children and young people understand staff expectations and their
daily routines.
3. Children have individual care plans.
4. Strong relationships between young people and staff
5. Staff must genuinely want young people to achieve and are pre-
pared to work extremely hard to support them to make progress.
6. Children have access to specialist services to provide them with
additional support, information and guidance.
7. The staff of the home work hard to maintain good relationships
with the families of the children (where possible), and good
arrangements exist for supporting family visits, contact and reuni-
fication (where appropriate).
8. Children are routinely consulted about decisions in the home, especially
in relation to individual care plans. Children should understand their
individual plan, including risk assessments and behaviour management
strategies, and work with staff to update and develop their plans on a
regular basis.
9. Children have access to education and a range of leisure activities.
10. There is clear evidence that children are thriving.
Having discussed the factors that are important in providing good qual-
ity care in children’s homes, we return to Anton and Oriana. We begin by
examining the impact of attachment, separation and loss on their lives and
then move on to explore a treatment intervention with Anton.
Anton and Oriana: Attachment, Separation

and Loss
As discussed earlier, there is overwhelming agreement that infant–care-
giver attachment is a universal feature of positive psychological and
emotional development, even though cultural manifestations in how
attachment behaviours are expressed or understood may differ (Murray
2001). Each stage of development presents different issues for children in
care and for their caregivers, but early childhood, specifically the period
from birth to three years, is the most important developmental phase in
life. In these early years, human beings form bonds and experience stimuli
that enable them to acquire the psychological tools needed for close rela-
tionships throughout their lives. Young children placed in institutions will
be bewildered by loss and the lack of a primary attachment figure. There is
no more telling sign of this for the social worker (or other visitor to a chil-
dren’s home in the Caribbean) than when tiny children rush towards you,
arms outstretched to be picked up, or else they fight each other to be the
first to clamber up onto your knee. If you should ever think this is well-
adjusted behaviour, consider how an infant reacts in your family when a
visitor walks into the house. The child instantly hides behind mummy,
daddy or granny and if you, the interloper, should come too close, the
baby’s face will crumple in readiness for an almighty wail. You may con-
sider that your outstretched arms reflect a benign, kindly gesture, but trust
is a psychological process that has to be learned and you will be rebuffed
until such time as the child has developed the internal antennae than
enable them to discern whom to trust and when. The infant will come
to you on their own terms, or not at all. These ‘stranger behaviours’ are
evidence of the emotional significance of attachment and indicate appro-
priate psychological development, but the infant who opens her arms to a
relative stranger is signalling that things may not be right in her world at
all. One of the most significant losses for the child who enters care is the
loss of the primary attachment figure. Anton and Oriana were placed in a
children’s home at the ages of one year and 10 months, respectively, and
although we know that their mother’s lifestyle was not conducive to them
remaining in her care, they had been with Charlene since birth and she
was their primary attachment figure for the crucial period for the forma-
tion of attachment behaviours—their first year of life. The attachment
process is summarised here by Simmonds (2004):
Although the exact way that this happens varies, the basic process is the
same for all cultures in all parts of the world: specific adults make themselves
available physically and emotionally to the baby, and from this developing
intimacy arises a highly organised set of behaviours and feelings that are the
attachment relationship. Each culture has evolved its own approach to this
but the basic theme remains the same. The purpose of a small child’s protest
is to ensure that the attachment figure stays in close physical and emotional
contact with the child when the child feels anxious or under threat. Small
children do not have the physical or emotional resources to protect them-
selves or meet their needs. Attachment relationships therefore have a pri-
mary objective of ensuring the child’s survival. Making sure that an adult
stays around who knows what you need and when you need it, and who can
provide it, is an absolute necessity (Simmonds 2004, n.p., www.scie.org.uk/
publications/guides/guide07/carersprofiles/simmonds.asp).
Any person who cares for young children will be aware of how dis-
tressed they become if they are separated from familiar adults with whom
they have a close relationship. These are observable signs of attachment,
but there are non-observable psychological processes that attachment
behaviours signify. These are connected to the development of the brain
and enable children to learn how to regulate their emotions and fears
(Dozier et al. 2005). Charlene’s parenting may have been poor, but her
children may still have been overwrought at being separated from her—a
loss compounded by never seeing her again would be tantamount to
experiencing a bereavement (Baker et al. 1992).
The disruption of primary attachment bonds and subsequent
placement in an institution where there are other young children, all
in need of individual attention, mean that the opportunity for Anton
and Oriana to develop new attachments with a caregiver will have
been severely limited. Indeed, the case study suggests that the most
important attachment for Anton was Oriana and vice versa. Writing
about the significance of attachment for children in residential care,
McIntosh states:
Attachment in not an optional extra in a child’s life. It is one of their core

needs. It is an affectional bond, but different from liking someone. In its
healthiest form, it is all of these things, but first and foremost, it is a bond
of psychological dependence. Children’s emotional, social and cognitive
journeys can take some curious, even deviant paths when they experience
long stretches of time without the genuine, focussed and consistent care of
one devoted carer or family, or when they endure the loss of such care.
Often too, children in care may never have developed a foundation of
trust, and have no clear understanding of what care means, as the link
between their needs and having them consistently and reliably met was
never met (McIntosh 2003, 12).
In her study of young children in care with attachment disruptions,

McIntosh (2003) reported feelings of isolation, of a lack of belonging,
of being unwanted and of believing that they are never in anyone’s
thoughts—their world was a place of prolific loss. Loss is as crucial
a concept to understand in residential child care as is attachment.
Children who enter care experience multiple losses, and it is almost
impossible to imagine the trauma to children who have been mal-
treated, subsequently enter care and then are abandoned by the person
they were closest to. Lacking the cognitive tools to process a loss, which
impacts human need at the deepest level and which may persist over
years, the internalised self-blame, low esteem and distorted self-image
that can result may lead to self-harm and anti-social and behavioural
disorders that can be very challenging for caregivers. This in turn often
leads to punitive, exclusionary measures by residential staff, which sim-
ply confirm to the child that he or she is unlovable. To the child, this
explains why the parent never visits. Given their ages on entering care,
Anton and Oriana’s emotional experiences of loss are likely to have
manifested themselves in distress and separation anxiety, although they
were so young that this will have quickly given way to adaptation to the
new environment. However, without replacement attachment figures,
loss will have remained as an unresolved fear which, in the pre-logic
and pre-speech stages of development, explains the desperate need the

children had for such close physical proximity to each other and for the
comfort of touch. Even as the children became a little older, they will
have been unable to articulate the reasons for how bereft they may have
continued to feel and, at some deep level, may have fantasised about
the reappearance of a mummy or daddy whom they had no concep-
tual memory of. These emotional responses are similar to the processes
of mourning that young children experience following parental death
(Baker et al. 1992). We must also recognise however, that where chil-
dren are able to draw on their innate resilience and where good protec-
tive/supportive environments exist, these factors can have a moderating
effect on children’s ability to cope with loss. Furthermore, whereas
some children may be deeply affected by parental separation, others
may adjust easily and do well, and we must remember also that emo-
tional and behavioural problems exhibited by the child cannot always
be attributed solely to the effects of loss and separation. Finally, we
cannot rule out the very real possibility that the insecure attachment
behaviours displayed by Anton and Oriana have their roots in their first
months of life, when they were in the care of their mother. If Charlene
had responded to her children’s physical needs harshly or inconsistently
or had constantly reacted to their distress with neglect or aggression,
they would have been left in a state of hyperarousal. Placed in an insti-
tution where attachment insecurity would have been heightened rather
than lessened, the children will have experienced the psychological
developmental delays evident by their behaviour.
Anton and Oriana faced loss at entering care and there is nothing
to suggest that this early loss of their mother and primary attachment
figure was resolved. Unregulated states of hyperarousal will have
been triggered again as caregivers separated the children from each
other. Caregivers responded by using punitive behavioural tech-
niques, but these children display evidence of reactive attachment
disorder (Millward et al. 2006), not misbehaviour. The emotional
and psychological consequences of enforced separation from possibly
the only attachment figures these children have at this stage of their
development can only compound their problems (Herrick and Piccus
2005). The patterns of behaviour these children exhibit suggest that
they have turned to each other (and now to other children) to help
regulate their stress through physical comfort: holding, stroking and
touch. Although the behaviours have a sexualised content, this may
be more a reflection of their stage of development than maladaptive
traits. Anton and Oriana are manifesting acute separation anxiety and
fears of rejection/abandonment, and it would seem that they have not
developed the psychological mechanisms to regulate emotions inter-
nally that would be expected at their ages (Maginn and Cameron
2013). Although Anton and his sister continue to live in the same
home, their enforced separation at bedtime and the consequent pun-
ishments they face when they seek each other out are practices which
will harm rather than help them. These children have been rejected by
their parents and family, and because of behaviours that caregivers do
not understand, they also face rejection from them too—‘rejection is
not simply one misfortune among many, nor just a bit of sad drama—
it strikes at the heart of what the psyche is designed for’ (Maginn and
Cameron 2013, 46).
Research with children in care shows that they often ‘understand their
siblings in a unique way because of their mutual experiences. These children
may have learned to relate to people and cope with stress in comparable
ways and in the end, they may face grieving shared losses. Thus, siblings can
potentially offer emotional support to one another in the face of adversity’
(Herrick and Piccus 2005, 851). Young children need caregivers who under-
stand the impact of trauma and loss and who have the skills and attributes to
promote secure attachment and who can provide nurturing care.
Sending for Help
The manager of the children’s home where Anton and Oriana lived referred
the children for psychotherapeutic help. Taking events in the chronolog-
ical order in which they occurred, let us track what actually unfolded.
The Home sent for the therapist much as one would send for an exorcist.
Her instructions were to come urgently and to stop Anton from desiring
the touch of his little sister, lest his unholy needs contaminate and ruin
the remainder of the child population in the residence. In the letter from
management, they made it clear that this was a case of sexual abuse, and
though only six years old, Anton was described as a juvenile sex offender.
We will take a look at what transpired in this specific case and at how
psychotherapy works as a therapeutic intervention within large group set-
tings in general. We also draw your attention to the state of mindful being
that a psychotherapist (or other social work or mental health professional)
needs to observe as well as what activities he or she needs to do with his or
her clientele. We begin with how therapists prepare themselves mentally
and emotionally for taking up this work, the work of treating issues which
are described as sexualised behaviours among children within a residential
home setting.
The Therapeutic Presence

Children in residential homes can cause psychotherapists particular
angst. In Part 2, we mentioned that the primary success of psychody-
namic psychotherapy lies in the development of the therapeutic alliance
between the therapist and her client. In psychotherapy groups, such as
the R.I.S.E. programme also described in that section, we mentioned
that groups require a therapist to focus as skilfully on eight or more indi-
viduals, equally at the same time, while also attending to the intra-group
dynamic. In residential homes, which (in the Caribbean) may be the
home of between 20 to 120 children, most of whom have been aban-
doned, neglected or abused, psychotherapists will usually feel their hearts
lurch and clench, just going in the door.
Bessel van der Kolk (2014) offers a view to a children’s clinical setting
in Massachusetts, USA. It is a medical clinic and therefore does not rep-
resent a residential facility where there also are playgrounds, games and
healthy structured activities of various kinds, within a ‘home’ setting.
However, in as much as children who have been neglected, abandoned or
abused, universally experience the same types of trauma symptoms, this
glimpse into a clinical reality does apply.
The Children’s Clinic at the Massachusetts Mental Health Centre was filled
with disturbed and disturbing kids. They were wild creatures who could
not sit still and who hit and bit other children, and sometimes even the
staff. They would run up to you and cling to you one moment and run
away, terrified, the next. Some masturbated compulsively; others lashed
out at objects, pets, and themselves. They were at once starving for affec-
tion and angry and defiant. The girls in particular could be painfully com-
pliant. Whether oppositional or clingy, none of them seemed able to
explore or play in ways typical of children their age. Some of them had
hardly developed a sense of self—they could not even recognise themselves
in a mirror (Van der Kolk 2014, 105).
Traumatised children display symptoms in varying degrees, ranging from

subtle factors that can be managed relatively easily to those that earn the
label ‘mental health issue’ and require psychiatric care. Therefore, therapists
working in children’s residential homes have to make careful assessments as
to where each child’s mental health status lies on a vast continuum. Even if
children in a group have come through very similar experiences, each will
have their own resiliency factors and unique personalities, and these make
a difference in how they present, how they are assessed and what treatment
plan should be put in place for the amelioration of each ill.
Transference and Counter-Transference
Therapists need to keep a relentless eye on themselves when working
within an environment of chronic emotional neediness, such as residen-
tial homes for abandoned children. To briefly explain the phenomenon
of transference and counter-transference, here is an example from adult
clinical experience.
An adult male client takes up sessions with a female psychotherapist.
His complaint is that he is unable to sustain long-term relationships
with women. He says that he starts out well but sooner or later things
turn sour for no reason that he understands. Women stop returning his
calls and he is invariably left to feel rejected and unlovable. He fears no
woman will ever find him attractive and he is doomed to the single life.
Before too long, finding his female therapist attentive and compassionate
(as she must be), the client has transferred his romantic feelings onto her
and may begin to act them out in session. A professional therapist will,
of course, recognise what is going on: that she has become the object
of her client’s affections. She will appreciate what the client is trying to
process and will bring this process into attention, using it as grist for the
mill in working out the client’s relationship problems. Skilfully, this can
be immeasurably informative, rich and healing. However, if the therapist
is not seeing about her business and particularly if she herself has not
mastered her own relationship perspectives, she may fall for the client’s
gambit and counter-transfer the energy in a harmful manner. She could
react in any number of ways, such as becoming offended or dismissive
and shaming him, or she may fall for his symptoms, encourage his needi-
ness and make his matters much worse. Great harm has come to clients
this way, not to mention that professional careers have been lost.
It is similar in the case of needy child clients from residential homes and the
therapists who inadvertently present a nurturing parental figure. Abandoned
children suffer for want of one maternal figure to call their very own or one
family who comes to claim them, take them up and swing them into the air.
This craving grows exponentially the longer the child remains in the facility
or the larger the number of transient caregivers who come and go. Lim Ah
Ken tells us that ‘institutions are inadequate and … have been proven to have
negative psychological effects on children due to the lack of proper attention
and love that a smaller unit such as a family can provide’ (2007, 3). Visitors,
new staff or social workers arriving at a residential facility are very likely to be
met with leaps and bounds of joy on the parts of the children, with clinging
to the neck and with heartbreaking need. It is difficult to resist this depen-
dency transference and longing for maternal love, especially if a caregiver or
therapist herself has come in search of acceptance and love, and to conduct
rescue missions. For example, rather than a therapist being mindful of her
precise role, recognising that she is there at the home for 1 or 2 hours a week
as the case may be and that regardless of how much she genuinely wants
to provide for the child, she is not their mother, her counter-transference
of need for the child’s adoration risks becoming manipulative of him and
this rubs more salt into his existential wound. Please note that children may
also show their desperation for maternal contact by acting in, rather than by
acting out. They may become withdrawn and listless, rather than extroverted
and clingy. But as the cliché goes, ‘children who most need love often ask
for it in the most unlovable of ways’. The transference/counter-transference

issue works in the same way here as described in the adult case above. If the
therapist or caregiver fails to compute the extreme neediness that trauma pro-
vokes in a child regardless of how he displays it, and to factor that dynamic
into their therapeutic relationship, an awful emotional mess will ensue, with
children the ultimate losers.
Many times it has been said that neglected children are taken to safety
in residential homes only to find themselves abused some more in there.
This abuse is not necessarily wilful but may take the shape of poorly man-
aged relationships between children and those who provide their care.
Psychotherapists are not exempt from the need to be rigorous with their
ethics when taking on this most urgent call of duty. Nor are caregivers,
who must attend to their own therapeutic care as well. If there is neglect,
abandonment and unprocessed emotional need in the backgrounds of
the caregivers (including administrative staff and management), risks
exist in which there are (1) children without any power but with chronic
psychological distress and (2) adults with chronic psychological stress and
a lot of power. For this reason alone, unintended abuses of authority may
manifest among populations of children in residential care.
Assessing Risk and Resiliency

Regardless of what a person has been through, psychotherapists (particu-
larly those from the Jungian psychoanalytic school of thought) believe
that there is a good and strong spirit within each individual, which can
be accessed and brought to light, given enough time and tools. In other
words, we believe that there is inherent resiliency which, when tapped,
re-orients a client to his own strengths and empowers him to rely upon
himself for his own emotional needs and sustenance. This works very well
with children as well as adults. It is a strengths-based approach, which leads
the client away from clinging dependency on a therapist, social worker
or any other and towards trusting and believing in their own capacities.
This is also a rights-based approach, which makes it clear (particularly to
children) that they have the right to claim basic provisions, such as food,
shelter, education, medical care and emotional support. No child is too
young to understand their basic human rights and to speak up for them-
selves in this regard. The balance is between knowing what services they
should access and what individual capacities they possess. In Anton’s case,
his list of resiliency factors included the following:
• He was being raised in a very good residential care facility, where all
material needs were being adequately met. There was no suspicion of
any form of physical neglect in this case; the children were generally
well protected.
• Anton’s medical examination showed him to be healthy in all respects
and tall for his age.
• His academic record showed Anton to be of above-average intelligence
and keenly focused on learning. Teachers said that he could become so
engrossed in a storybook for example, that he would lose himself to
the point of not hearing his name called. He was fascinated by the
characters and lives of the people in books.
• Anton showed unusual kindness to his sister, providing a great depth
of empathy and generosity for her.
• In sports, Anton also excelled. This was the one time in which he
socialised willingly with other children of his age. He preferred
competitive over team sports (running and swimming over soccer or
relays) and would exhaust himself in order to win.
Considering a client’s risk factors is also essential to determining the

kind of treatment plan that will eventually be put in place for him.
Anton’s were these:
• In his first two years of life, there is a strong probability that he did not
receive adequate nutrition. The effects of under-nourishment on his
developing brain would have to be considered, along with their possi-
ble manifestations in behavioural traits.
• Potential physical or mental health issues emerging later on in life, as
a result of a gestation period within a drug- and alcohol-addicted
mother. These include mood alterations which could severely impact
Anton’s behavioural choices and his ability to self-soothe. At the
point of the initial assessment, there was no evidence of this, but the
potential for dysfunction needed to be noted for the future. Foetal alco-
hol syndrome for example, which is often undetected until school age,
counts difficulties with controlling emotions, socialising and high-risk
sexual activity, among their symptoms. (See Koren et al. 2003.)
• No understanding of the role of the family in a child’s life. No mater-
nal or paternal role model and therefore no understanding of what
constitutes acceptable social behaviour as a member of a family, includ-
ing the inappropriate nature of sexualised touching with his sister.
• The likelihood that Anton witnessed adult sexual activity, from up
close, during the first two years of his life. He would have no verbal
memory or explanation of this, but his other senses may have absorbed
information that he may subconsciously be processing and acting
upon.
• No one dedicated maternal figure with whom he could bond. Anton
was well cared for, but there was no one he could call his own (save his
sister). He clearly craved a deep relational bond and was already dis-
playing strong symptoms of attachment disorder.
• Anton’s ability to concentrate so powerfully on one thing, which is
listed as a resiliency factor above, may also be listed as a risk factor in
consideration of the shadow side of one-pointed concentration. His
capacity to shut everything out at will could conceivably lend itself to
reclusive, avoidant or low-grade sociopathy, particularly given the cur-
rent environment in which he was being shamed and ostracised.
• One further risk factor emerges, not as a matter of Anton’s personality
or experiences but as an external threat not as yet known even to him.
The neighbours from his village of origin have telephoned the Home
to report that a man has come snooping around the village twice
recently, asking about the two children, Anton and Oriana. They
believe he is the children’s father. He told villagers that he had recog-
nised the boy child as his during his last visit and he wanted to estab-
lish contact with him. Charlene recognised him but gave him no
information and neither did anyone else.
Based on these factors of risk and resiliency, a treatment plan was drafted
for Anton. The first phase of his care incorporated the following elements.
Developing a Treatment Plan

Incorporating a good understanding of the issues Anton would probably face
based on his external or given circumstances, phase 1 of the treatment plan
involved getting to understand his internal or psychological representations
of his reality. One good tool in this regard is the Thematic Apperception
Test, or TAT, designed by Henry Murray (in the spirit of Rorschach) and
now quite widely used. Described in Part 4 of this book, in the case of Levi,
the TAT is a projective test (meaning that it causes users to project their
internal feelings outward onto the object in question). Says Van der Kolk:
The TAT … uses a set of cards to discover how people’s inner reality shapes
their view of the world … the cards depict realistic but ambiguous and
somewhat troubling scenes: a man and a woman gloomily staring away
from each other, a boy looking at a broken violin. Subjects are asked to tell
stories about what is going on in the photo, what has happened previously,
and what happens next. In most cases their interpretations quickly reveal
the themes that preoccupy them (Van der Kolk 2014, 106).
As we have noted previously, remember that an equally weighty part of

this equation is the therapist’s own interpretation of the responses given
by the client. One universal concern regarding the most elite types of
psychometric tests, or any kinds of tests, is that there is heavy depen-
dency on the clinician’s interpretations of results, which may well vary
widely in accuracy. Nevertheless as professionals often do, the therapist
assigned to Anton’s case supplemented the original deck of cards with
other images based on the culture-specific context. One card created for
Anton was taken from artist Shaun Tan’s book The Red Tree (2010). The
Red Tree has been used in detailed art therapy exercises, such as those
described by Russel-Bowie and Thistleton-Martin (2002) and which
can be accessed for public use here: http://wps.pearsoned.com.au/wps/
media/objects/6853/7018422/The%20Red%20Tree.pdf.
Another was created out of a drawing made by one of the other chil-
dren in the home, which showed a small boy being bullied by a number
of bigger boys, and no adult in sight to help him. A third card was created
from a magazine, in which there was a scene of a black family (mother,
father, two sisters and one brother) playing on a tropical beach, but with
dark storm clouds hanging ominously in the sky. Van der Kolk describes
the results he derived in one of his TAT assessments.
One of our cards depicted … two smiling kids watching dad repair a car.
Every child who looked at it commented on the danger to the man lying
underneath the vehicle … but the traumatized kids came up with gruesome
tales. One girl said that the little girl in the picture was about to smash in
her father’s skull with a hammer. A nine year old boy … told an elaborate
story about how the boy in the picture kicked away the jack, so that the car
mangled his father’s body and his blood spurted all over the garage … We
had not selected these photos because they had some hidden meaning …
they were ordinary images of everyday life. We could only conclude that for
abused children, the whole world is filled with triggers (and) they can only
imagine disastrous outcomes (Van der Kolk 2014, 107–108).
In Anton’s case, he ‘passed’ every TAT test. He gave calm, considered and
highly optimistic descriptions of each scene that he was shown, over some
4 weeks of meeting twice weekly, in this discovery phase of psychotherapy.
Did this indicate that he was psychologically calm and optimistic, deep
within himself? No. Unfortunately, this indicated that Anton had already
learned how to give the answers that he thought adults preferred. He had
been wrenched from his mother so young and had never developed attach-
ment with any other safe and secure primary caregiver in the ensuing years,
despite his adequate material care in the Home. He had been separated from
his sister at age four (at bedtime), during a crucial time of night terrors, and
left to fend for himself in his most vulnerable moments in a lonely dormi-
tory. He had been shamed and ridiculed by peers and then ostracised by
them. Caregivers had branded him a sex offender and perpetually treated
him to the ‘bad eye’. Now, there was a lady named Psychotherapist, giving
him the type of undiluted attention he had never received in his life before.
Anton certainly had brains enough not to want to mess this up. He gave
‘right’ answers, having nothing to do with what he really felt inside.
How does a psychotherapist come to know whether a child client
is deliberately mis-representing his reality? The paper tests present one
truth; why challenge test scores? Because working with human beings
requires more than can be computed by questions and answers in clinical
settings, where all patients are on their very best behaviour and deter-
mined to pass all tests. A psychotherapist working with children needs to
go the extra yard. No, mile.
By taking hours and hours, the therapist assigned to Anton’s case was
able to observe him at play in the school yard, in the Home’s yard, during
quiet time with his sister indoors, while concentrating on school books
inside a classroom, while eating a meal, while leaned up against a coco-
nut tree watching waves recede on a sunset beach. Anton was one open,
unhealed wound, despite his measured social and clinical behaviours. In
this six-year-old, one could see a frantic, controlled longing behind his
eyes if one looked closely enough. But by six years of age, Anton had
already mastered the game.
Clinical observation revealed that Anton was experiencing a variety of
troubling symptoms. These symptoms are commensurate with symptoms
that most children in his situation face. They are the following:
• Displaying an indiscriminate and random pattern of showing open

affection to caregivers and strangers—and no particular connection to
any one person
• ‘Has been subjected to frequent changes in primary caregiver’ (Jongsma
2006, 54)
• Alternatively, and for no apparent reason, switching from relating with
open affection to relating in a withdrawn and rejecting manner
• A general detached manner towards everyone (except his sister)
• Refusing food or exhibiting a reduced appetite
• Displaying uncharacteristic aggression during competitive sports and
in other situations where competition is inferred, such as choosing
which TV channel to watch in the Home
• ‘Hypervigilance, such as feeling constantly on edge, trouble falling
asleep and a general state of irritability’ (Jongsma 2006, 43). This was
Anton’s night-time plague.
• Avoiding talking at any length or in any depth about his loss or grief
(concerning loss of both parents, to begin with).
Added to these behavioural symptoms listed above, the DSM IV will list
several dozens more that apply to Anton’s situation. Within the scope of
this assessment and treatment planning period, a much more vital engage-
ment was taking place than could ever be expressed through psychometric
testing, as is evidenced as his story unfolds. Anton was developing a felt
relationship with his psychotherapist. Based upon her consistent presence
at the Home and in observation of his various events at school and at play
(including at Church), Anton began to experience security, safety, com-
mitment and trust, from a purely emotional or spiritual point of view.
The psychotherapist fought her urge to offer or imply more than she
could reasonably give within the scope of her practice, and the boundar-
ies of their relationship were carefully and sensitively articulated in a way
that Anton could comprehend and accept. This therapeutic relationship
proved to be essential in supporting Anton through what would happen
next—quite suddenly and with no preparation, his sister was placed in an
adoptive family. We were not aware of the bureaucracy surrounding the
adoption, nor how the decision was made to divide brother and sister, but
the end result was Anton left alone, again. We pause here to remind the
reader that the research on the topic is unequivocal: the separation of sib-
lings in care is rarely in their best interests, and in many cases it causes the
most profound sense of loss—akin to a bereavement. For some children in
care, the presence of a brother or sister is fundamental to identity formation
and to emotional survival. Where separation is decided, the only justifiable
reason is that this is in the children’s best interests. If separation means that
one child can be placed in an adoptive family, as in the case of Anton and
Oriana, the children will need to be prepared and to be supported through
their anxieties and distress and provided with ongoing contact with their
sibling. The situation we have described in Anton’s case reflects very poor
child-care practice, and the long-term damage, given his traumatic history
of losses to date, is likely to be considerable. Separation anxiety behaviours
we can expect from both Anton and Oriana are described below.
Anton was shattered. Just about broken. And it was the psychotherapist
who received his full transference of grief, loss, clinging and begging, in
regard to every sadness and fear he had ever experienced in his short
little life.
Separation Anxiety Behaviours
• Excessive emotional distress and repeated complaints (e.g., cry-

ing, regressive behaviours, pleading with parents to stay, temper
tantrums) when anticipating separation from home or close
attachment figures
• Persistent and unrealistic worry about possible harm occurring to
close attachment figures or excessive fear that they will leave and
not return
• Persistent and unrealistic fear expressed that a future calamity
will separate the client from a close attachment figure (e.g., the
client or his/her parent will be lost, kidnapped, killed, the victim
of an accident)
• Repeated complaints and heightened distress (e.g., pleading to
go home, demanding to see or call a parent) after separation from
home or the attachment figure has occurred
• Persistent fear of avoidance of being alone as manifested by exces-
sive clinging and shadowing of a close attachment figure
• Frequent reluctance or refusal to go to sleep without being near a
close attachment figure; refusal to sleep away from home
• Recurrent nightmares centering on the theme of separation
• Frequent somatic complaints (e.g., headaches, stomach-aches,
nausea) when separation from home or the attachment figure is
anticipated or has occurred
• Excessive need for reassurance about safety and protection from
possible harm or danger
• Low self-esteem and lack of self-confidence that contribute to the
fear of being alone or participating in social activities
• Excessive shrinking from unfamiliar or new situations
(Jongsma 2006, 264).
Added to Anton’s critical issues, the psychotherapist was experiencing

difficulties of her own, most of which would be common to therapists
working in residential facilities for children. Remember that every child
in a home has been removed from their family of origin for any number
of reasons. So each child is a potential Anton, displaying each or some
of these symptoms. In this particular home, when Anton went into the
therapy room with the psychotherapist and they closed the door behind
them, the children would not let them have a moment’s peace. Up to
12 or more of them at a time pressed on the door, knocking, pounding
and kicking. ‘Miss, what you all doing in there?’ ‘Miss, let me in’, ‘Anton,
I have something for you, come and get it’, ‘Miss, what about me what
about me what about me?’ They climbed on each other’s shoulders to
reach the window and look in, clinging to the bars and making mon-
key tricks. Anton’s strongest resiliency factor, his ability to concentrate
on one task to the exclusion of all else, was the factor which saved the
sessions. The psychotherapist was struggling with irritation the whole
way. Most disappointing was the absolute lack of support from mem-
bers of staff. Numerous times, the therapist had beseeched the caregivers
and administration to keep children away from the therapy room. They
always agreed. But then, only too relieved to have a few of the children
disappear to pester someone else from time to time, they lifted not one
finger to stop this. Additionally, the therapist was reminded that she had
been contracted to ‘fix’ Anton’s ‘sexual deviance’ towards his sister. So
with the sister out of the picture, they did not see the necessity for keep-
ing a therapist on the pay roll. She needed to plead her case over and over
again, but six months into treatment, her working hours were reduced
by half, although she continued to volunteer the rest, thus sustaining her
personal commitment to Anton.
Narrative Therapy
The treatment modality chosen for phase 1 was narrative therapy.
Narrative therapy is a post-structural approach which is both strengths-
and human rights-based, is non-pathologising and works to make mean-
ing of life events through storytelling. As such, it is particularly effective
as an intervention for Caribbean people, who are raised with traditional

storytelling as a cultural-educational tool. Furthermore, it is particularly
effective for use in children’s homes, as children there typically have no
photographs, scrap books or other memorabilia of the families and com-
munities they left behind. When the therapist broached this issue with
administration, pointing out that having photographs of family members
is fundamental to the construction of personal and social identities, the
response was ‘It wasn’t good for them where they were, so now that they’re
here, they’d best forget all about that past’. This wilful erasure or appro-
priation of children’s memories—the good as well as the bad—impacting
their present and future self-concepts, is taken as a preferred state in more
than one facility where abused children are housed. Narrative therapy is
used extensively by indigenous people the world over for this very rea-
son and in therapy groups working with abused and displaced persons.
Narrative therapy makes the following assumptions:
• We become who we are through relationship—through the meaning

we make of other people’s perceptions of us and interactions with us.
• We organise our lives through stories. We can make many different
stories or meanings of any particular event. There are many experi-
ences in each of our lives that have not been “storied”. Each of those
events could, if “storied”, lead to a different, often preferable, life
narrative.
• The dominant discourses in our society powerfully influence what gets
storied and how it gets storied. A discourse is a system of words,
actions, rules, beliefs and institutions that share common values.
Particular discourses sustain particular worldviews. We might even
think of a discourse as a worldview in action. Discourses tend to be
invisible, taken for granted as part of the fabric of reality.
• Locating problems in particular discourses helps us see people as
separate from their problems. We seek to identify the discourses that
support problematic stories. Once a problem is linked to a problem-
atic discourse, we can more easily help people oppose the discourse or
choose to construct their relationship in line with a different, preferred
narrative (Narrative Therapy Chicago, www.narrativetherapychicago.
com/narrative_worldview/narrative_worldview.htm.).
Under narrative therapy, Anton gradually emerged from the sunken place
he had gone to dwell in his mind. His endless ruminations lessened; he
stopped burrowing around in his heart to find memories of the love of his
sister and stopped digging even further into his depths for memories he did
not remember he had. Anton had made a veritable trench in his being and
had become so fixated with it that the psychotherapist was led to scribble ‘sui-
cidality’ into her notes, barely able to believe that she was witnessing a wish
to die in one so young. This period of time spent in creating new, hopeful
narratives was, in fact, to serve Anton well when he faced the cruellest blow
yet. At least, one can only hope that the therapy did serve him well and that
he may not have seen his next life’s event as cruel. The psychotherapist turned
up for work with Anton one day, only to be told that he had been reunited
with his natural father and taken abroad.
This transaction was performed in the space of 2 weeks, over the
Christmas holiday break, with no information given the therapist as to
where he had gone, how he took the parting, whether he was happy to
find that he had a father, and certainly without being allowed to say good-
bye either to her or to his sister. Later, we discuss the importance of family
reunification and the role that fathers, even those who previously absented
themselves from their children’s lives, can play in helping children in resi-
dential care gain a sense of belonging. However, the situation we have
described in regard to Anton is the very worst way to re-establish contact
with a parent. It is evidence of extremely poor practice on the part of
the children’s home and the social services responsible for the transfer of
this child’s care to his father. What runs through Anton’s story is the fail-
ure of adults to put his best interests at the heart of decisions concerning
him and the failure to consult with him and prepare him for the multiple
changes, losses and transitions he has faced.
As this chapter began with a warning that self-care is imperative for
child psychotherapists working in residential homes, we end on the same
note. In the case of Anton, the psychotherapist needed to coach herself
through a protracted period of grief and rage over the breach of civili-
sation that she considered had taken place in the disappearance of her
young charge.
This book is about child sexual abuse, and although the case of Anton
and Oriana is not one of abuse, it does describe very troubling sexualised
behaviours that children sometimes engage in. In this case, the behav-
iours were arrested and transformed before turning into real pathology,
as can quite often be achieved once there is the timely intervention of a
skilful therapist or of very well-trained caregiving personnel. We have
also seen how the intense emotional needs of children who have expe-
rienced adverse circumstances, and who are then placed in residential
homes where secure attachments are not usually forthcoming, can give
way to chronically dysfunctional relationships among both children and
the adults within the residential home population. We now turn towards
exploring the importance of family contact and reunification for children
in residential care.
Family Contact and Reunification

We do not know why Charlene never visited her children, and although
she is accountable for her actions, social workers and residential care
workers have a responsibility to help parents maintain contact with their
children in care—this is a right enshrined within the CRC (unless such
contact is assessed (by professionally trained workers) to be a risk to the
child’s well-being, UN 2010). The lack of resources available to homes
can make it very difficult to facilitate family contact, but greater under-
standing of the social and emotional factors that impact a parent’s capac-
ity to be involved in the care of their child can help staff to create the
conditions to make this happen. The two examples of practice that follow
illustrate how.
Practice Example 1
‘Joan was a young woman of 14 with learning disabilities. When she

was placed at the home she had very little contact with her mother
although the care plan identified increasing family contact as being
in Joan’s interests. It was difficult to get Joan’s mother to visit and
she was not sure she could manage Joan at home. Previous records
(continued)
(continued)
suggested a lack of interest on the part of the mother; however, our
assessment was different. This was a single mother … with five other
children and the family was living in a state of poverty. She was quiet
and seemed unassertive; it appeared to us that her experiences of deal-
ing with the social services department had left her on the outside of
her daughter’s care. Unable to look after her child, she did not feel she
had the right to question those who did and in any event caring for
her other children depleted her time and energy. She could not leave
her other children to visit Joan but could not afford to pay someone
to mind them. If she did come to visit she was so anxious about being
away from home that it affected the quality of the visit.
We invited all of the family to come to share a … meal with us
and it soon became commonplace to see her and all her children
together at the home. In quiet ways she let us know that even hav-
ing a break from cooking was valuable respite. Over time the family
was able to see how we managed Joan’s behaviour and increasingly
our practice was emulated. Although we did not realise it at the
time, this helped to provide a consistency of approach that eventu-
ally made it possible for Joan to spend long periods with her family.
As the other children became more comfortable they would often
play with the children in the home and Joan and her mother were
able to spend more and more time together. When Joan’s mother
asked if it was OK to take Joan out on Saturdays, we offered finan-
cial assistance (to pay child minding costs, travel, meals and so on)
to support the plan and did the same when she was ready, for over-
night and then weekend stays.
By taking the impact of poverty into account, instead of being
excluded, Joan’s mother became more involved in her daughter’s
care. She was able to attend most reviews, she brought her family
to all the leaving parties and other functions in the home and she
was involved in all decisions regarding the care of her daughter.
When Joan was ready to move on to a home for adults she was
(continued)
(continued)
instrumental in finding the right placement and in developing
the support plan. Additionally by involving the whole family,
Joan developed a closer relationship with her siblings’
(Jones and Waul 2005 pp . 6–7).
The second practice example, taken from research into residential care
in Trinidad and Tobago, concerns a parenting programme, developed by
the manager of the children’s home to facilitate the re-integration of chil-
dren into their families. The three children this example refers to entered
care because the small wooden house that was their home had burned
down. It transpired that the children and their mother, an uneducated
young woman who had been forced into a marriage at a very young age,
had been brutalised, physically and sexually, by the husband. He was
subsequently imprisoned for his crimes.
Practice Example 2
‘One mother of three children comes in every day and brings her baby.
The manager has drawn up a programme through which the mother
teaches her children to read and learns how to care for her own chil-
dren from the carers. While she is there she is provided with food
for herself and the baby, plus pampers and other items for the child.
This programme helps her out economically, teaches her skills she can
use with her children and maintains family relationships. Also, the
children are happier and better behaved. The plan is for these chil-
dren to go home when this is possible—Family Services are helping
the mother with accommodation. This is a good example of everyone
working together for the children’ (Jones and Sogren 2004, 14).
Jones and Sogren further commented.
“while parenting programmes are internationally accepted as an effective

method of enhancing parenting skills, this was the very first time we had
come across such an initiative in a children’s home. The ease with which this
programme had been incorporated into the daily life of the home meant
that the mother who was the recipient of the support was not stigmatised in
any way. Furthermore, she not only clearly gained from the formal support
that was provided, but being in an atmosphere in which there were positive
examples of child-rearing and problem-solving being modelled all the time
meant that the formal training was reinforced in subtle ways by the range of
carers in the home (Jones and Sogren 2004, 15).”
What these examples show is the value of taking an ecological systems

approach to children’s care which recognises that the child has a past and a
family. Working creatively with the family system enables those who most
have an investment in a child’s progress to have an input in their care; this
has major benefits for children and can actually relieve some of the pressure
on the caregiver. As can be seen from the Anton and Oriana’s genogram, they
have older brothers and sisters who could be an important source of support
and friendship. These siblings are cared for by extended family members,
but the fact that they were not able to look after Anton and Oriana does not
mean they would not be willing to have contact or to offer support. These are
all avenues to explore. Facilitating family contact can help in preventing the
complete fracturing of relationships and can aid rehabilitation efforts. This
approach is supported by the UN guidance on alternative care for children:
When a child is placed in alternative care, contact with his/her family, as

well as with other persons close to him or her, such as friends, neighbours
and previous carers, should be encouraged and facilitated, in keeping with
the child’s protection and best interests. The child should have access to
information on the situation of his/her family members in the absence of
contact with them (UN 2010, 13).
Writing specifically in relation to residential care in the Caribbean,

Sogren and Jones (2015) also highlight the importance of a systems
approach. In a study which involved focus groups with 64 children and
young people aged 7–17 years, they stated:
“the young people appropriately identified their hierarchy of needs and

matched the cognitive and the affective elements required for their healthy
development and mastery of developmental skills’. [These affective elements
referred to the] ‘multiple systems in an individual’s environment’ (Sogren
and Jones 2015, 105.”
These systems interact and influence development to generate ‘healthy,

nurturing, growth-producing environments … in which children usually
respond favourably’ (Sogren and Jones 2015, 105).
Adopting a holistic ecological philosophy of care requires a willingness
to engage with the child’s pre-care history and to maintain contact with
the family. It also means considering the possibility that poor parenting
and child abandonment not only may be about individual inadequacy but
often have much to do with structural inequality and situational adversi-
ties. This is not to assume that all parents of children in care have faced
such adversities, that poverty and other problems always affect parenting,
or indeed to ignore the fact that some people are simply unable to parent
their children effectively. However, we must be willing to explore the barri-
ers that stand in the way of children being able to maintain or re-establish
contact with their families where this is in their best interests. It may be the
case that Charlene has no interest in re-establishing herself in the lives of
her children or that such a step would not be in their best interests, but we
do not know this. A review of research into residential care in 10 Caribbean
countries reported that nearly all children separated from parents and liv-
ing in institutions were from families in which single women were support-
ing a household (2007). Like the two mothers in our examples, Charlene
may be a victim of her circumstances too, and although it is not helpful to
be over-optimistic, the possibility remains that with outreach support she
may be able to play a role in the lives of her children that could help them
begin to resolve their feelings of loss and rejection.
Fathering
No one could have anticipated that Anton’s father would turn up to claim
him; but how much better for this child’s well-being would it have been
had social workers made attempts to establish contact earlier, to assess
the suitability of Anton’s father to care for him, and to enable Anton to
build a relationship with his father. Paternity is not parenting and it is
parenting that Anton needs. Although the situation may turn out well
for Anton, the manner in which it happened is a complete disregard of
basic standards of ethical practice and may have set this child up for fur-
ther trauma or rejection down the road. One cannot help but draw the
conclusion that the father’s turning up was seized upon to solve a man-
agement problem for the home rather being part of a well-thought-out
future plan for the child.
The absence of fathers in the stories of children in residential care is
an important issue to address though. Many fathers may not know that
their children are in institutions and although this suggests that they have
not maintained a parenting role or even an interest in their children,
this is not something that should be taken for granted. Perhaps Anton’s
father always intended to take responsibility for his children, perhaps he
was denied access by Charlene. Public, private and scholarly discourse
on Caribbean societies both condemns and accepts as inevitable the
abandonment of too many children by their fathers. Perhaps a different
approach is needed, one that neither condemns nor accepts this reality
but instead promotes responsible fathering and engages social workers in
serious family reunification work to trace and involve fathers who could
play a positive role in their children’s lives.
A director at the US Family Violence Prevention Fund explains the
importance and some of the challenges of engaging in this work. We find
similarities between what he describes and what we experience in the
Caribbean, where we tend to follow matrilineal patterns of child rearing, in
which mothers have the default legal authority over children at birth, and
newborn babies are almost always put in the mother’s name if she is not
married to the baby’s father. In the USA, ‘In the child welfare system, fathers
have historically been ignored. The files are put in the mother’s name, and
services for women are often designed so that fathers need to be out of the
picture’ (http://www.risemagazine.org/PDF/Rise_issue_12.pdf ).
However, it is increasingly recognised that children do much better
when fathers are in their lives somehow. In the Caribbean, where gendered
inequalities render single mothers much less able to financially provide
for their offspring than fathers, it is at least fiscally responsible to ensure
that fathers be made to keep in touch and fulfil their basic responsibilities
of material provision. However, there are emotional and psycho-social

needs as well, and family courts are now grappling with itinerant dads to
urge them to give their children some time. But the US director points
to an important flip side.
‘The flip side is that some child welfare systems are not thinking well about
issues of violence … some women work really hard to separate from fathers
who have used violence. Then child welfare workers with good intentions
undo their efforts to separate from abusive partners. It’s not that men who
have been abusive should disappear, but that they must change their behav-
iors. … The good news is that men can change and fatherhood can be a
motivator for change. … Most people want to be good parents. Child welfare
systems can help children by giving fathers the tools to stay involved’ (Rise
Magazine, 2009 http://www.risemagazine.org/PDF/Rise_issue_12.pdf ).
Family contact and reunification are also important for long-term plan-
ning for children. There is a desperate lack of leaving care and after-care
support services in the Caribbean, and as young people reach the age
where it is no longer appropriate for them to live in the children’s home,
and lacking other choices, they often gravitate back to their families of
origin. By this time, relationships have often been fractured beyond repair
and the emotional distance and unresolved issues set the chances of failure
for re-integration too high. Even the most dysfunctional of families usu-
ally have something to offer their children, and exploring the possibili-
ties of contact while children are young enough to rebuild a relationship
with their families can have positive results. This type of practice, known
as ‘inclusive practice’ (Leathers 2002), requires careful assessment, plan-
ning, support and monitoring and must always ensure that the child’s best
interests (and their viewpoints) are at the centre of the process (Kirk 2001;
Wulczyn 2004). A useful source of information to guide social workers
through family reunification work can be found at the US Child Welfare
Information Gateway (www.childwelfare.gov/pubs/issue-briefs/family-
reunification/). The information on this website is based on US residen-
tial child-care and welfare policy but much can be easily adapted for the
Caribbean. Another useful practice model to support family reunification
work is the family group conference model which was discussed in Part 2
of this book. In the next section, we discuss life story work, which can be
considered a family reunification process of a ‘virtual’ kind.
Life Story Work

There are numerous challenges that impact the child living in residential
care. A child does not arrive at a children’s home without a history, regardless
of how young they were when they were placed. The history they bring with
them is a fundamental aspect of who they are, but as they learn to adapt to
their new life in the home, it is as if they were plucked out of the air, their
prior life expunged. And yet understanding those prior experiences is crucial
to helping a child develop a healthy sense of self and identity (Anglin 2014).
Children who enter care are likely to have been abused or neglected or to
have experienced domestic violence, extreme poverty, parental drug misuse,
poor parenting or the loss of a parent. In some countries of the Caribbean
and Latin America, this is as likely to be the consequence of homicide as
any other reason, a fact which presents major challenges for children’s psy-
chological health. They are also more likely to have developed insecure or
disorganised attachments prior to entering care. These are histories of harm
and maltreatment, but this is not the whole story—hidden in the back-
ground are also histories of joy and belonging—histories that get lost when
children enter care. When children lose track of their past, they have no
anchor points for subsequent emotional and social development. Life story
work is an attempt to give back some of this past to children separated
from their families of origin and, though initially developed to help address
attachment issues in adoptive placements, is now a common approach used
by social workers in many care settings. Life stories are an effective tool to
help children in institutions get a sense of their place within their families of
origin, develop a realistic understanding of the events that led to their enter-
ing care, build a sense of identity and deal with loss and early trauma (Rees
2009; Rose and Philpot 2005).
This would have been an excellent method to use with Oriana—gaining a
sense of origin and locating self in a historical and family space are essential
for children who have to learn how to bond to new caregivers and find their
place in a new family. There are several excellent practice-focused guides,
many of which can be downloaded from the internet (see, e.g., Anne Peake’s
beautifully illustrated booklet: www.oxfordshire.gov.uk/cms/sites/default/
files/folders/documents/childreneducationandfamilies/educationandlearn-
ing/schools/virtualschools/Life_Story_Work_Booklet.pdf ).
The practice example below describes a social worker creating a life story
book with a child in a home (within the Caribbean) for children living with
HIV. Life story work might not result in (or aim towards) family reunifica-
tion, but in this instance this is what happened. The example illustrates the
range of issues that emerged during the process and shows how important
it is to have a good understanding of attachment theory.
Practice Example 3
The method known as ‘life story’ work is particularly valuable to

children in a residential setting. For children separated from their
birth families, ‘life story’ work is one way of filling in the gaps about
their lives and it also helps the child to understand his or her life
story and family background, thus promoting a positive self-image.
Children in residential care definitely need their self-image to be
boosted since they are often deprived of many things that children
in normal families take for granted.
The task required that I gather as much information as possible
from past and present caregivers who had had some impact upon
the child’s life. This was challenging since there was limited infor-
mation on the child’s personal file. Crystal (not her real name) has
been a resident of the agency from the age of seven. The only infor-
mation on her background was that her mother died of AIDS and
that she had spent a number of years on the hospital wards prior
to her admittance to the home. Her birth was never registered, nor
were there any records of her existence. Crystal is a slow learner
and constantly seeks attention. She does not associate much with
peers but gravitates more towards much younger children. Her
developmental capacities were affected as a result of parental depri-
vation and loss of attachment figures in her life. Parental depriva-
tion refers to an absence of adequate and purposeful interaction
with parents or caregivers during the formative years.
(continued)
(continued)
According to Bowlby (1973, 127), ‘the predictability and
continuity of close relationships enable the child to move for-
ward developmentally. Where the child’s life has been disrupted
the child can become stuck at certain stages’. This appeared to
be the case with Crystal, who at age 15 displayed low cogni-
tion, low self-esteem and insecure attachment. By age five, a
child needs many of the qualities required for adult life: to be
emotionally ready to learn, to have a clear idea of herself as a
person, to have the ability to relate to other children, to control
and postpone urgent needs, to use initiative and to find gratifi-
cation in play and activities that are socially acceptable. Crystal
was deprived of these, having spent her early childhood on the
hospital wards. Memories of these early years were traumatic for
her as she recalled being abused and neglected. A former nurse
at the hospital, who indicated that Crystal was sometimes locked
away on a ward and left alone, confirmed the abuse. Memories of
being scorned and handled with gloved hands were uppermost in
the child’s mind as well as memories of being physically abused
by some of the nurses.
On the hospital ward, there was less warmth and reduced
meaningful physical contact, less intellectual, emotional and
social stimulation as a consequence of the stigma attached to the
illness. In this environment, there was also a lack of encourage-
ment and help in positive social learning. The hospital setting
in which she spent her early developmental years contributed
to her delayed developmental processes. Researchers have found
that maltreated children have difficulty in linguistic development
and significant problems in emotional and social functioning,
including depression and improverished relationship with peers.
This was the case with Crystal, who did not know how to relate
to her peers and also had a linguistic problem. The central task
(continued)
(continued)
of establishing identity was stressful for Crystal, who had been
rejected and abused, lived in a residential home and bore a stig-
matised label that made her feel different from other teenagers.
She had no friends in her age group and was at a stage where
peers were essential for successful resolution of life tasks. Crystal
was also faced with environmental pressures, such as being iso-
lated from other children for fear of transmission of the virus
through contact.
Although she began kindergarten at eight and primary level at
12, Crystal is slowly developing skills that assist in communicating.
Crystal sometimes sees herself as a failure when she cannot relate to
the work that is taught at school. Children who have experienced
physical or emotional deprivation are more likely to under-achieve
and feel increasingly rejected and marginalised at school.
Working along with Crystal in the development of her life
story required that I interact with family members, her grand-
father and sister. The emergence of these figures in her life filled
her with a sense of hope and of new beginnings. She could now
fulfil that dream of belonging to a real family of her own. This
new hope improved her self-image which was displayed by her
eagerness to talk about the relatives whom she had only quite
recently met. This unification of Crystal’s family was a direct
result of the life story work since it has changed her status from
being an orphan with no history to a child with biological rela-
tives: a grandfather, a sister, two brothers and a nephew, who
have all now acknowledged her. My encounter with her grandfa-
ther was very pleasant. He was most willing to help and offered
as much information as he could remember. He indicated that
he was unaware that Crystal was alive, hence his reason for not
playing any active part in her life. He was also unaware that
people lived that long with the illness. When asked to take a
(continued)
(continued)
photo of himself and the house that Crystal’s mother grew up
in, he quickly agreed and allowed me to take the photographs
for Crystal. Life story work entailed that I work at the child’s
pace. I did this by allowing her to develop her own ideas and to
implement them. For example, in the development of a family
tree, which was eventful for her, she assisted in the construction
of the family tree and named the significant people in her life on
each branch. The emphasis of life story work is on helping chil-
dren and young people to resolve feelings and gain knowledge
and understanding. It is a commitment to enabling the child to
develop a positive sense of self-worth and a sense of being an
actor in her own life rather than just a passive recipient of care.
In working with Crystal on her story over these past few weeks,
I felt that I had achieved a great deal in assisting her to recon-
struct her thought processes, thus allowing her to gain more
confidence and self-awareness. Life story work is a most interest-
ing way of communicating with children and young people, and
I felt extremely gratified in being able to produce a documented
and accurate account of this child’s life history. Crystal now has
a book of her childhood, complete with explanations, photo-
graphs and evidence of her journey this far.
All children are entitled to an accurate knowledge of their past
and their family. Life story work is one way of giving this to them.
A life story book is a useful and essential item for children as it
enables them to understand and reflect on their past and present. It
is most useful for children in long-term care and is recommended
for all children in residential institutions. (Adapted from Jones and
Sogren 2004, 65.)
Life story work is not a one-off event but an ongoing process; chil-
dren should be encouraged to build on their life story books as they
grow, adding photographs, letters and other mementos from their pres-
ent life so that they can build a sense of continuity. As can be seen from
the work with Crystal, this child-centred therapeutic tool can be very
effective in building resilience, and it is a method that can be used even
with young children like Anton and Oriana. We have mentioned the
value of this method in preparing children for adoptive homes but it
equally has value in family reunification work. The creative possibili-
ties for creating life story books are extensive. (see Wrench and Naylor
2013 for some wonderful ideas) and can engage children’s interest and
enthusiasm in a way that is not always possible with other therapeutic
methods (Peake 2009).
Finding creative strategies to help children overcome the effects of loss
and trauma allows social workers, caregivers and therapists to explore
a large range of techniques, such as yoga, sensory therapies, relaxation,
music, drama and art therapies (Lefevre 2004). The Caribbean has a
rich cultural heritage that institutions can draw on to enhance chil-
dren’s self-esteem and give them strategies to regulate their emotions. In
Trinidad and Tobago, for example, many children’s homes participate
in the hugely popular children’s carnival that is part of the country’s car-
nival celebrations (Jones and Sogren 2004). Making costumes, compos-
ing calypsos and rehearsing for a dance band are activities that children
are routinely engaged in. Imagine the potential benefits of infusing
these techniques with a therapeutic approach as part of a planned nur-
turance strategy. For example, carnival is all about masquerade; using
masks can help children role-play significant people and events from
their lives that generate fears, sadness, despair, confusion, beliefs and
hope. The safety of the ‘facade’ means they can physically remove and
put away the mask and its associated emotions when they need to. By
building this into their repertoire of internal resources, children can
learn to recognise the triggers of anxiety and use this method to con-
tain or put away unmanageable thoughts and at the same time signal to
caregivers that they need help. In Part 6, we explore some of the pos-
sibilities of art as therapy in more detail.
Conclusion
In this section of the book, we introduced you to siblings Anton and
Oriana and used their case study to highlight the importance of foster,
adoption and kinship care for young children. We have also stressed the
need for good quality residential child care for older children and articu-
lated what this involves. In the process, we identified some of the chal-
lenges and training needs of caregivers, and although we acknowledge
the constraints that they face, we argue that this is no excuse for practice
that compounds children’s trauma. We make a case for nurturance-based
care which inserts the functions of parenting into the caregiver’s role and
acknowledges the central importance of issues of attachment, separation
and loss and which ensures that the best interests of children are the basis
of all decisions made about them (Browne & Mulheir 2007). In our
therapeutic intervention with Anton, we discussed methods for assess-
ing and treating his emotional and psychological states. As the reader
will be now be aware, when young children present sexualised behaviour,
this may be linked to experiences of sexual abuse but equally it may be
the manifestation of deep-seated distress and unmet emotional needs.
Nevertheless, sexualised behaviours towards other children can result in
this becoming a strategy for seeking comfort that may turn into harmful
sexual behaviour in the future and the child may need to be referred for
help. As you will see though, from our intervention, the focus of help
was on reframing negative narratives of the self and not on the behav-
iour itself. We did not use behavioural techniques because these require
that children have the cognitive, emotional and social skills to interpret
behavioural cues and responses. Children like Anton, who show signs of
attachment disorder, may struggle with meeting the expectations gener-
ated by behavioural methods.
We moved on in our discussion to explore the importance of fam-
ily contact and reunification for children in residential care. Anton’s
story revealed the worst of practice but to countermand this we
provided two examples of excellent practice: simple home-grown
approaches which recognise the adversities faced by many of the fami-
lies of children in care and build plans for family support with this in
mind. In this section, we also discussed the importance of fathering;

with careful assessment, implementation and planning, we imagine
that many fathers might be willing to reclaim their children, but care
is needed to ensure this done in a way that is best for the child. We
introduce the concept of life story work and stress the value of this
method in helping children regain a sense of who they are—crucial
for self-esteem.
This is a book about child sexual abuse, but in this section, we have
discussed everything but this critically important subject. As we bring
this section of the book to a close however, we remind the reader of
Charlene, the children’s mother. She suffered sexual and physical abuse
from the age of seven, was pregnant with her first child at the age of
15 and by the time she left school at 16, was plunged into the world of
commercial sexual exploitation. We have no way of knowing whether
the sexualised behaviours of Anton mean that he was sexually abused
at some point in his care, but we do know that his mother was. She
was a victim of a sexual violence throughout her childhood, but there
is nothing to indicate that she received any support or that anyone was
prosecuted for this. Interventions, such as those described in Part 2 of
this book, may have changed her life course and prevented what subse-
quently happened to her and her children. Although Charlene is now an
adult and able to make her own choices, choice is a nefarious concept
for someone whose livelihood depends on being able to provide sexual
gratification to others. We understand her difficulty in maintaining con-
tact with her children (although parental abandonment is the cruellest
of rejections for children to bear). We understand this because the chil-
dren were born out of loveless sexual encounters for cash, presumably
with men she would prefer to forget. To face her children is to face this,
is to face her abandonment of them, is to face her failings as a mother
and is to face herself. One day she may find the courage to do this and
one day she may find herself a client in your practice or agency. We hope
you will remember that her trials began with sexual abuse and hope you
will respond accordingly.
References
Anglin, J. P. (2014). Pain, normality, and the struggle for congruence: Reinterpreting
residential care for children and youth. London: Routledge.
Baker, J. E., Sedney, M. A., & Gross, E. (1992). Psychological tasks for bereaved
children. American Journal of Orthopsychiatry, 62(1), 105.
Bowlby, J. (1958). The nature of the child’s tie to his mother. International
Journal of Psycho-Analysis, 39, 350–373.
Bowlby, J. (1969). Attachment and loss (vol. 1, ). London: Hogarth Press.
Bowlby, J. (1973). Attachment and loss (Vol. 2). Separation: anxiety and anger.
New York: Penguin Books
Brown, N. R., Kallivayalil, D., Mendelsohn, M., & Harvey, M. R. (2012).
Working the double edge: Unbraiding pathology and resiliency in the narra-
tives of early-recovery trauma survivors. Psychological Trauma: Theory,
Research, Practice and Policy, 4(1), 102–111.
Browne, K. and Mulheir, G. (2007). De-institutionalizing and transforming chil-
dren’s services: A guide to good practice, www.wearelumos.org/sites/default/
files/research/DI%20manual%20Europe%20GMulheir.pdf. Accessed June
20, 2015.
Cambridge, I. (2012). Policy for youth re-integration into society. Caribbean
Dialogue, 6(1/2), 41–53.
Cameron, R., & Maginn, C. (2008). The authentic warmth dimension of pro-
fessional childcare. British Journal of Social Work, 38(6), 1151–1172.
Dozier, M., Lindhiem, O., & Ackerman, J. P. (2005). Attachment and biobe-
havioral catch-up: An intervention targeting empirically identified needs of
foster infants. In L. J. Berlin, Y. Ziv, L. Amaya-Jackson, & M. T. Greenberg
(Eds.), Enhancing early attachments: Theory, research, intervention, and policy,
Duke Series in Child Development and Public Policy (pp. 178–194). New York:
Guilford Press.
Dozier, M., Zeanah, C. H., Wallin, A. R., & Shauffer, C. (2012). Institutional
care for young children: Review of literature and policy implications. Social
Issues and Policy Review, 6(1), 1–25.
Early Childhood Act. (2005). Legislations—EC act 2005. Ocean Boulevard,
Jamaica: Jamaica Early Childhood Commission. www.ecc.gov.jm/legisla-
tion_05.htm. Accessed July 30, 2015.
Early Childhood Regulations. (2005). Legislations—EC act 2005. Ocean
Boulevard, Jamaica: Jamaica Early Childhood Commission. www.ecc.gov.
jm/legislation_05.htm. Accessed July 30, 2015.
Furnival, J. (2011). Attachment-informed practice with looked after children

and young people. IRISS Insights, 10. Glasgow: The Institute for Research
and Innovation in Social Services. www.iriss.org.uk/. Accessed July 15, 2015.
Herrick, M. A., & Piccus, W. (2005). Sibling connections: The importance of
nurturing sibling bonds in the foster care system. Children and Youth Services
Review, 27(7), 845–861.
Jones, A., & Sogren, M. (2004). A study of children’s homes in Trinidad and
Tobago. Huddersfield: University of Huddersfield Repository.
Jones, A., & Waul, D. (2005). Residential care for black children. In
D. Crimmens & I. Milligan (Eds.), Facing forward: Residential care in the 21st
century. London: Russell House Publishing. http://eprints.hud.ac.uk/4193/
Kirk, R. (2001). Tailoring intensive family preservation services for family reunifi-
cation cases. Phase 2: Field testing and validation of the North Carolina Family
Assessment Scale for Reunification. Project report to the National Family
Preservation Network and the David and Lucile Packard Foundation.
www.ibrarian.net/navon/page.jsp?paperid=1224469&searchTerm=family+p
reservation+services. Accessed August 3, 2015.
Koren, G., Nulman, I., Chudley, A. E., & Loocke, C. (2003). Fetal alcohol spectrum
disorder. Canadian Medical Association Journal, 169(11), 1181–1185.
Leathers, S. J. (2002). Parental visiting and family reunification: How inclusive
practice makes a difference. Child Welfare, 81(4), 595–616.
Lee Loy, J. (2008) http://smallaxe.net/wordpress3/works/2008/10/28/jaime-
lee-loy/
Lefevre, M. (2004). Playing with sound: The therapeutic use of music in direct
work with children. Child and Family Social Work, 9(4), 333–345.
Lim Ah Ken, P. (2007). Children without parental care in the Caribbean: Systems
of protection. Eastern Caribbean: UNICEF, www.unicef.org/easterncarib-
bean/cao_resources_children_without_parental_care.pdf. Accessed July 5,
2015.
Maginn, C., & Cameron, R. J. (2013). The emotional warmth approach to
professional childcare: Positive psychology and highly vulnerable children in
our society. In C. Proctor & P. A. Linley (Eds.), Research, applications, and
interventions for children and adolescents: A positive psychology perspective.
London: Springer.
McIntosh, J. (2003). The inside journey through care: A phenomenology of
attachment and its loss in fostered children. Children Australia, 28(3), 11–16.
Millward, R., Kennedy, E., Towlson, K., & Minnis, H. (2006). Reactive attach-
ment disorder in looked-after children. Emotional and Behavioural Difficulties,
11(4), 273–279.
Murray, J. A. (2001). Loss as a universal concept: A review of the literature to

identify common aspects of loss in diverse situations. Journal of Loss and
Trauma., 6, 219–241.
Narrative Therapy Chicago. (2014). www.narrativetherapychicago.com. Accessed
November 29, 2014.
Newman, T., & Blackburn, S. (2002). Transition in the lives of children and
young people: Resilience factors. Edinburgh: Scottish Executive Education
Department.
Norman, E. (2000). Resiliency enhancement: Putting the strengths perspective into
social work practice. New York: Columbia University Press.
Peake, A. (2009). Life story work—A resource for foster carers, residential social
workers, adoptive parents, and kinship carers. https://www.oxfordshire.gov.uk/
cms/sites/default/files/folders/documents/childreneducationandfamilies/
educationandlearning/schools/virtualschools/Life_Story_Work_Booklet.
pdf.
Perry, B., & Hambrick, E. (2008). The neurosequential model of therapeutics.
Reclaiming Children and Youth, 17(3).
Rees, J. (2009). Life story books for adopted children: A family friendly approach.
London: Jessica Kingsley Publishers.
Rise Magazine. (2009). Putting fathers back in the picture. www.risemagazine.
org/PDF/Rise_issue_12.pdf. Accessed July 20, 2015.
Rose, J. (2010). How nurture protects children: Nurture and narrative in work
with children, young people and their families. Skelmersdale, West Lancashire:
Responsive Solutions.
Rose, R., & Philpot, T. (2005). The child’s own story: Life story work with trauma-
tized children. London: Jessica Kingsley Publishers.
Russel-Bowie, D., & Thistleton-Martin, J. (2002). Let’s get a pup. http://wps.pear-
soned.com.au/wps/media/objects/6853/7018422/Let_s%20
get%20a%20Pup.pdf. Accessed August 4, 2015.
Sogren, M., & Jones, A. (2015). Towards modernising residential care in the
Caribbean. Caribbean Journal of Social Work, 11, 91–112.
Tan, Shaun (2010). The red tree. http://wps.pearsoned.com.au/wps/media/
objects/6853/7018422/The%20Red%20Tree.pdf. Accessed August 5, 2015.
Timmerman, M. C., & Schreuder, P. R. (2014). Sexual abuse of children and
youth in residential care: An international review. Aggression and violent
behavior, 19(6), 715–720.
Trotman Stoby, E. (2002). Social services delivery in the OECS & Turks and Caicos
Islands: A research component of the project: Family law & domestic violence,
legal and judicial reform in the organisation of eastern caribbean states (OECS)
& Turks and Caicos Islands. Barbados: OECS, UNICEF and NCH.
UN. (2010). Guidelines for the alternative care of children, A/RES/64/142. http://
www.unicef.org/protection/alternative_care_Guidelines-English.pdf .
Accessed July 20, 2015.
UNICEF. (2006). World report on violence against children. Geneva. http://www.
unicef.org/lac/full_tex(3).pdf. Accessed August 20, 2015.
UNICEF. (2014). Call to action to end the placement of children under the age of
three in residential care endorsed at 35th CARICOM Heads of Government con-
ference. Panama City, Panama. www.unicef.org/easterncaribbean/ECAO_
PR_Children_in_institutions_CARICOM_Call_to_action_03_07_2014.
pdf. Accessed January 1, 2015.
Van der Kolk, B. (2014). The body keeps the score. Brain, mind and body in the
healing of trauma. New York: Viking.
Waters, E., & Cummings, E. M. (2000). A secure base from which to explore
close relationships. Child Development, 71(1), 164–172.
Wrench, K., & Naylor, L. (2013). Life story work with children who are fostered
or adopted: Creative ideas and activities. London: Jessica Kingsley Publishers.
Wulczyn, F. (2004). Family reunification. The Future of Children, 14(1), 95–113.
6
Art as a Therapeutic Modality
Historical and Cultural Context; Art for
Self-Healing; Art for Communal Healing;
Art for Children’s Healing
Fig. 6.1 ‘Venus’ © Jaime Lee Loy 2008

‘Venus’ is taken from the series ‘Roaches and Flowers: War in the Home’
which investigates violence. … Visually it aims to share with the viewer the
psychological distress and paradox that occurs when something or some-
one so familiar becomes suddenly unfamiliar and threatening … using
items … such as flowers and cooking utensils. These items were then
furnished with nails and positioned in a staged environment. They form
insects and dangerous creatures—representative of the transformation one
endures when living in a sustained hostile environment—you yourself
become hostile and defensive. The image is simultaneously beautiful and
repulsive, a metaphor for the confusing emotions that occur when you are
violated by someone you know or trust (Lee Loy 2008, n.p.).
Introduction
This final section of the book discusses multiple usages of art, and art
therapy, for healing emotional trauma. Several cases are sketched as illus-
trative of practices that work, or do not work, either within the context of
a professional clinical practice or as a part of a wider community setting
where the simple presence of a compassionate guide will suffice.
The discussion is presented by Hazel Da Breo, a psychotherapist in
private practice, and by Jaime Lee Loy, a professional contemporary artist
and survivor of child sexual abuse. Though we hope that our exchange
on these pages will be seamless, we have identified Lee Loy’s first-person
narrative in italics in order to privilege the artist’s voice.
The Historical and the Contemporary-Culture

and Context
Throughout history, from one culture to the next, art has been used to
illicit memories, dreams and emotions that may have remained buried
in the subconscious realm for ages. By medium of visual images, dance,
song or any number of art forms, emotions become dislodged from their
shadow land and sent swirling to the surface, often causing trouble as
they ascend. Throughout time, art has also been used strategically and
politically in order to mould the attitudes, behaviours and images of a
6 Art as a Therapeutic Modality 283
populace. Liturgical art, beginning with the early Christian church (circa
300 AD), provides a good example. Here, illuminated manuscripts,
mosaics and stained glass were some of the methods used to invoke spiri-
tual submission to the power and glory of God. ‘Liturgical celebrations
need to involve the whole person: body, mind, the five senses, imagina-
tion, emotions, memory … while the environment must be beautiful
to look at … to focus worshippers’ attention on the central event of the
liturgy’ The Liturgical Commission (2004).
The art of the African drum provides another example in the case of
legendary Angolan slave, Cato, whose coded rhythms steadfastly urged
hundreds of slaves to run like the wind away from oppression and death,
towards the freedom of the Underground Railroad to Canada, in the
early 1700s. Further South, in yet another culture and time, the art of the
Mexican Revolution (1910–5) demanded a new visual language in which
painters, poets and politicians alike were encouraged to take up a lingo
that was purely, unambiguously nationalistic. With Mexico’s illiteracy
rate nearly at 90 % at the time, the three great muralists (los tres grandes),
Rivera, Orozco and Siqueiros, were commissioned by the government
to paint explicit, realistic narratives that the grassroots population could
freely access and relate to.
Rivera’s murals were a total divergence from the art of his time, and they
were hailed by Soviet poet and renegade futurist Vladimir Mayakovsky as
‘the world’s first communist frescoes …’ The artists played an instrumen-
tal role in building up a national identity. Their murals found inspiration
in the visual remains of the Catholic conquistadores and the wall paint-
ings of Aztec culture in an artistic vocabulary that united the complex
histories of the Mexican people. The actualisation of these scenes in the
form of the mural served a social purpose—to establish a public, unre-
stricted dialogue (Von Wiegand n.d.).
There is also the contrary argument that art has no purpose, per se,
but that it exists purely for its own sake alone. An artist may be moved
to capture a sunset, a group of children at play, a nude or a still life
simply because that is what stirs them in that moment and time. In the
Caribbean, although many contemporary artists uphold the art-for-art’s-
sake position, there are more who believe that artists’ priority is social
responsibility. A quick survey of Caribbean art over the past decades
provides us with Edna Manley’s sculptures, of which Negro Aroused

(1935–40) and The Dying God Series (1941–8) represented a search for a
new political order in Jamaica, a vision of her people awakening to a new
consciousness (Jamaica Information Service, 2015). Dany Laferrière is a
Haitian novelist whose first novel, How to Make Love to a Negro without
getting Tired (1987), is ostensibly about a Caribbean man wandering the
streets and slums of Montreal making love to white women, but also
works as a provocative political commentary on interracial sex. It is, as
Laferrière has remarked, ‘the story of a young man who has acquired a
culture he was never meant to have; he covets that culture, he wants you
to know he’s acquired it … but he doesn’t want to lose his identity in the
meantime … he has a distinctly critical eye on the new culture around
him, even as he is trying to move into it’ (Laferrière 1987, 9). In I am
a Japanese Writer (2011), Laferrière delivers a part postmodern fantasy,
part Kafkaesque exploration. While posing as an art-for-art’s-sake oeuvre,
he again throws out seductive political musings and calls into question
everything we think we know about how art is made and defined.
Moving to performance art, Jaime Lee Loy describes a Chinese artist,
this time working in Trinidad and Tobago, 2006, who strongly chal-
lenged notions of what art is and what purpose it serves, if any.
While participating at the ‘Big River’ workshop in Trinidad, Yingmei Duan,

an artist from China, conducted a performance about her experiences visit-
ing the Caribbean in 2006. She jumped frantically while slapping her legs
in the street outside the exhibition space, while viewers were watching the
show inside, and at the end during social festivities. Yingmei meant to con-
vey the discomfort she felt when bitten by mosquitoes, simultaneously com-
menting on discomfort in general and on the frustration of poor
communication as she spoke little English. Comments were mixed and per-
sons not familiar with conceptual work insisted that this was not art. As a
contemporary artist living in Trinidad, I witness that this question is still
debated at exhibitions where newer mediums and processes are used. Some
audiences are adamant that art must take time and may be unwilling to
accept work created in mere seconds. Others are stringent about medium,
message or the qualifications of the creator, even insisting that it must result
in a commodity that can be sold.
Art and the Psyche
To psychodynamic or psychoanalytic psychotherapy, the question is all
the same. Whenever someone or some group—professional artist, child,
Church or State—produces an image, film or narrative describing what
is on their mind or within the scope of their gaze—landscapes, instal-
lations, menacing dreams or symbols from mythology—it begins with
what has been stirred within themselves. The art object stands in as a
projection of what first came up from the subject’s own soul and, in its
making, has its own story to tell. For each time that we randomly spin
the globe and allow our gaze to fall upon any place, in any time, we are
sure to find evidence of how art is used by all peoples to define social or
political movements, transform cultures and selves, and make us feel. Art
moves us collectively and individually, to tears, to worship and to war. Art
has built us up and torn us down; those wanting to cripple nations have
known to reach first for their art and architecture to shatter.
Every year in August, sections of Grenada’s population erupt into the
writhing, chanting, greased-down mob of humanity known as Jab Jab, the
most deliciously feared band of any Carnival parade. It is appropriate to
acknowledge Carnival as the cultural phenomenon that it is and, in this con-
text, the massive transformative properties that it carries on very many levels.
Many cultures throughout history have arranged for their populace to
put a halt to all mundane responsibility, close down shop for a week or a
day and become absolutely anything they want to be, within an absolutely
non-judgemental cultural container. It is only required that at the end of
the stipulated period of ‘mas’ each performer re-integrate him- or herself
into the healthy social functioning from which she came. (This is a lot
like what a psychotherapist seeks to provide in her clinic or an artist in
her studio.)
Carnival’s roots stem in part from the Dionysia. The Dionysia was a
festival in ancient Greece in honour of the god Dionysius, also called
Bacchus, and from which we in the Caribbean get Bacchanal. During
this five-day springtime festival, there was great rejoicing, and even pris-
oners were released to join in.
Dionysus was both a merry god (symbolized by a phallus) who inspired

great poetry and a cruel god; the Greeks realistically saw wine as something
that made people happy and also made them drunk and cruel. Thus, like
the god, his festivals seem to have combined contrasting elements of poetry
and revelry. The (festivals) were bawdy affairs held in December or January
at the first tasting of new wine. Besides dramatic presentations, there were
processions of slaves carrying the phallus, the singing of obscene lays …
processions of jesting citizens through the city and dramatic presentations
(Columbia Electronic Encyclopedia 2015, n.p.).
Our Caribbean carnival is also rooted in French pre-lenten festivities

(beginning early 1200s, Nice), in which there was a frantic excess of
feasting, drinking and making a mockery of everything (Church, State,
bosses, neighbours) from behind the respected anonymity of masks.
And Africans have traditionally used masks for many more purposes
than hiding one’s ribald and inappropriate behaviour during the baccha-
nal (or hiding one’s shadowy emotions, in psychological terms). With the
oldest found African mask dating to 7000 BC (www.historyofmasks.net),
masks were used to communicate with ancestral spirits or animal spirits
or to scare away the enemy, among many other usages. Caribbean carni-
vals generally take from all of these traditions, including others brought in
by the many diverse cultures making up this region. Grenada’s Spicemas
festival and Trinidad’s j’ouvert, for example, both reference Jab Jab as a
transformative cultural experience. The smearing on of pre-dawn mud
(Grenadians prefer old oil—they are the Black Jabs, whereas Trinidadians
prefer mud or paint) recalls a return to the original Eden; a provocative
and sensuous primal mud from which we wriggle and thrust our way
to fresh new life when the sun rises over jour’ouvert, a symbolic brand-
new day for all masqueraders, or at least for all Jabs. Jab is the French
patois for Diable (Devil), and Molassie is the French patois for Mélasse
(Molasses). The Jab Molassie is one of several varieties of devil mas played
in Trinidad and Tobago Carnival. This type of devil is often smeared with
tar, grease, lard and/or various dyes (most often red, green and blue).
Errol Hill describes the Jab Molassie as a ‘leaping, prancing, masker, his
body daubed with black or blue paint, sometimes with molasses, who
threatens to besmear spectators unless they pay him off’ (Hill, http://www.
traditionalmas.com/project/jab-molassie/). Certain Jab Molassie will

adopt aspects of other devil mas, such as ‘the beast’, incorporating the use
of shackles and restraints to hold back one of the devils in the group. The
use of metal restraints and shackles has also been linked to slavery and, in
combination with molasses and soot, as a reference to ‘the treatment of
estate gangs in route to a cane fire’. Jab Molassie are among the wildest
masquers seen in Trinidad today and one of the few traditional mas styles
still actively played. The dancing and performance of the Jab Molassie
are often accompanied by steel drums (as opposed to the tonal steel pan)
made of found items, such as fired biscuit tins (http://www.traditionalmas.
com/project/jab-molassie/).
This section of the book aims to speak of art and about how it is used
for therapeutic purposes within the Caribbean. We would have been
remiss not to begin with Carnival, which if nothing else is the ultimate
canvas, upon which every man, woman and child is equally invited to
shed all bottled up and repressed states of being, to be as bad as they can
possibly be, no questions asked and then to recreate life anew. As the late
Trinidadian painter Boscoe Holder often said to me when I worked with
him in Toronto, ‘Oh God, child. Queen Victoria has made a mess of
my people and shut us down in a closet. We have to wait to make a ‘mas
before we can get out!’
Art as Therapy
At this juncture, we turn to conversations on how art may be used
as therapy for individuals and small groups, with a focus on how art
is therapeutic for victims of child sexual abuse. Whether art is to be
used by professional therapists or artists in clinical settings or simply
accessed by teachers, parents and other caregivers to help troubled souls
self-express, it is understood that art has particular therapeutic value
among Caribbean people, who intuitively, historically understand how
art makes us feel.
Note that neither Da Breo nor Lee Loy is a professional art thera-
pist. Da Breo is a professional psychotherapist who uses art as one of the
modalities in her tool kit. Da Breo directs the Sweet Water Foundation
in Grenada and Toronto, where the R.I.S.E. programme for adolescent

girls who have experienced sexual abuse is housed (see Part 2). There,
art makes up a significant portion of the 14-week curriculum. Lee Loy
is a professional contemporary artist and writer living in Trinidad and
Tobago. She says:
As a survivor of both sexual and domestic abuse, I have pursued art for my
own professional and personal use. I am not a professional art therapist, psy-
chologist or academic, and when conducting workshops using the expressive
arts, I hire the services of a licensed professional. My references here are from
personal experiences and observation. Art is universal. It can communicate
and be expressed despite language barriers and the passing of time. It has the
power to heal the artist/creator as well as its audience. Here, I draw on my
own experiences and artistic methods as well as those of children I have
worked with in art programmes. I focus on the ways in which artistic method
and process have positively affected the way in which I and others have coped
with and transcended various forms of trauma, including that of sexual
abuse. Sexual abuse is a type of violation that is extremely personal and inti-
mate. Often it is committed by someone that the victim trusts, and if the
aggressor is a stranger this type of abuse can still affect the victims on a very
personal level. I have chosen to include examples of those who suffered abuse
by parents and lovers as the psychological effects are oftentimes extremely
intense, but the use of art can assist towards healing outcomes.
A Survivor’s Story
I grew up with a single mother, as my father died when I was three years old. I
am extremely close to my father’s side of my family. Most of my formative years
were spent with neighbours and relatives, as my mother’s increasing mental
illness led to physical/verbal abuse and neglect. Home became a place I spent
alone or afraid. I spent long periods of time being raised by other people. During
those early years, I was exposed to abuse of a sexual nature. The abuser was con-
stantly in my home, and although he was not violent he would participate in
indecent touching and groping and view me naked against my will. When it was
brought to my mother’s attention, I was accused of lying and the abuse contin-
ued. The lasting effects were severe, as it continued for years and I lived in a
constant state of fear doubled with the already hostile environment in the home.
To this day, my experience is regarded as a lie and ‘if it is true’ I am told I am

wrong for feeling anger—that if I do not forgive, the pain I feel is of my own
doing and my fault. The perpetrator has convinced them that I am lying.
Although this is something I have struggled with for most of my life,
I have suppressed the memories and express myself mainly through art. I
have relied on feedback from childhood friends, as I remember little and
the specific details are a blur.
I had never confronted the abuser or demanded anything other than
personal distance. This would not have been a situation to ‘deal with’ had
they also left it a secret, but more pain was caused by reactions of those I
loved than the violations themselves, and it was that atmosphere that
allowed the effects of the violation to exacerbate. Bottled emotions sup-
pressed for over 20 years emerged, and I began to build the courage to
express it in my art and to speak about it in chosen settings. Prior to this,
my art would express feelings from this situation, but I would always
fictionalise it in order to keep the secret hidden to public audiences.
Fig. 6.2 ‘Still’ © Jaime Lee Loy

I have always been artistic, even as a small child. I would constantly draw,
and in primary and secondary school, my art had already begun to reflect
my living situation at home. I was labelled as ‘troubled’ as my art frightened
fellow students. Even to this day, my art can make others uncomfortable.
Prior to looking at how art may be used as a form of self-therapy or

as a professionally prescribed clinical modality, it is important to recognise
that Lee Loy’s situation is not unlike the situations of many Caribbean
children who are left to fend with sexual abuse in their own homes. Many
children are raised in single-parent families, as absentee fathers pres-
ent a normalised pattern in which child-rearing responsibilities are left to
women, for a variety of reasons. Although Lee Loy identifies her mother
as subject to increasing mental illness and although no research has been
done into the clinical mental health status of Caribbean mothers who fail
to protect their children from abuse within the home, one can neverthe-
less identify with women who struggle alone with the demands of child
care. And although a general holistic and systemic approach to child
sexual abuse prevention must include supports to mothers as they strug-
gle with various aspects of the very rigorous business of child rearing,
every single mother, struggling or not, has had moments of utter fatigue,
self-doubt and despair while tending her babies. Yet for children who have
been violated at home, their disappointment with mothers who failed to
protect them is tangible and has lifelong repercussions. ‘I don’t believe she
never smelled the smell of his ejaculate when she came into the room’, one
victim of incest told me. ‘It was there, fresh like old fish. There’s no way she
didn’t smell it and know what it was, yet she never asked a question. I won-
der if she was mad for herself’. Said another one, ‘Forget therapy, I’ll never
be able to trust another woman as long as I live. Women don’t care about
each other. Especially if something bad happened to them before, they’ll just
be glad it’s your turn now, and they’ll watch to see how you handle it. Sick’.
So, apart from a generalised sense that mothers who fail to protect their chil-
dren from chronic incest must be ‘mad‘, there is the additional consideration
of mothers who do have a recognised mental health condition but who are
left to struggle with child-rearing alone. Family, friends, colleagues and social
workers surrounding parents with poor mental health must systemically visit
and support them, in much the same way as we routinely visit the old and
the infirm in our communities. It is urgent to ensure that the needs of the
children in the family are being met and abuse is not perpetrated or silenced.
It is also crucial to note that Lee Loy says I have suppressed the memories
and express myself mainly through art. I have relied on feedback from child-
hood friends, as I remember little and the specific details are a blur. Childhood
traumas are very often suppressed. At a recent visit to a primary school just
after the Easter holidays, children were invited to sit in circle and share
stories of their holidays. They vied with each other for best recounts of
happy times spent at the beach, on hiking trails, at home with Grandma
and so forth. No child rushes to publicly disclose their violations and hard
times. In fact, it is often in a victim’s mature years that he or she feels con-
fident enough to come forward and make their revelations.
One of the functions of art, and art therapy, is to catalyse the movement
of deeply buried traumas out of the darkness and up towards the surface
where they can be seen, named and transformed. In the Caribbean, art ther-
apy is particularly apt as our children have art and culture around and about
them as a part of their daily life experiences. However, art is used for self-
expression anywhere in the world that a child reaches for crayons or paint.
Art as a Form of Self-therapy

Art can communicate better than words. In one of my art workshops, there
was a young girl at the age of eight who wanted to share her feelings about
her father’s second marriage and the fears she had about a stepsister that
was not yet born. She began describing how she felt and then asked me if
she could invent a story instead. Using paper and pencil, she drew a family
unit of stick figures to represent her mother, her father and herself. She
then marked an X over her mother and herself, leaving the father present.
In her next drawing, she drew her father and a baby girl and also drew
herself, but this time she drew herself on the far end of the page with a
thick line separating them.
This example relays how children are often unable or unwilling to speak
about their feelings and how using methods that are familiar and comfort-
able such as drawing can benefit both the one communicating and the one
who is trying to relate or understand them. She successfully expressed that
she felt she would no longer exist or be important to her father once he had
another child. However, it was difficult for her to verbalise it. When we
expect someone to describe their feelings in words, it can be difficult not
only because what they feel is intense but because they may not fully
understand what they are feeling. Expressing emotion demands self-
analysis, and often the person trying to communicate may feel a mental
block, emotional numbness, or a surge of diverse emotions that can become
muddles. They may also say ‘I feel sad’ but not divulge further.
Summer Heroes
‘If you were a superhero what would you look like? What would your
special powers be and what would you do with them? Who would your
secret super hero identity be?’ These simple questions are the basis of
a therapeutic summer arts programme Lee Loy has developed for chil-
dren in Trinidad. Titled ‘Summer Heroes’, the programme uses art
approaches and original creative activities that are therapeutic in nature
and that promote self-healing and personal development (www.summer-
heroestt.com). In its launch year 2012, Lee Loy and her team worked
with 124 participants from 16 children’s homes and centres. ‘The results
were amazing. … All participants shared their secret super identities with
us and gave us the opportunity to enter their worlds, their minds and
ambitions—and we realised that these amazing young people were very
perceptive about their country and its needs, and despite many of them
having lived through harrowing and abusive situations, they were all able
to identify their personal strengths and a desire to help others’ (http://
trinidadhomestudio.com/charity/summer-heroes/).
‘Half Woman’ is a superhero avatar created by a 10-year-old participant in

my Summer Heroes art programme. Half Woman had a line drawn verti-
cally through the centre of her body, with one half of her face smiling and
the other half of her face full of tears. Her avatar description included ‘I
have super counselling powers to help others cope emotionally. I can read
other people’s thoughts to know when something is wrong’. After further
sessions, it was revealed that this participant was removed from her family
home and separated from her siblings, who were placed in different chil-
dren’s homes. She often kept up an upbeat exterior to motivate her younger
Fig. 6.3 Volunteers and children at the 2013 Summer Heroes Workshop
© Jaime Lee Loy (2013)
friends and felt at times that she could not speak about her pain or
frustration. She wished for someone to confide in and valued her role as
someone others told their secrets to. She felt torn literally in half by her
desire to be liked by others and her desire to speak about her pain, and this
was something she could not articulate in early sessions. The development
of her avatar and subsequent activities helped her to eventually express in
words what her drawings articulated with ease.
‘Half Woman’ had already shared details about her reality, but she
expressed more effectively when using fiction. While at ‘play’, she would
share more precisely how her superhero felt and the situation the superhero
and her hero’s advocates would feel after being helped. She was more
confident to speak about herself when pretending it was about someone
else, and she did this through her creative process.
This Half Woman scenario raises several points pertinent to the visual
art medium as a potentially safe receptacle for anxieties. Notice that the
young girl asked the facilitator whether she could ‘invent a story instead’.
Invention assumes that the stories are not based in a pre-existing reality
but emanate freshly from the mind of the subject. Therefore, the girl
knows she cannot be caught and blamed for anything she manifests on
the page, nor would she be obliged to answer any questions about her
Fig. 6.4 Half Woman © Jaime Lee Loy (2013)
drawings. This is a very positive usage of projective identification, which

we discussed earlier in Part 2. It is always helpful for children (or adults)
who are suffering anxieties and traumas to transfer the bad feelings out of
their own psychological systems onto a safe, non-judgemental, external
source (such as any art form); art will not argue back or challenge, but
simply allows the bad feelings to come as they will. If the subject is a child
who has experienced sexual abuse, the images she conjures may be dark
and troubling, even for art instructors or anyone else privy to what she
draws. This introduces another scenario in which projective identifica-
tion may have a harmful effect, not on the part of the subject but on the
part of the persons (re)viewing the work.
In this story, the subject ‘wished for someone to confide in and valued her
role as someone others told their secrets to. She felt torn literally in half by her
desire to be liked by others and her desire to speak about her pain, and this was
something she could not articulate in early sessions’. What if instructors of
art classes where children reveal deep psychic pain are themselves victims
of childhood trauma they have never expressed? Projective identification
also works upon anyone within the purview of an art object, as art causes
us to feel. Witness the full range of responses to public art which is cre-
ated by others for public consumption. Along with the examples given at
the start of this chapter, also consider the silent, contemplative visitors to
mainstream art galleries and museums around the world; tearful patrons
at film noir screenings in cinema, the mad rush to put down billions of
dollars in purchase of the recent runaway literary success Fifty Shades of
Grey (James, 2012) (although many artists will argue that this book is not
‘literature’, this is a discussion for another time). So if an art instructor
witnesses a child manifest a drawing which seems to depict a tragic scene,
the adult instructor may unwittingly project her own pain upon the art
and subconsciously begin to seek a resolve for her own psychic distress
while positioning that distress as the child’s. The instructor may become
very depressed, angry, over-protective or punitive while pretending (or
genuinely projecting) these feelings as coming from the child. If it is that
a sexual abuse appears clear in the drawings, the instructor may set about
urging the child to disclose who it is and how it was and to take steps to
tell on the perpetrator and catch him up. This exchange does not indicate
malicious intention on the part of the therapist; this is the thing about
repressed trauma: it acts upon the subject subconsciously and will find a
way to leak out in usually inappropriate circumstances unless dealt with
effectively in some sort of therapeutic setting.
And how does the child in such a scenario react? Perhaps with abso-
lute horror, perhaps with re-withdrawal into betrayed stupefied silence,
perhaps with a firm promise never to self-express again. In the rarest
of cases, a child may be relieved to have her story exposed in this way.
All children who are being abused desperately need the abuse to stop,
but the integrity of the victim needs be protected as a primary concern,
every time. Every time. When ‘truths’ are yanked from the pages of art
books and journals in a process of transference and counter-transference
between instructor (or therapist) and child, opportunities for confidence
and trust are destroyed, replaced instead by pure chaos.
We are not experts telling clients what their work means. There can be great
pressure, from clients and colleagues, for interpretations of art. Historically,
there has been a notion that a cure can be generated by the application of a
correct interpretation. When the therapist is involved in interpretive moves
with the art, it may be experienced by the client as a kind of disempowerment,
as though she were deemed incapable of creating her own representation
and body of meaning. Interpreting art through an objective, distanced and
dualistic perspective needs to be resisted (Halifax 2003, 43).
The issue of mandatory reporting, which is a new legal phenomenon

for many Caribbean states, now comes to mind. Our statistics of child
abuse are so high that intentions to catch and punish perpetrators are at
an all-time fever pitch. However, while the tenets of the law are adhered
to, the sanctity of the child victim still needs to be upheld as a priority.
If, under the auspices of instructors or therapists, tentative disclosures are
committed by victims to canvas and these disclosures are snatched away
from the child’, more harm will be done than could be repaired any time
soon.
Journaling is another projective identification methodology. Many
creative arts retreats worldwide use journaling as one means for encour-
aging psychic darkness to come to light. Adults wrestle with confusing
imagery from dreams, intrusive memories or glimpses of voices from the
past. The method is every bit as good for children as it is for adults.
But this is an area where privacy is really risked. Many adolescent female
victims of child sexual abuse that I work with, both in the Caribbean and
in Toronto, and to whom I have given journals as one means of coping
with painful feelings have given the journals back to me with unfortunate
stories of facing further violation when their disclosures were discovered
by family members. Lee Loy has mentioned earlier that ‘more pain was
caused by reactions of those I loved than the violations themselves’. In
one art class at Sweet Water Foundation’s R.I.S.E. programme, a girl
drew a picture of a pair of lips, sewed tightly shut with a zipper. Once
having told that her stepfather had been making it a habit of raping her
in the night and once the family had viciously berated her for her ‘lies’,
her bedroom was consistently searched for journals, notes, schoolbook
narratives, drawings or any expressions that might offend other family
members. It was week 10 of a 14-week programme at R.I.S.E. before this
young lady trusted the group enough to speak about her real feelings. Lee
Loy comments:
As a facilitator of art programmes where the focus is one of expression and

not artistic excellence, I must highlight how critical an atmosphere of
acceptance is when working with children or other clients. All pre-
conceived notions of the validity of art or any of its forms must be
abandoned. Art becomes a vehicle or method for someone to communicate
feelings, thoughts and ideas, with the appearance or end product as a non-
valid goal. For example, during a drawing exercise with children from a
local children’s home, caregivers submitted drawings they thought to be
skilful, dismissing those they believed to be amateur. Although they were
briefed on the purpose of the activity as one of self-expression, they
neglected those they felt unworthy of submission. At another centre, the
head supervisor remarked that some of the drawings were ‘too dark’,
lamenting that the negativity expressed by the children was a ‘bad thing’
and therefore should be omitted. The participants who noticed the attitude
of their caregivers refrained from communicating visuals they feared would
be judged. Only when they were left alone with trusted facilitators did they
reveal their honest feelings.
In the Summer Heroes programme (discussed earlier), I worked with
one seven-year-old boy who drew ‘Super Boy Lightning’, a superhero
avatar he created based on his interpretation of his actual identity and
based on his aspirations of a more powerful self. During the exercise, this
boy would constantly erase his drawing and become displeased when it was
not ‘perfect’. Facilitators were sensitive to this and had to guide him to
focus on his imagination and dissuade him from casting his own judge-
ments or insecurities about what he was creating.
The potential for the inadvertent re-victimisation of a child subject dur-

ing art making is one of the reasons for which the formal discipline of art
therapy was brought into being. As Lee Loy observes, it must be noted that
art therapy is a term reserved for art therapists who are licensed psychologists or
psychotherapists and who are trained to use specific art activities with clients
usually on a one-on-one basis. In this clinical setting, the therapist may be able
to diagnose mental illness or use their findings to deliver a strategic programme
aimed at assisting their patients. In this setting, the art produced is extremely
confidential and the objectives will strive for more than mere self-expression.
However, educators, parents, caregivers and subjects themselves
can incorporate art-based activities when pursuing or aiding others in
self-healing. Art work is especially beneficial for young children and
children with cognitive delays who may have difficulty with verbal cues
and interaction. Children are naturally more playful and visual and
eager to interact with craft. When art is used for personal reasons, be it
for stress relief, practice or creative expression, it is the process that is
of utmost importance. The moments during creative play are crucial,
especially for those who are dealing with trauma, repressed memories
and emotion and who have problems communicating with others or
understanding their feelings. It is less about the creation and more
about the creating.
Psychotherapy and psychoanalysis find equivalent meaning in art
that is private or public. The art of socialist realism, which developed
in the Soviet Union, became dominant in many socialist countries, and
had a profound impact upon many artists in the Caribbean and Latin
American region (e.g., Mexico), is an art which glorified depictions of
communist values in a realistic manner. One of the socialist realist’s
primary advocates, Anatoly Lunacharsky, who was head of the Bolshevik
People’s Commisariat for Enlightenment (Ellis 2012), advised that ‘The
sight of a healthy body, intelligent face or friendly smile was essentially
life-enhancing’ (Ellis 2012, 21).
We may argue that this type of realism is not, in fact, faithful to the
realities of many but rather represents a desired reality, designed by those
who have an interest in shaping the sensibilities or zeitgeist of a given
culture and time. Other examples include the Catholic stained glass
narratives referenced before, the portraiture of the Renaissance, and the
Black Power movement in America, to name just a few. We may also
argue that each and every artist working for women’s fashion magazines
can fall into this category of strategically constructing images which pro-
foundly affect a culture’s views on what reality ought to look like.
Butoh is a form of Japanese dance theatre, arsing in the 1950s as a

response to World War II. Common features of the dance include absurd
or extreme environments, grotesque movements and taboo subject mat-
ter. Originally called ankotu butō (dance of darkness), dancers perform
nude and in white paint, expressing physical and psychological decay and
the transmutation of the human body (and spirit) into other forms.
Unsurprisingly, Butoh is employed as a psychosomatic therapeutic
modality and has been taught in mental hospitals in Tokyo to excellent
effect. Although Butoh dance is a performing art shown in front of an
audience, Butoh is also keen on what is going on internally in the dancer’s
mind–body rather than how his or her body appears to the audience.
Apart from the choreographed movements for a stage performance, the
on-going process of mind–body interaction is most significant in Butoh
dance. Butoh dance and its training method can be used for psychoso-
matic exploration and integration because it enables people to live their
own naturally arising emotions such as anger, depression, sorrow, fear,
joy and so on—the suppressed emotions that are socially thought to be
Fig. 6.5 Velez, dance of darkness series. © Edin Velez. (Work in progress. Large-
scale glicee photographs of Japanese Butoh dancers) (www.edinvelez.com)
unwelcome under certain circumstances—by actually occurring bodily

reactions of spasm, unintentional jerks, tremor, facial or bodily distor-
tion, falling down, stamping, rolling on the floor and so on. Butoh also
gives an opportunity for our aesthetic or spiritual sentiments to come
out from the forgotten layer of our mind, and it often becomes a soul-
purifying experience (Kasai 1999, 311).
As therapeutic as performing or experiencing Butoh may be, the
art form often has a jarring effect on the audience. Clients of mine in
Toronto have told me that they found the performances so obscene they
wished they had the nerve to run up on stage and attack the bodies there.
Whether we want to acknowledge the reality of the pain and suffer-
ing of humankind or not, what emanates from the soul speaks the soul’s
truth. We look if we have the guts to, or we can turn away. Another
option is to rip up, burn down or hack away those representations of real-
ity we cannot tolerate, and history is rife with such examples too. What
type of art is a trauma survivor likely to produce? What representations of
reality are children who are being sexually abused going to draw?
In the examples given by Lee Loy and in many other cases around the
Caribbean and elsewhere, some caregivers are horrified at dark images and
stuff them away. Needless to say, this is yet another method for silencing
victims of abuse, and whether those caregivers intend it or not, silencing
is equivalent to ripping up or burning down. And it is equally as unfortu-
nate for the caregivers, who, perhaps already repressed, are missing another
opportunity to engage with their own shadow and bring it to light.
One supervisor of a children’s home recently came up with a scenario
that seemed to suit the best of both worlds. As she faced an audit from
donors who wished to tour the residence prior to releasing the next
tranche of funds, caregivers installed an impromptu gallery of drawings
the children had been working on for months. During the preview, the
manager came across some images she could only describe as ‘Horrible!
Terrifying! You mean to tell me we are raising a set of demons inside of
here?!’ She ripped the offending images off the walls so that the image of
her establishment met with the criterion she thought she needed as a mat-
ter of securing financing: see the happy children here. However, she kept
the troubling images and contracted a therapist to work with the children
who had authored them, behind the scenes. Joy Schaverien reminds us
that inter-generational trauma may also be at play whenever parents or

caregivers react disproportionately to the expressions of young artists. She
says ‘we know that traumatic experiences may continue to have psycho-
logical consequences beyond the generation immediately affected. … We
know that there are times when what has been experienced by one gen-
eration cannot be assimilated by the individuals of that generation. In
such cases trauma may be transmitted, through unconscious processes,
to the next generation’ (Schaverien 1999, 57).
Fictionalising Painful Truths

Art can facilitate the communication of details that are too painful to
address using a confessional approach. I can read poetry to friends and
family, stand at public forums and talk about my work yet only hint that it
touches on real experience with a mix of fiction. My audiences are aware
that the experiences I am relating bear some truth, but they are never quite
certain to what extent unless I tell them. Even in instances where 99 % of
what I have expressed is true, the audience will always doubt what parts are
real and walk away knowing only the feeling and connection they shared
with me which is my intention. I can share a very painful experience, even
indulge in all of the delicate details, without the fear of being victimised
further by an overwhelming feeling of vulnerability. Likewise, the audience
can appreciate the work with an understanding that it has a concrete
reference, yet they are not distracted by the reality. In knowing that some
of it is fiction and some of it is real, they can experience the work as pure
art and at the same time grasp its intensity.
The medium of art creates a safety barrier between myself and the
audience and sometimes even between myself and the pain. I can often
focus on the beauty of the visuals or the words used in poetry, rather than
what the work conveys, while I communicate about an event or emotion.
In my short story ‘Bury Your Mother’ (see Lee Loy, 2008), I exaggerated
the story for fictional purposes. My editor was insistent that I include a
motive for murder as the story was published in a noir collection. In the
story the protagonist is raped. These alterations to the truth that allow the
story to become fiction also allow me to include events exactly as they
happened in the story while hiding them as fiction. The following is an
excerpt detailing a true event.
The protagonist (me) has run from the bathroom to her mother’s room
to retrieve a towel that she has forgotten. She is unaware that her mother’s
boyfriend is in the house. She freezes naked in front of a mirror and for two
minutes he stares at her, smiling. The mother explodes: ‘Why you always
trying to make me jealous boy?’ She shakes her head and turns to me. ‘As if
you are anything compared to me. Next time, bring a damn towel with
you. You know the man have keys.’
And further into the scene:
‘Parker is this little girl you watching? Don’t let her get to you’. And just
like that he slips outside. No spectacle. He just oh-so-slowly disappears
behind the door, saying, ‘You getting big fast’. Making a subtle sucking
noise, ‘Aye, Marie?’
In the film version of this story, there is a scene where the girl is writing
over the walls of her room and on her body in frustration and moments
where she rocks herself back and forth for a long time. In one scene, she is
ripping family photographs and in another her mother is having a violent
meltdown.
Art allows me to look at myself in the third person. I can almost pretend
I am speaking about someone else. When experimenting with materials
and playing with concepts built around my feelings and emotions, the art
process allows me to fictionalise myself—to myself. This is important
when dealing with something so intense that it can emotionally unravel the
artist producing the work or the person dealing with the trauma. It is not
only about masking to create distance from others, but a way of creating
safe distance from the reality of the pain.
Scapegoating
When we first spoke of projective identification in Part 2, we likened it to
scapegoating. Let us look at the notion of scapegoating again. Although
it often has negative connotations of laying wrongful blame, it can in fact
have a very positive purpose, as originally intended.
In the Book of Leviticus, on the Old Testament laws relating to sacri-
fice, scapegoating is described as a religious ritual in which an object is
made to take on the sins of a family or tribe and then is cast out, leaving
the tribe free of blemish again.
‘And Aaron shall lay both his hands upon the head of the live goat, and
confess over him all the iniquities of the children of Israel, and all their
transgressions in all their sins, putting them upon the head of the goat,
and shall send him away by the hand of a fit man into the wilderness’
(Leviticus 16:21) The Holy Bible, 2000.
This archetypal Jewish theme is one we often see played out in dys-
functional modern families. If one very sensitive member of a family or
team visibly breaks down under the emotional pressure from other family
members who are abusive but appear more strong, the sensitive member
is made to carry the brunt of the entire family’s grief and dysfunctional-
ity. ‘Look at that boy!’ they will say. ‘He’s not right in the head! He drives
the rest of us mad!’ Female victims of domestic violence and child victims
of sexual abuse are often scapegoated in the same way. Abusive heads of
homes keep victims oppressed and silenced and this invariably leads to
acting out or other neurotic behaviours on the parts of the victims, at
which point the oppressor can triumphantly claim ‘Look at you! Mad!’
and escape without blemish.
Schaverien (1999) describes how this metaphor informs analytical art
psychotherapy, whether we are looking at individuals or whole societies.
Unwanted or rejected elements of a society get blamed, scapegoated or
projected onto. We have heard of ‘lazy blacks’, ‘dumb blondes’, and in
Schaverien’s example ‘The experiences of the Jewish people in Germany
in the 1930s was an extreme example of scapegoating carried to its ulti-
mate conclusion’ (Schaverien 1999, 60).
Within analytical art psychotherapy, acting out is encouraged.
Projective identification is a tool which is put to very positive purpose
when a suffering person is given access to expressive art, whether they are
conscious or unconscious of the source of their buried pain and how it
will manifest in paint or song.
The picture may become embodied with previously unconscious, or partly

conscious affect, and so, like the scapegoat, it holds this separate from the
person. The artist may be in a state of identification with the newly created
image. This is followed by a series of processes through which separation
gradually begins to take place. There is a gradual familiarisation with the
pictures content, acknowledgement of its multiple meanings and eventu-
ally assimilation of the import of these. There is an alteration between
active and reflective processes. A picture, embodied with affect, offers the
opportunity for the enactment of a full scapegoat ritual, in its original
sense, including disposal. … Pictures offer a means of mediating … and
permitting expression … because there are some experiences which are lit-
erally unspeakable … (but) need an outlet (Schaverien 1999, 61–2).
Sandplay Therapy
Sandplay therapy is another pictorial means of allowing clients to come
into contact with their own mental and emotional processes, with mini-
mal input from the therapist. The premise is that just as the physical
body has the inherent capacity to heal itself if provided with optimum
conditions, so does the psyche self-regulate in environments that are safe
and non-judgemental. In sandplay, the client works with miniature figu-
rines in a tray that is approximately the size of a kitty litter box and that is
filled with sand and perhaps a little water. The figurines may number in
the thousands, depending upon the size of the therapist’s practice. They
will include figures of ‘normal’ dads and moms, boys and girls, domes-
tic animals and the accoutrements of everyday life, such as living room
furnishings and children’s toys. There will also be figurines that are sym-
bolic of psychological states, such as a volcano, tidal wave, ghost, demon or
ghoul. And there are figures from myth and legend, such as wizards, fairies
and pirates. In other words, a well-tooled kit should include ‘a breadth of
symbolic objects necessary to create a world’ (Weinrib 2004, 12).
In my Caribbean practice, where formal sandplay figurines are not
available unless ordered from abroad at significant expense, I supplement
my collection with found objects which clients may use as representa-
tive of people or things: coloured stones, sparkly seashells, strangely bent
twigs and so forth.
… the client creates a concrete manifestation from his or her imagination

using sand, water, and miniature objects. In this way, Sandplay helps honor
and illuminate the client’s internal symbolic world, providing a place for its
expression within a safe container (www.sandplay.org).
Originating from a meld between Jungian psychoanalytic thought and

Tibetan Buddhist philosophy (Dora Kalff, Switzerland, 1950s), sandplay
therapy can:
… establish an inner peace which contains the potential for development of

the total personality, including its intellectual and spiritual aspects. ... It is
the role of the therapist to perceive these powers and, like the guardian of a
precious treasure, protect them in their development. … The client is
encouraged by the therapist to make whatever he or she likes in the sand
tray and is given no further instructions. The remarkable feature of sandplay
is that, as the client fashions and moves the figures in the trays, his or her
psyche concurrently moves into new and healthier configurations. This
takes place with no intermediary. Instead it is a direct link of psyche, or
brain patterns to three dimensional figures that “write” and “re-write” its
configuration to healthier, fuller functioning. I know of no other treatment
modality that works with this immediacy with the brain and mind’ (Howes
2010, n.p.).
In my work with an eight-year-old boy whose parents recently divorced,

Anslem (not his real name) was so grieved by the separation that he stopped
talking. He came into the third week of treatment, having not uttered a
single word to any family member, teacher or playmate. Language is the
first capacity to shut down during trauma, even if temporarily. But art,
which is non-verbal, will eventually help to stimulate language. Without
obliging Anslem to converse with me, as his therapist, we simply set up the
sandplay room and he was invited to play, while I sat aside observing and
making notes. ‘One prerequisite, among others, for the unfolding of inner
forces is something I have designated as the free and protected space. It is
the therapist’s task to give shape to such a space: a free space in which the
client feels fully accepted. It is a space protected by the fact that the sand-
play therapist recognises the patient’s boundaries. The therapist becomes
a trusted person. In this way negative or destructive tendencies are not
suppressed but are portrayed and transformed’ (Kalff 1991, 3). Sandplay
therapy, unlike other approaches we have described, requires credentialed
expertise; in addition to psychology training, the therapist must be able to
fulfil two all-important prerequisites:
1. Since the sandplay process expresses itself in a symbolic language, a

profound knowledge of the language of symbols—as expressed in reli-
gions, myths, fairy tales, literature, art and so on—is indispensable.
This applies especially to the depth-psychology interpretation of sym-
bols as developed by C. G. Jung. Above all, one must have experienced
these symbols and their efficacy on the basis of one’s own psychic mat-
uration process. Only this practice makes it possible to accompany the
client’s experience effectively.
2. On the other hand, as we have already seen, the therapist/counsellor
must be capable of establishing a free and protected space. What we
want to mediate for others should emerge from our own experience.
This means that the therapist/counsellor should possess an openness
that is the fruit of an open encounter with one’s own dark and unknown
sides. Also important, however, is an experience of one’s own deep-
seated positive potential—an experience which guarantees an inner
security which thus enables one to create a protected space for others
(Kalff 1991, 4).
Returning to my work with Anslem, what emerged over the follow-

ing weeks was his terror of being forgotten by his beloved father who
had moved out of the house and of being replaced in his beloved moth-
er’s affections by the infant she was at the time carrying. Fear of being
stranded, isolated and unseen by both distracted parents was the equiva-
lent of his full existential annihilation—no surprise that he had given
up his rights for speech; people who do not exist do not talk. But as the
months went by, Anslem’s sandplay took a new tack, in which he gave
symbolic re-birth to himself (much as the new baby had been born into
his life). He described (pictorially) greeting himself anew and finding new
spaces for himself within a new cosmology. When he was sure again who
he was and what role he was meant to play, he spontaneously spoke again
and returned himself to the optimistic, happy child he was pre-divorce.
All this Anslem did on his own, through sandplay, with the therapist
watching gently and without censure (UC San Diego, https://extension.
ucsd.edu/programs/customprogram/documents/whatisSandplay.pdf ).
In another example, Stephen is a 17-year-old boy who struggles with
self-expression and is addicted to gaming. Stephen (not his real name)
intensely dislikes his father, hates his mother with a vengeance and remains
locked in his bedroom, never coming out except to take meals or on his
way to college where be barely manages a pass. He shares not a word in
the house and it is only by overhearing him chat online to a small circle
of peers about gaming activities that the parents know he retains the abil-
ity to communicate. The parents claim they have no idea what caused his
virulent hatred of them or why he says they ‘emasculate him’, but it has
gone on for a long time. Stephen similarly speaks as little as possible in ses-
sion; one would call it a matter of pulling teeth. However, when he enters
the game (via his descriptions of the games in session), his personality
undergoes a profound transformation. He comes alive, finds purpose and
describes strategic moves like a seasoned army general and with a linguistic
fluidity he gives no hint at outside of this forum. And he tells of the world
wide web of ‘close’ teammates with whom he communes on this ‘first-
person shooter’ planet; he is an extremely popular young man after all.
I was at first reluctant to engage with the games. All the ones he named
began and ended with violence. However, as it was only through the
games, Stephen’s method of projective identification, that he would allow
any rapport at all, I followed him in. Katherine Bradway reminds us of
the relationship between analyst and analysed: ‘let the sandplayers’ psyche
guide the two of them’ (Weinrib 2004, xviii). Stephen’s game of choice
is “Call of Duty”, and of this and similar games, gamesradar.com writes:
The gun is typically regarded as a phallic symbol of masculine agency,

through which power is won and maintained. In any first-person shooter,
a power dynamic is reinforced between subject (the player’s subjective sense
of self ) and object (the rest of the game world.) The player is forced to
accept militarism and conquest by violence, historically masculine behav-
iours, as the only course of action. To play a first-person shooter is to enter
into a context in which only the male perspective exists, regardless of the
gender of the character or player (www.gamesradar.com, n.d., 1).
Billions of multiplayer matches in games such as Call of Duty are

played annually. Violent video games now rival Hollywood films for
money-making potential, first-person shooters being top of the charts.
In her article for The New Yorker, Konikova refers to psychologist Minaly
Csikszentmihalyi, who contemplates the success of the games.
What is it that has made this type of game such a success? It’s not simply
the first-person perspective, the three-dimensionality, the violence, or the
escape. These are features of many video games today. But the first-person
shooter combines them in a distinct way: a virtual environment that maxi-
mizes a player’s potential to attain a state (called) … “flow”—a condition
of absolute presence and happiness … when the rest of the world simply
falls away. … Flow is mostly likely to occur during play, whether it’s a gam-
bling bout, a chess match, or a hike in the mountains. Attaining it requires
a good match between someone’s skills and the challenges that he faces, an
environment where personal identity becomes subsumed in the game and
the player attains a strong feeling of control. Flow eventually becomes
self-reinforcing: the feeling itself inspires you to keep returning to the
activity that caused it … (Konikova, New Yorker 2013, n.p.).
According to Lennart Nacke, director of the Games and Media

Entertainment Research Laboratory at the Ontario Institute of
Technology, it is not just the first-person experience that helps to create
flow; it is also the shooting. ‘This deviation from our regular life, the
visceral situations we don’t normally have’, Nacke says, ‘make first-person
shooters particularly compelling’. It is not that we necessarily want to
be violent in real life; rather, it is that we have pent-up emotions and
impulses that need to be vented (Nacke cited in Konikova 2013, n.p.).
In Stephen’s case, the games may be positioned as his sandbox, so to
speak, where ‘the aim … is to offer really free play, in safe circumstances
that are devoid of rules. It offers an opportunity for being and doing
without encumbrances’ (Weinrib 2004, 14). This may account for the
wide appeal of the games to a youth market, but apart from expert savvy
in creating a psychologically astute hook, this is where any similari-
ties between psychoanalytic art therapy and first-person shooter games
end. In the violent gaming industry, no opportunity is provided for
individuals to choose non-contentious outcomes for their psycho-social
problems. Creativity manifests on the part of the game designers; none
is allowed on the part of the players, who in the end have to succumb to
choosing violent outcomes to each presenting issue. There is no oppor-
tunity for resolving conflict, processing relationship issues, shedding
emotional trauma, returning troubled psyches to equilibrium or gradu-
ally re-integrating into a healthy home life. In violent video games, one
remains trapped within a destructive shadow land forever.
One of the fundamental successes of both psychodynamic and psycho-

analytic psychotherapy is that the parts of ourselves that we are unable
or unwilling to see (our shadows) are gradually brought to light during
the treatment process. This is crucial to our self-actualisation as adults
in general, not only an objective for trauma victims or abused children.
Repressed anger, unwanted impulses and compulsions may rattle around
in our subconscious minds, affecting our moods and behaviours in ways
we do not understand and therefore cannot manage. Note that we may
hide away positive traits as well, burying courage and decency if they have
not served us well at a crucial stage.
In Stephen’s case (as with all addicts to activities and substances), the
major challenge facing us was to clearly articulate the relevance of first-
person shooter games to his overall emotional needs. We needed to remove
engagement with this purely destructive shadow energy and find another,
more healthy pursuit that would provide Stephen with alternatives to the
adrenalin rush, the satisfaction of stirred-up bloodlust, illusions of hero-
ism and interaction with community that his soul craved. No small task.
Although we have no evidence that Stephen has trauma in his background,
trauma often becomes a part of the arousal template for victims. In ther-
apy it would be important to allow that to come to light, to name it and
then work to transform it. The denial of negative energy cuts us off from
growth, but with Stephen spending hours a day shooting up fictitious char-
acters in his room alone, he would have no opportunity to acknowledge his
need for violence as a now-ingrained aspect of his personality and would
not trouble himself to muster the required moral effort to integrate these
darker needs with a balanced, healthier lifestyle. First-person shooter games
appear as a foreign and harmful piece of trickery in our cultural landscape,
an electronic Trojan horse; not even Jab is so entirely without redemption.
And, worthy of note, Stephen finds the very idea of Jab Molassie an affront
to his ‘intellectual’ soul.
Art therapy, be it visual, dance, music, the performing arts or carnival
(which encompasses all of the forms), is a phenomenal tool in identify-
ing and reclaiming lost or disowned parts of our identity. For example, a
young girl may know herself to be free, happy, trusting, dependent and
vulnerable, at a sweet and innocent stage of early childhood. If she then
is made to suffer the tortures of chronic sexual assault, she may decide
(consciously or subconsciously) to protect or disown her sweet innocent

self, and she will stuff her vulnerable, trusting aspects deep down into
the subconscious realm. She may then take on the personality of a more
cold and hardened youngster, with a stern face, harsh responses and
brusque demeanour. The princess archetype is replaced by the contem-
porary gangsta bitch. However, as she grows, her inherent need to trust
others and her natural human yearning for relationships that are loving
and safe may leak out in a dysfunctional manner. Such a person may
present in a therapist’s office, saying ‘I don’t know why I seem to fail
at my intimate relationships. I really crave companionship and I just
don’t know why I can’t seem to make relationships last’. Relationship
issues for abuse survivors are rarely confined to just intimate partner-
ships alone but may also extend to relationships with colleagues and
friends. Any psychodynamic treatment plan, which aims to put a client
in touch with her hidden, core needs, will work in the realm of the
shadow (subconscious), aiming to bring at least parts of it to light. Art
therapy is perhaps the best modality for achieving connection with the
shadow, engaging with it and re-integrating our whole, vital selves in a
safe, non-judgemental container.
Art therapy is a mental health profession in which clients, facilitated
by the art therapist, use art media, the creative process and the result-
ing artwork to explore their feelings, reconcile emotional conflicts, foster
self-awareness, manage behaviour and addictions, develop social skills,
improve reality orientation, reduce anxiety and increase self-esteem. A
goal in art therapy is to improve or restore a client’s functioning and his
or her sense of personal well-being. Art therapy practice requires knowl-
edge of visual art (drawing, painting, sculpture and other art forms) and
the creative process as well as of human development, psychological and
counselling theories and techniques (www.arttherapy.org).
Regaining Control of Self

Victims of abuse can suffer from low self-esteem and a diminished sense of
control over their own lives. Feelings of vulnerability can ensue and com-
municating personal pain can exacerbate those feelings. Art as an alternative
channel can promote a form of role-play that allows the victim to assert
themselves in ways they find impossible in real life. I may not be ready to
confront my abuser from childhood and I may not be capable of resolving
conflicts with an abusive parent, but making art about them allows me to
control what they did to me. It gives me a sense of freedom to ‘talk back’ and
to act back as I please. I can do so without the weight of guilt—an emotion
that is common among most victims of abuse.
Persons who have been abused can live with a heightened sensitivity to
danger and often feel fear, even when a real threat is absent. A safe space is
important, be it a church, a home, a psychologists office or the solitude of
paper and pen or paint. The creative process is dictated by the creator, who has
the power to reveal only what they wish to reveal and in a manner they choose.
Art also allows me to confront my perpetrator safely. I am not physi-
cally afraid of my childhood abuser, but I am repulsed at the idea of ever
seeing him in real life. Not only is this form of talking back beneficial for
regaining a sense of control, but I am able to do so and feel safe. Direct
communication with him would make the situation ‘too real’ when I am
actively trying to lessen the real effects of what has happened, trying over
time and through process to fade its power.
Note the expression of repulsion at the idea of ever seeing the abuser
again in real life. Given that cases of incest are said to make up over 90 %
of all rapes against children and that small children are ‘groomed’ by their
perpetrators for years before and during the abuse, victims are in fact
made to swallow and suffer the repulsion of seeing their abusers sitting at
the table across from them each day, for years. The need to regain a sense
of control not only is a cognitive or intellectual exercise but can refer to a
real physiological crisis as well. Lee Loy explains how she used art to help
regulate a bout of real debilitating anxiety.
Once, while participating in an international artist residency, I received bou-

quets of flowers with accompanying cards delivered to my studio. I had recently
escaped an abusive relationship and these flowers followed me outside of my
own country. I immediately felt the same sense of panic and anxiety I had felt
in the person’s presence. In an act of defiance, I stripped the flowers and pinned
the petals to my studio walls in the shape of a giant cockroach. I left the flowers
to die for weeks. This performance and resulting installation piece helped to
abate an anxiety attack, a recent phenomenon I began experiencing while
being stalked in Trinidad. I was able to create something that gave me a sense
of accomplishment (a resulting artwork) that helped me to immerse myself in
the emotional space while pursuing an aggressive physical act that released
tension and dictated the outcome of the threatening flowers.
This image is taken from Lee Loy’s installation ‘Roaches and Flowers:
War in the home’, in which she used the flowers that were delivered to
her studio at The Vermont Studio Centre. She explains:
Struggling with feelings of fear, repulsion and anxiety, I created a large

insect from the petals that I pinned painstakingly with silk pins to the wall.
The insect was then photographed in different stages of decay. Landscapes
of pins and petals were also made from this installation. Attached to the
flowers was a paper note from the flower shop stating: How to care for your
arrangement, which really struck me. The flowers themselves were an
intrusion, a bribe that many times before had been rejected and that had
followed me outside the confines of Trinidad. These beautiful arrange-
ments evoked an intense sense of terror bridging on paranoia, as memory
Fig. 6.6 The roaches © Jaime Lee Loy (2008) (http://smallaxe.net/wordpress3/

works/2008/10/28/jaime-lee-loy/)
and history refused to let me enjoy their presented offerings of peace. It was
like receiving a bouquet of roaches. It was then I began to realise that unfa-
miliarity in a familiar space or through familiar means is like surviving a
war. Nostalgia and new-found freedom cannot resolve the discomfort that
remains.
In the example Lee Loy gives, she has experienced a trigger (the
bouquet of flowers sent by an abusive ex-partner) which emotionally
destabilised her and provoked feelings of vulnerability and helplessness.
These feelings are typical of panic attacks, in which we feel we must do
something very urgently to help ourselves. This one example illustrates
the case of many. Once we have had a bad experience, human nature
leaves us susceptible to intrusive memories and recurring nightmares
of the traumatic event. Consider, for example, the people of Grenada
who lost homes and livelihoods during the devastation of Hurricane
Ivan in 2004. Many people say they still flinch when wind blows hard
and their hearts pound, if only for a moment or two. On the further
end of the spectrum, the psychiatric diagnosis of post-traumatic stress
disorder (PTSD) describes a series of physiological responses that trip
off reflexively when we get reminders of pain and fear. Take a soldier
who has returned from war apparently healthy, happy and heroic but
who dives for shelter whenever a bus backfires in the road outside.
He is uncontrollably triggered to respond to his memory of bombs
exploding, a memory which signifies a very real and present danger.
PTSD as a result of abuse or rape is no less intense, although victims
of these tend to suffer in silence, leaving pathology to manifest and
magnify inside.
Events such as rape and torture are associated with higher rates of
PTSD than events such as accidents and natural disasters. … In a study
of survivors of war or mass violence … de Jong et al. (2001) found
prevalence rates of PTSD of 37 % in Algeria, 28 % in Cambodia, 16 %
in Ethiopia and 18 % in Gaza. Higher rates of PTSD are found in refu-
gees and asylum-seekers who have fled from their country of origin
(Grey 2009, 2).
In regard to Lee Loy’s anxiety attack when the flowers were pre-
sented, note the ‘nowness’ or immediacy of her reaction. This is also
typical of survivors of sexual abuse who are suddenly reminded of past
harms.
Due to high levels of arousal at the time of the trauma, the trauma memory
is poorly elaborated, fragmented, and poorly integrated with other auto-
biographical memories, and can be unintentionally triggered by a wide
range of low-level cues. In particular, there is no ‘time-code’ on the mem-
ory that tells the individual that the event occurred in the past. Thus, when
the memory intrudes, it feels as if the event is actually happening again to
some degree (Grey 2009, 6).
Cognitive-behavioural therapy (CBT) has a number of excellent

tools for mitigating the anxiety attacks that follow a flood of pain-
ful memories along with the accompanying sense of dread. All of
these tools need to be taught to clients by professional psychologists
over a protracted length of time in clinical sessions. CBT has a good
rate of success with their moves. However, if we take the Caribbean
reality, in which thousands of Grenadian people were left traumatised
after hurricanes Ivan and Emily in 2004 and 2005, respectively, or
the multiple thousands of Haitians affected by the 2010 earthquake
and if we take our prevalence of violence in the region which is said
to impact one in every three women across their lifetime, then it
clearly behoves our population to seek a more community-based type
of healing intervention for our disasters of various sorts rather than
reliance on individual therapists. One such example was the ‘com-
munity caravan’ which was commissioned by the then government of
Grenada and which travelled from village to village after Hurricane
Ivan, working with children and families to role-play their experiences
and to draw their memories. These processes were transformative in
themselves, but the exhibition of art work that was produced revealed
an individual and collective trauma on a large scale. It was following
this that the same government initiated a programme of free counsel-
ling training—for lay persons as well as professionals. The belief that
underpinned this initiative was that communities can heal themselves
if they are given the tools to do so.
Lee Loy has described a method of using art as self-therapy which

helped her and which can help others in similar fashion. In The Courage
to Heal (1992), Bass and Davis offer several art therapy exercises which
are easy and effective. Here are some excerpted:
From hating your body to loving your body.
Draw yourself: Another way to shift your image of your body is

to draw it. …While (one artist) was remembering her abuse, she
created an extensive series of self-portraits. “At first, the agony was
drawn all over them, but bit by bit, they became softer. In the begin-
ning, the lines were hard and black and angular, but then I would
force myself to sit in front of a mirror and draw my own body nude,
and try to draw it with all the sensual softness of a female body. I
would use charcoal, which is very soft, and I’d keep drawing until I
could draw my body very soft and very sensuous. And I learned to
love my body through that.” (Bass and Davis, 1992, 251)
Sharing
Sharing is also a very important benefit of using art to heal. Often those who
have survived abuse can feel lonely and isolated, especially if their reality is
one of secrets and feelings of shame. The act of sharing dilutes the anxiety,
allowing someone to part with some of the stress by communicating it with
others or by transferring it onto another medium such as clay or paper.
In a recent group exhibition, I installed ‘SORRY’, using petals from eight
dozen roses and silk pins. The petals were pinned to the wall in the shape of
the word ‘Sorry’. It had been created to show how the word is sometimes
insufficient or even false. The rose petals were left to die over the period of a
month while their form kept changing. At the show, several people spoke to
me about the ways in which they connected with the artwork, sharing their
own experiences of love and regret and even their own interpretations of the
piece. We engaged each other through the artwork. I did not divulge the
specific meaning behind the piece, which was also about sexual abuse.
Draw your feelings: Amy Pine, a creative arts therapist in Santa

Cruz, California, suggests trying to draw a feeling that you have.
Use color, shape, texture, degree of pressure, space, and literal
pictures to help you express this feeling. Stick figures are also
fine. Then draw the way you want to feel. Share these draw-
ings with someone. What do they represent? What do you notice
when you look at them? Then draw a third picture that takes
elements of the first through a transition that brings it to the
second. What had to happen to connect them? How did you do
it? Is there any correlation with what you might do in your life?
(Bass and Davis 1992, 228)
When I create art, I can deface photos, shred petals, use any process to
express an idea or emotion that has personal significance. I can do so safely
without judgement from others or myself. In ‘Summer Heroes’, our par-
ticipants allow their superhero drawings to be exhibited as it conveys their
super selves. They do not always exhibit other works that express frustra-
tion or anger or fear. In the same light, I can choose what to exhibit and I
only release work when I am ready for it to be shown.
Facilitators can also use this opportunity to engage the art in a personal
way in sharing their own experiences or feelings. When communicating
with ‘Half Woman’, I spoke to the child who produced it her about her
drawing and how it affected me deeply. I told her as a child I often felt torn
with emotions (I did not divulge my story) and that I liked the way she
chose the colours of the costume—turquoise blue for happiness and brown
for sadness. I could have chosen to take sharing a step further and com-
pleted a module with her, choosing to draw my own avatar or express my
own frustrations in a creative activity.
In this last example, take note of the quality of the sharing that Lee
Loy describes. Earlier in this section, we spoke to the harmful nature
of imposing interpretations upon others’ art works (or ideas or dis-
closures), particularly in the case of adults attempting to appropriate
meanings from child subjects they believe are hiding secrets. But in the
example of ‘Sorry’, the audience wholeheartedly engaged with the work,

conveying a simple message of ‘I hear you’, ‘I see you’ or ‘I empathize with
your pain’. This is a great example of art as therapy, in which an artist
(or client) projects her troubling emotions outwards for contemplation, and
her audience/community simply allows her to do this, holds a safe space
open and validates her effort as meaningful and therefore transformative.
This indeed is the quintessential sharing—more a matter of being than of
doing anything fixative.
Transcendence and Transformation
Art enables someone to create something new. The act of processing and
transforming their experiences into a physical object, display or perfor-
mance allows the process to take on new form. Although the work is
being produced as an expression of something specific—be it an emo-
tion or event—the resulting artwork is a separate entity that can be
admired, assessed and appreciated for what it is, independent of why it
was made.
Sometimes survivors of abuse ask themselves ‘why me?’ or ‘how is this
fair?’ I have personally used art to create another identity that is positive
despite the trauma and that assists my process of transcendence or transfor-
mation. The work may be dark but I will have transformed that trauma and
moved beyond it by making something new and viable from the experience.
I often decide that my experiences were not in vain, that I chose to allow
them to serve a purpose. That purpose is the art I have created, the career I
have created, the meaning I have sought from it and the opportunities it has
presented for me to help others. My personal drawings that others may never
see, my art exhibitions, the novels I write, and the art-based programme that
I implemented—they continue to heal me. I have not emerged from those
experiences empty-handed. I have transcended them.
Art as a process is meditative and can calm. As with any other therapeutic
process, it can relax the brain and allow more understanding of one’s own
thoughts and emotions. It can help with mental blocks and rages of emotion.
An individual operating under high levels of stress needs some activity to relax
them—be it yoga, exercise or reading. The act of scribbling, ripping, moulding,
spilling, doodling and more—they allow relaxation or release. As a practice,

it would help the overall therapeutic process, and I would recommend anyone
working through trauma or with others who have experienced trauma to
implement some form of artistic method as part of their healing process.
At the ‘Summer Heroes’ workshop, a hired art therapist conducted an activ-
ity with shoeboxes. Participants were asked to think about a physical place that
made them feel safe and to decorate the box to express that space. The activity
concretised the idea of a safe space to the students, and they were encouraged
to mentally visit that space whenever they felt afraid or alone. On another day,
they created ‘talismans’ from clay and were asked to design an object that would
symbolise protection. Catholics may rely on a rosary or scapula for protection
with the knowledge that it is not the object but their belief or divine protection
that operates through the object to ensure their safety. When the students had
the opportunity to create a talisman of their design, they were able to person-
alise the experience and channel their desire for protection into an activity and
object that in a psychological context promoted a feeling of security.
While someone is speaking about a difficult experience, it is helpful to let
him or her draw or paint unconsciously. With a pen or crayon but without
any instruction, they may automatically begin to make shapes and lines while
speaking which helps to relax them and distract them from their emotions
during the session. Collage is also another approach in which the participant
may prefer to stick items onto a surface in various patterns rather than make
Fig. 6.7 Clay talisman—Summer Heroes Workshop, 2013, © Jaime Lee Loy (2013)
their own marks on paper. Clay has additional soothing capabilities and can
be replaced by children’s moulding clay. Regardless of the method chosen, art
definitely offers a productive expressive outlet that can benefit both the person
working towards self-healing and those working to assist them.
Conclusion
In this section of the book, we have discussed the significance of history
and culture in the creation of art and the many functions art plays in
social life and promoting well-being. Our case study was the personal
narrative of survivor and author Jaime Lee Loy. Her reflections have
enabled us to unravel the techniques and methods for self-healing that
are part of her transformation from victim to survivor. We have dis-
cussed the potential of art to help the survivor to rise above the devasta-
tion of sexual abuse and create safe spaces in which she can regain some
control over her life.
This part of the book includes examples and methods for using art
for therapeutic purposes, techniques which, for the most part, can eas-
ily be replicated in numerous and diverse settings. Also, though we have
consistently highlighted the importance of the trained therapist, we have
given equal recognition to the power of the self as a healing force, to the
potential of the untrained but sensitive facilitator as a healing force, and
to the role of others—spectators, viewers, participants and community
members, who by engaging in the creative endeavour also contribute to
the healing process.
In a theme-based psychodynamic group for women with a history of
depression and abusive relationships, art therapy was one of a full cur-
riculum of self-expressive methods—‘… a variety of techniques were
used alongside the art therapy, such as relaxation, stress management
or visualisation exercises at the beginning of the group to give focus to
themes and as a response to themes that emerged out of discussions’
(Lawrence and Barford 1999, 43). In the psychotherapy group for girls
who have experienced sexual abuse in Grenada, as discussed in Part 2 (the
R.I.S.E. Project, Sweet Water Foundation, www.sweetwaterfoundation.

ca), a professional artist participates as a central part of the programme.
Along with visual arts, R.I.S.E. also includes yoga therapy and drum
workshops as part of getting in touch with shadow selves and releasing
pent-up traumas. Taking from the carnival arts, R.I.S.E. includes one
segment in which masks are made. Participants are asked to design their
own masks out of available art materials and then asked to share (if they
like) those aspects of themselves that are hidden and what might happen
if those underground aspects were to rise to the fore. Participants are
also invited to dance in their masks, or to perform the realities of their
hidden selves, without verbal analysis. This is similar to the technique
we described in Part 5, in which carnival masks can be used as a form of
therapeutic self-expression for children in residential care.
In group settings such as these examples, it is not only the art that
counts as therapy, it is the emotional synergies created by being part of
a group dynamic while at the same time constructing meanings out of
the artistic process and product that matter at the deepest personal and
individual level.
The internet is full of art projects and exercises that may be under-
taken by group leaders, or by individuals, as a method of self-exploration.
Jonathan Morgan, of Regional Psychosocial Support Initiative (REPSSI
[South Africa]), has published an excellent system for working with chil-
dren affected by poverty, conflict and HIV-AIDS. His Making a Hero
Book is free and available online. It is an evidence-based, psycho-social
approach in which art and autobiographical storytelling are used to find
solutions for the problems children face. As the child is permitted to be
author, illustrator and main character, their stories can be all true, par-
tially true or all made-up, leaving control of the narrative firmly within
each child’s hands. One of the activities, ‘Road of Life’, which focuses on
My Birth Family, Where I Live Now, and Along the Way, is particularly
good for children in residential care.
The Journey Program, also fully available online, was developed in Tulsa,
Oklahoma, for children who had been removed from abusive homes and
subsequently exhausted the foster care system. Frightened, fatigued and
acting out with
‘major league behavioural problems … the Journey is a unique approach to

counselling and behaviour management. It sparks a child’s imagination
with a mythological story and then uses an adventure game to teach chil-
dren to follow rules, develop life skills, and train their brains ... the goal is
for them to re-write their own stories’ (https://www.facebook.com/the-
journeyprogram/info).
Out of this concept, The Warrior Journey was developed, particularly

for use with the Native American population at Eagle Creek Residential
Treatment Centre (see www.thejourneyprogram.com). The Tree of Life
is another one we highly recommend. Like the Hero Book and the
Journey Program, Tree of Life is a counselling method for people who
have been traumatised. It was developed by child psychologist Ncazelo
Ncube of Zimbabwe and is now available through the Dulwich Centre,
Australia. In the Caribbean, the Caribbean Art Therapy’s Facebook
page is a good source of information on developments in the field. Art
Therapy Barbados also has a very dynamic Facebook page, as does Art
Therapy in Jamaica. Additionally, there are numerous art therapy exer-
cises demonstrated on YouTube and several electronic apps which give
good, easy examples.
As we bring this book to an end, we remind the reader that all of these
therapeutic forms, like the methods of practice described throughout the
book, require a commitment to Emotional Intelligence (discussed in Part
1), which requires ongoing work upon oneself to deepen one’s own capa-
bility of giving authentic help and to ensure the best of self-care.
References
Bacchanal. The Columbia Electronic Encyclopedia®. (2013). http://encyclope-
dia2.thefreedictionary.com/bacchanal. Accessed 9 August 2015.
Bass, E. & Davis, L. (1992). The courage to heal, a guide for women survivors of
child sexual abuse. New York: HarperCollins.
Cozolino, L. (2010). The neuroscience of psychotherapy. Healing the social brain.
New York: W.W. Norton & Company.
Ellis, A. (2012). Socialist realisms: Soviet painting 1920-1970. Skira Editore

S.p.A., 2012, 21.
Grey, N. (2009). Cognitive therapy for traumatic stress reactions. In N. Grey
(Ed.), A casebook of cognitive therapy for traumatic stress reactions. New York:
Routledge.
Halifax, N. (2003). Feminist art therapy: Contributions from feminist theory
and contemporary practice. In S. Hogan (Ed.), Gender issues in art therapy.
London: Jessica Kingsley Publishers.
Howes, R. (2010, February 3). Cool intervention: Sandplay. https://www.
psychologytoday.com/blog/in-therapy/201002/cool-intervention-4-
sandplay. Accessed August 5, 2015.
Jamaica Information Service. (2015). http://jis.gov.jm/famous_jamaicans/edna-
manley/. Accessed August 5, 2015.
James, E. L. (2012). Fifty shades of grey. New York: Vintage Books.
Journey Program. https://www.facebook.com/thejourneyprogram/
Kasai, T. (1999). A Butoh dance method for psychosomatic exploration.
Memoirs of the Hokkaido Institute of Technology, 27, 309–316.
Kalff, D. M. (1991). Introduction to sandplay therapy. Journal of Sandplay
Therapy, 1(1), 1–4.
Konikova, M. (2013, November 25). Why gamers can’t stop playing first-person
shooters. The New Yorker. www.newyorker.com, http://www.newyorker.com/
tech/elements/why-gamers-cant-stop-playing-first-person-shooters. Accessed
August 13, 2015.
Laferrière, D. (1987). How to make love to a Negro. Toronto: Coach House
Press.
Laferrière, D. (2011). I am a Japanese writer. Vancouver: Douglas and
McIntyre.
Lawrence, C., & Barford, H. (1999). Echoing the steps of my ancestors. In
J. Campbell, M. Liebmann, F. Brooks, J. Jones, & C. Ward (Eds.), Art ther-
apy, race and culture. London: Jessica Kingsley Publishers.
Lee Loy, J. (2008). Bury your mother. In L. Allen-Agostini & J. Mason (Eds.),
Trinidad noir. New York: Akashic Books.
Schaverien, J. (1999). The scapegoat. Jewish experience and art psychotherapy
groups. In J. Campbell, M. Liebmann, F. Brooks, J. Jones, & C. Ward (Eds.),
Art therapy, race and culture. London: Jessica Kingsley Publishers.
The Holy Bible, ‘Leviticus’ (2000). Authorized King James Version. New York:
New York Bible Society.
The Liturgical Commission. (2004). Ministries of liturgical art and the environ-
ment. Archdiocese of Caberra and Goulburn, the Liturgical Commission.
Von Wiegand, E. (n.d.). Art of the Mexican revolution: Forming a United National
identity. www.theculturetrip.com. Accessed August 12, 2015.
Weinrib, E. L. (2004). Images of the self: The sandplay therapy process. Cloverdale:
Tenemos Press.
Index1
A Aitken, 102n3
abandonment, 47, 49, 69, 125, 235, Alcoholics Anonymous, 128, 135
258, 274, 284 Allington-Smith, 105, 106
abortion, 35, 39–46, 50, 51 Alternative Care of Children, 233
Academic self-esteem subscale, 51 American Psychological Association,
Acceptance and Commitment 40, 43
Therapy, 195 AMPLE programme, 77
accurate self-assessment, 10, 11 anatomical dolls, 108–12
adaptability, 13–14 Angelides, 112, 113
Adelson, 79 ankotu but, 309
adolescent category, 51 Ann-Marie, 131
adolescent mothers, 68–77 Anslem, 316, 317
adult sex offenders, 177, 178 Anton and Oriana
Africans, 296 attachment, separation and loss,
agencies, 42, 53, 75, 103–4, 132, 250–4
136, 168, 169, 174, 199, 211, children come into care, 235–6
278 extent of problem, 234–5
age nine, 48, 59, 150 factors of risk and resiliency, 261
Ainsworth, 70 family contact, 272
1
Note: Page number followed by ‘n’ refers to footnotes.

Clinical Settings, DOI 10.1057/978-1-137-37769-2
326 Index
Anton and Oriana (cont.) Australia, 130

family history, 223–30 Aztec culture, 294
fathering, 274
institutional care necessarily bad, 237
life story work, 281 B
narrative therapy, 268–9 Bailey, 69, 71
presenting problem, 231–3 Barber, 58
sending for help, 255 Bass, 326
treatment plan, developing, behaviour therapy, 204
261–7 Belsky, 72
Antonio, 29 Big River, 295
approach vs. avoidant, 163 Blackburn, 244
Apsche, 195 Black Jabs, 297
art Bolshevik, 309
fictionalising painful truths, Borduin, 175
311–13 Bowlby, 70, 102, 234, 278
historical and contemporary- Brackett, 4–5
culture and context, 293–5 Bradshaw, 40
and psyche, 295–7 Bradway, Katherine, 318
regaining control of self, 321–7 Brian, 29
sandplay therapy, 314–21 British birth cohort, 36
scapegoating, 313–14 Bury Your Mother, 312
self-therapy, form of, 301–2 Butoh, 309, 310
sharing, 327–8
summer heroes, 302–11
survivor’s story, 299–301 C
transcendence and Call of Duty, 318
transformation, 328–9 Cameron, 242, 245, 248
art therapy, 2, 58, 112, 191, 193, Canada, 130, 209, 211–13, 293
262, 292, 301, 308, 319–21, caregiver, 19, 70–2, 127, 159, 185,
326, 330 231, 234, 235, 240–5, 248,
Art Therapy Barbados, 332 254, 263, 278, 308, 311
Art Therapy in Jamaica, 332 Caribbean, 29, 210–12
Attachment and Biobehavioral abortion, 41, 42
Catch-up Intervention, 74 adolescent mothers, enhancing
attachment-based interventions, 74 attachment behaviours,
attachment behaviours, enhancing, 76–7
76–7 agencies, 136
Index 327
art therapy, 301 child maltreatments, 36, 38, 68, 71,

child protection services in, 103, 98, 100, 126, 165, 168
104, 155 child protection agencies, 103–4,
child sexual abuse, 74, 145, 157 155, 166
Convention on the Rights of the child protection systems, 3, 23, 31,
Child, 237 43, 44, 103–4, 116, 132, 136,
cultural forms, 57 157, 167, 173, 207
cultural traditions, 20 Children’s Clinic at the
Dionysia, 296 Massachusetts Mental Health
family resiliency, strengths and Centre, 256
ability, 132 child sexual abuse (CSA), 1, 27, 33,
harm of sexual abuse, 2 57, 145, 153, 157, 170, 172,
institutional failings within, 3 173, 210, 211, 214
inter-agency system, 168 adolescent female victims, 307
narrative therapy, 267 art as therapy, 298
Organization of Eastern Emotional Intelligence, 4
Caribbean States, 134–5 prevention, regional system, 204
primary caregiving role in, 159 systems model for, 201–3
residential child care, 229, 232–4, UNICEF study, 203
240, 248, 273 Child Welfare Information
RJ strategy, 199 Gateway, 276
Sexual Offence Rehabilitation chronic emotional neediness, 256
and Treatment Project, Circle of Security Intervention, 74
203–5 circles of support aid, 209–13
violence and abusive Circles of support and accountability
relationships, 17 (CoSAs), 202, 208–13
young people with sexually clay talisman, 329
harmful behaviour, 169–78 cognitive-behavioural therapy
Caribbean Community (CBT), 194, 203, 325
(CARICOM), 172, 233, collage, 329
233n1, 236 communication, 12, 19, 38, 39,
Caribbean-contexted model, 203 100–1, 107, 118, 123–4, 136,
Carnes, 156 161, 311
catholics, 329 community-based model, 204
Charlene, 230, 251–3, 269, 273, 274 community caravan, 325
Child Behaviour Checklist contemporary-culture, 293–5
(CBCL), 236 contemporary fashion industry, 65
child-centredness, 56 contextual issues, 97–100
328 Index
Convention on the Rights of the disabled children, 19, 37, 98, 103–5,
Child (CRC), 167, 237, 269 136
Conversation Piece, 228 disequilibrium, 115
coping strategies, 40, 115, 118 doll play, 108–12
Core Conflictual Relationship domestic violence, 36, 44, 68, 164,
Theme (CCRT), 61 196, 313
core member, 211, 213 Down syndrome, 14, 18–19, 93,
counter-transference, 256–8, 306 97–101
The Courage to Heal, 326 Dozier, 74, 236
Crawford, 156 drug addiction, 230
creative process, 321 DSM IV, 264
creativity, 21, 319 Dunning, 6, 7
criminal justice systems, 67, 172,
196, 203
crisis intervention, 19, 106, 115–21, E
125, 128 Eagle Creek Residential Treatment
Crystal, 278–81 Centre, 331
Culture Free Self-Esteem Inventories, Early Childhood Regulations, 237
Third Edition (CFSEI-3), 51 ecological systems theory, 1, 27, 70,
culture of accountability, 168 130, 200
ecomap
Levi, 149
D Melissa, 34, 39
Mr. D, 154 Nina, 96
Da Breo, Hazel, 293, 298 Egeland, 71, 81
Daly, 198, 199 Elliott, 156
Davis, 326 Emily, 325
de facto method, 43, 124, 210 emotional constriction, 145
de Jong, 324 Emotional Intelligence (EI), 2–9, 16,
denholm, 36 33, 332
denial, 156 Emotional Intelligence Workbook, 10
Mr. Dewan, 92–5, 101, 104, 106, emotionally intelligent approach, 7, 12
117, 118, 121–3, 122, 125–9, emotional responses, 160, 253
128, 134, 135 emotional self-awareness, 10–12
Diable, 297 emotional self-control, 10, 13
Diagnostic and Statistical Manual of emotional skills, 4
Mental Disorders (DSM), 22 emotions, 8, 9, 11–13, 60, 113, 119,
Dialectical Behaviour Therapy, 195 127, 181, 192, 252, 282, 293,
Dionysia, 296 309
Index 329
empathy, 24, 145, 146, 191, 198, 215 Finkelhor, 180

Engel, George, 194 Fraiberg, 78
environmental factors, 33, 70, 74, Franklin, Benjamin, 5
81, 200 Fritzl, Josef, 153
equilibrium, 115, 118
Erickson, 23
G
Games and Media Entertainment
F Research Laboratory, 318
facade, safety of, 282 gangsta bitch, 320
Faller, 155 gender-specific sexual predatory
family boundaries, 122 behaviours, 150–6
family contact, 269–76, 283 General self-esteem subscale, 51
family dysfunction, 35–9, 45 genogram
family group conferencing (FGC), Anton and Oriana, 230
19, 68, 128–36, 146, Levi, 148
196–9, 198, 199, 207–9, Melissa, 30, 208
208–9, 213 Nina, 94
family roles, 38, 118, 121–122 George, 29–31
family rules, 124 Gilbert, 100
Family Services, 272 global self-esteem quotient (GSEQ),
family system, 27, 47, 117, 118, 51–3
122, 125, 130, 272 Goldenberg, 118
family values, 125–8 Goleman, Daniel, 8
Family Violence Prevention Fund, good lives model (GLM), 161–3
275 Gormley, Phil, 172
father–daughter incest (FDI), 152 Green, 155, 158
feelings, 60–2, 81, 112–16, 119, Grenada’s Spicemas, 297
126, 302, 306–8, group-based intervention, 78
324, 326 group intervention, 2, 51, 78
abortion, 40 group psychotherapy, 47, 50, 51,
emotional self-awareness, 11 58–9, 66, 255, 330
of isolation, 252
self-hate, 55
shame, 7, 12, 24, 78 H
vulnerability, 321 Half Woman, 303–5
Feldman, 78 hands-on methods, 108
female sex offenders, 159 harmful sexual behaviour,
Fifty Shades of Grey, 304 143–6, 180
330 Index
harmful sexual behaviour (cont.) women and sexual abuse, 159–61

abuse and neglect, protecting working with Levi, 181
young children from, young people with, 170–4
163–8 Harvard Psychological Clinic, 187
circles of support, 209–13 Hay Group, 10
collaboration, partnerships and herein, 49
systemic practice, 179–80 Hill, Errol, 297
ecological systems approach, 200 The Home, 229
family group conference, 207–9 How to Make Love to a Negro without
female sex offenders, research, getting Tired, 294
158–9 Hurricane Ivan, 325
getting plan right for Levi, hyper-activity, 59
193–5 hypervigilance, 264
helping Levi draw breath, 191–3 hypothetical treatment approaches, 2
juvenile sex offenders and young
people with, 170–4
juvenile sex offenders, I
interventions, 169 I am a Japanese Writer, 294
Levi’s stance with therapist, 184–5 imbalance, 117, 118, 122
Levi’s story, 146–7 incest, 150, 152, 155, 156
Levi telling his story, 189–90 inclusive practice, 276
meeting Levi, 183–4 individualised treatment approach,
mothers, messages from research, 19, 180
156–7 initiative, 13–15
perspectives from literature, institutional care, 233, 234, 236–9
150–6 intelligence quotient (IQ), 4
presenting problem, 147–50 inter-agency system, 167, 168
professional concerns, 174–9 internet, 213, 240, 331
psychotherapy, 181–2 inter-personal violence, 46, 145
restorative justice for sexual intersecting harms, 27, 35–9
offences, 196–9
sessions with Levi, 186–7
Sexual Offence Rehabilitation J
And Treatment Project, Jab Jab, 296, 297
203–7 Jamaica’s Early Childhood Act, 237
sexual offending, assist clinical/ Jennifer, 146–7, 156, 166
practitioner interventions, Jennings, 195
161–3 Jenny, Aunt, 68
social drivers and determinants of jittery movements, 59
abuse, 201–3 Mr. and Mrs. John, 28–9, 31, 47
Index 331
Mr. Johnston, 94, 95, 98 Lee Loy, Jaime, 20, 292, 293, 295, 298,
Jones, Adele D., 3, 74, 164, 169, 299, 302, 303, 305, 307, 308,
176, 235, 238, 243, 245, 249, 311, 322–6, 328, 329
272, 273 Letourneau, 175
journaling, 307 Levi, 18, 19, 37, 145, 163
Journey Program, 331 abuse and neglect, protecting young
Juffer, 75 children, 163, 164, 166, 167
Jung, C.G., 192, 316 ecological systems approach, 200
juvenile sex crimes, 177 family group conference, 208,
juvenile sex offenders, 7, 19, 169–74, 210–13
177–80, 199–204, 209, 210, family history, 146–7
255 gender-specific sexual predatory
ecological systems approach, 200 behaviours, 152–6
interventions for, 169 getting plan right for, 193–5
providing treatment, 170–4 helping draw breath, 191–3
juvenile sex offenders, 169, 170
meeting, 183–4
K presenting problem, 147–50
Kabatt-Zinn, 194 professional concerns, 174–6
Kamal, 92–5, 121, 128, 129 psychotherapy, 181–2
Kaplan, 155, 158 sessions with, 186–7
Kendall-Tackett, 107 sexual offence rehabilitation and
Kisiel, 46 treatment project, 203
Knutson, 98, 99 sexual offences, restorative justice,
196
social drivers and determinants of
L abuse, 201–3
La Diablesse, 188, 192 telling his story, 189–91
Laferriere, Dany, 294 theoretical models, 162, 163
language, 100–2, 107, 108, 316 with therapist, 184–5
Latin America, 17, 41, 42, 233, 235, women and sexual abuse, 159
249, 309 working with, 181
learning disabilities, 104–8, 270 life-span issues, 71
applying the model, 121–8 life story work, 276–82
doll play, 108–12 Lim Ah Ken, 236, 242, 257
drawings, 112–14 Lisak, 145, 146, 161
family group conference, 128–33, Liturgical art, 293
128–36 Love Thy Neighbour, 182
social work with parents, Loy, Jaime Lee, 20, 28, 92, 144, 228
115–21 Lunacharsky, Anatoly, 309
332 Index
M mind-created projection, 192

Maginn, 242, 245 Mindfulness-Based Cognitive
Mahoney, 22, 24 Therapy, 195
Making a Hero Book, 331 mindfulness-based stress reduction
mango tree moments, 59–63 (MBSR), 193–5
Manley, Edna mindfulness-based yoga, 63
Negro Aroused and The Dying God mindfulness skills, 195
Series, 294 Mitchell, Keith, 233
Mayakovsky, Vladimir, 294 Mode Deactivation Therapy (MDT),
Mayer-Salovey-Caruso Emotional 195
Intelligence Test (MSCEIT), 5 Moesha, 131
McAlinden, 199 Molassie, Jab, 297, 320
McIntosh, 5, 252 Mollon, 7
Meichenbaum, Donald, 25 Morczek, 158
Melissa, 18, 27, 29, 30 Morgan, Jonathan, 331
abortion, 41–4 mosaicism, 99
chronology of events, 31 mother-son incest, 153, 154, 215
family dysfunction and multisystemic therapy (MST), 35,
intersecting harms, 35–9 203, 204
family history, 28–9 Murray, Henry, 261
presenting problem, 29–30 Myers, 121, 122
presenting symptoms and
treatment, 59–68
psychodynamic group N
psychotherapy, 59 Nacke, Lennart, 318, 319
psychological assessment, 46–53 narrative therapy, 267–9
psychotherapy, 54 Nash, 49
R.I.S.E. programme, 55, 58 National Crime Agency, 171
social work and attachment, 68, National Down Syndrome Society
69, 73, 74 (NDSS), 99
summary, 33–5 Ncube, Ncazelo, 332
Mellow Babies Intervention, 74 neglect, 235
Mellow Mums project, 77 children with disabilities, 98
mental illness, 37, 70, 299, 300 Levi’s story, 201
metamorphosis, 144 protecting young children from,
Mexican Revolution, 293 163–8
Michaelidou, 112, 113 residential care, 235
middle childhood, 48 reviewing cases of serious, 168
Index 333
Negro Aroused, 294 Parad, 115

Nevis, 73 parental deprivation, 278
Newman, 244 Parental/Home self-esteem subscale, 52
New York University Psychoanalytic a passive vs. active manner, 163
Institute, 154 Paul, 29
New Zealand, 129, 130, 134, 136 People’s Commisariat for
Nina, 18–19 Enlightenment, 309
chronology of events leading, 95 Perls, Fitz, 194
communication, 123 personal competencies, 8–10
communication challenges, 100 Personal self-esteem subscale, 52
contextual issues, 98 physical punishment, 36, 214, 237
crisis intervention, 117, 118 physical restlessness, 59
disability and stressors, 101–2 physical violence, 20, 39, 156, 157,
Down syndrome, 99 180, 202
family goals, 125 Pillars of Parenting, 245, 248
family group conferencing, 129, 135 positive psychology approach, 244,
family history, 92–3 245
family values, 126–8 post-traumatic stress disorder
learning disabilities, 104–13 (PTSD), 24, 50, 185, 324
presenting problem, 94–5 precipitating event, 115, 118, 119
procedural rules, 124 Prevention Project Dunkelfeld
non-judgemental approach, 173, 304 (PPD), 204
non-residential care, 237 prostitution, 230
nurturance-based care, 242–5 proximal parent-child interactions, 75
nurturance care, 229, 245–50 psyche, 295–7
psychoanalysis, 154, 185, 309
psychodynamic group psychotherapy,
O 58–9
Ó Ciardha, 161 psycho-educational group
Ontario Institute of Technology, 318 programme, 50, 58, 195
organisational support, 203 psychological assessment, 22, 46–53
Organization of Eastern Caribbean psychology, 2, 22, 194, 245
States (OECS), 234–5, 235n2 psychopathology, 45
Oriana, 19 psychotherapy, 22, 59–68, 181–3,
255, 309, 314, 319
psychotherapy groups, 50, 51, 58–9,
P 66, 255, 330
painful feelings, 61, 81, 119, 307 public health approach, 1, 43, 173, 176
Pakura, 130 Purcell, 47
334 Index
R Salovey, 4–5
rape, 30, 39–43, 48, 58, 62, 189, sandplay therapy, 314–21
197, 324 Saradjian, 158
rapport, 54, 119 scapegoating, 192, 313–14
region, 42, 73, 75, 169, 170, 174, Schaverien, Joy, 311, 314
242 secure attachment relationships, 91
Regional Psychosocial Support self-awareness, 9–10, 13, 66
Initiative (REPSSI), 331 self-care, 25
residential child care, 229, 232–4 Self-Care for Trauma Psychotherapists
critical issues, 239–40 and Caregivers: Individual,
nurturance-based care, 242–5 Social and Organizational
training, 240–2 Interventions, 25
in Trinidad and Tobago, 271 self-confidence, 12
resiliency, 116, 118, 258–61 self-esteem, 56
respect, inspiration, self-esteem and self-loathing, 63, 175
empowerment (R.I.S.E.) self-management skills, 9–10
Project, 39, 54–6, 54–8, self-regulation model (SRM), 161–3
55–6, 63, 64, 67, 255, 298, self-reported training, 240–2
307, 330 self-therapy, 301–2
restorative justice (RJ) systems, 19, sensory-based methods, 108
30, 130, 136, 146, 148, separation anxiety behaviours, 253,
176–7, 196–9, 207–9 265, 266
reunification, 268–76 Serious Case Reviews, 167
rights-based approach, 56, 259 sex-offender treatment programmes,
risk assessment, 22, 258–61 170, 174, 176–7, 199
Roaches and Flowers, 28 sexual abuse, 1, 27, 33, 57, 145, 153,
Road of Life, 331 157, 170, 172, 173, 210, 211,
Rogers, Carl, 186 214
role-play exercise, 67 adolescent female victims, 307
Rudominer, 153–4, 155 art as therapy, 298
Russel-Bowie, 262 determinants of, 201–3
Russell, 152 Emotional Intelligence, 4
Rwanda, 197 prevention, regional system, 204
protecting young children from,
163–8
S systems model for, 201–3
Sadia, 37 UNICEF study, 203
Safeguarding Children Boards women and, 159–61
(SCBs), 179 sexual assault, 148, 150, 158
Index 335
sexual crime, 41, 209 Stroebel, 152

Sexual Offence Rehabilitation and A Study of Children’s Homes in Trinidad
Treatment (SORT) Project, and Tobago, 240, 242
202–5 Sullivan, 98, 99
sexual offences, 161–3, 196–9 Summer Heroes, 302–11, 329
sexual violence, 41, 55, 66, 169, 173, Summers, 58
177, 179, 197, 210, 214, Sweet Water Foundation, 54, 298,
215 307, 330
shame, 7, 12, 30, 327
Shapiro, 78
sharing, 64, 327–8 T
Sharon, 131 Tanik, 94, 123, 128, 129
Shem, 131 Tan, Shaun
short-term interventions, 75 The Red Tree, 262
Simmonds, 251 teenage mothers, 73, 230
Slade, 40 The Dying God Series, 294
social awareness, 15–17 Thematic Apperception Test (TAT),
social betrayal, 166 186–8, 190, 192, 261, 262
social competencies, 8, 15–17 The Red Tree, 262
social drivers, 201–3 Thistleton-Martin, 262
Social self-esteem subscale, 52 time-limited method, 116, 118–19
social support, 73, 162 timeline
social worker-led attachment Anton and Oriana, 232
intervention, 77–81 Levi, 151
social workers, 5–6, 22, 23, 33, 43, Melissa, 32
80, 81, 103, 108, 115, 117, Nina, 97
121, 127–9, 181, 240, 259, transcendence, 328–9
269, 277 transference, 256–8
sociocultural context, 58, 74, 76, transformation, 328–9
180 translocation, 99
Sogren, 235, 238, 243, 249, 272, trauma membrane, 64, 65
273 treatment plan, 174, 175, 261–7
Soviet Union, 309 Tree of Life, 331
Stalker, 103 Trevarthen, 102n3
steady state, 119 Trinidad and Tobago, 234, 240, 244,
Steinhardt, 112, 114 271, 282, 295
Stephen, 317–20 trisomy 21, 99
St. Kitts, 73 Trotman Jemmott, Ena, 98, 164,
strengths-based approach, 259 168, 176
336 Index
Truth and Reconciliation violence, 1, 13, 17, 18, 20, 35, 37,
Commissions of South Africa, 130, 158, 214
197 vis-à-vis psychotherapy, 154
Tzu, Chuang, 182 volunteers, 211, 213, 303
vulnerability, 55, 97, 98, 101, 136,
321, 324
U
ubuntu, 196
UNICEF, 103, 155, 203 W
United States of America (USA), 42, Mrs. Walsh, 147
130, 176, 197, 256, 275 Ward, 152, 161, 162
unresolved crisis, 115, 121 The Warrior Journey, 331
unresolved/disorganised/ disoriented Waul, 245
attachment classification (U/d), Weekes, Shamar, 168
71 Welsh, 109, 110
unsafe abortion practice, 42, 43 Western Bible’s Ten
US Child Welfare Information Commandments, 182
Gateway, 276 women, sexual abuse, 159–61
US Family Violence Prevention World Report on Violence against
Fund, 275 Children, 237–8
US National Center on Child Abuse
and Neglect, 115
Y
Yingmei, 295
V yoga therapy, 58, 63, 193–5, 330
Van Der Kolk, Bessel, 54, 186, 256,
261, 262
Velez, Edin, 310 Z
venus, 92 Zeanah, 156
venus traps, 92, 292 Zen Buddhism, 193
Vermont Studio Centre, 322 Zimbabwe, 332

Childabuseincaribbean

Uploaded by

Copyright:

Available Formats

You might also like

Childabuseincaribbean

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Childabuseincaribbean

Uploaded by

Copyright:

Available Formats

TREATING CHILD SEXUAL

ABUSE in FAMILY, GROUP

ADELE D. JONES; ENA TROTMAN JEMMOTT;

Treating Child Sexual

ISBN 978-1-137-37768-5 ISBN 978-1-137-37769-2 (eBook)

Library of Congress Control Number: 2016942787

© The Editor(s) (if applicable) and The Author(s) 2016

Cover image ‘The Roach – Landscape’ © Jaime Lee Loy 2008

Printed on acid-free paper

This Palgrave Macmillan imprint is published by Springer Nature

and Opinions on Child Sexual Abuse in the Eastern Caribbean’ (Jones

1 The Gifted Practitioner: Emotionally Intelligent

2 Working with Adolescent Girls who have been Sexually

3 Working with Children with Learning Disabilities:

4 Working with Young People with Harmful Sexual

Theoretical Models to Assist Clinical/Practitioner

5 Interventions with Children in Residential Care:

Family History 221

6 Art as a Therapeutic Modality: Historical and Cultural

Fig. 1.1 Dimensions of emotional intelligence based on the pioneering

Fig. 4.1 ‘Metamorphosis’ © Jaime Lee Loy (2008) 139

Table 4.1 Possible areas of focus in rehabilitation and treatment 202

© The Editor(s) (if applicable) and The Author(s) 2016 1

and families. Using case studies, we demonstrate the interconnecting

The academic framework for this book is informed by the theo-

This book is about abused children and practitioners/clinicians/thera-

The EI research shows that it is twice as important as IQ in predict-

if traditional schooling increases cognitive abilities … it might be possible

The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT)

Applicability of EI in Therapeutic Settings

overestimates his or her skills in helping a traumatised child and mother;

In general, people’s self-views hold only a tenuous to modest relationship

Achieving congruence between how a person views their performance

At this juncture, we should recognise that there is a large body of

EI, briefly summarised, is the capacity to effectively handle one’s own

Fig. 1.1 Dimensions of emotional intelligence based on the pioneering work

Personal Competencies: Self-Awareness

When beginning work with a sex offender, a psychotherapist may expect

Self-awareness and self-management skills (described below) should

who is committed to ongoing personal and professional development

Emotional Self-awareness in Action

Fig. 1.2a Self-awareness skills

Emotional self-awareness means being aware of one’s feelings/emotions,

Accurate Self-Assessment in Action

Fig. 1.2b Self-awareness skills

Accurate self-assessment is helped by knowing one’s strengths and limita-

Fig. 1.2c Self-awareness skills

Where work performance is concerned, the relationship between

Emotional Self-Control in Action

Fig. 1.3 Self-management skills

The reader is encouraged to undertake further self-directed learning

Social Competencies: Social Awareness

Social Awareness and Relationship

Self-Awareness Social Awareness

Emotional Self- Empathy

Fig. 1.4 Emotional Intelligence illustration based on the pioneering work of

and interests of others and help the practitioner to build consensus

meaningful therapeutic intervention, is almost predetermined—