Jane* always saw her seven-year-old daughter Mercy* as quiet and reserved. "She never used to speak for herself or express her feelings," she recalls. "I assumed that's just how she was."
However, she discovered the real reason why her daughter was so withdrawn when she went upstairs one evening and witnessed Mercy being sexually abused by a male member of her extended family, someone Jane had trusted to babysit many times. "I was in so much pain. I wanted to kill him," says Jane, who went to the police the following morning. Her daughter was interviewed, but no charges were brought due to lack of evidence. Jane was left wondering whether the police believed her or not.
Then Mercy and Jane were offered the opportunity to attend Letting the Future In (LTFI), a therapeutic service run by the NSPCC for children and young people who have been sexually abused. Jane admits she had her doubts. "At first I thought ‘What's the point of going there? The damage has been done, it's not going to help'," she says.
It took several calls from an NSPCC practitioner to convince Jane, but eventually Mercy embarked on the programme at a centre in the West Midlands and after just a few sessions, mum could see the positive change in her daughter.
LTFI aims to provide a safe environment for traumatised children to explore their feelings and start the recovery process. It draws on a range of therapeutic approaches including creative therapy and play therapy to help children process experiences and express difficult emotions they may not be able to speak about or even have the words for. Parents or carers also have sessions with a practitioner to help them support their child's recovery.
Element of control
Careful thought is put into every aspect of the programme including the surroundings. At each session, the first stop is the kitchen, where the child can choose a drink. This is a chance for the practitioners to attune to the child's mood and a simple way of giving the child an element of control.
From the kitchen they go into one of the bright, colourful rooms filled with teddy bears and dolls of all sizes, a dolls' house, a toy kitchen, boxes of smaller toys, and painting and craft materials. One box contains "scary" action figures, which children sometimes use to act out scenarios where they feel threatened or hurt.
This kind of role-play and activities such as painting, drawing, storytelling and clay modelling can all be used to help children make sense of what has happened to them, explains NSPCC social worker Dom Wain, who worked with Mercy.
"Traumatised children often have a jumbled and confused internal narrative about what happened," he says. "We can help them unpack that in a safe way so that at the end of the therapy, the child can take away with them a more complete, more coherent narrative."
It is also a way for children to let out feelings they may have kept to themselves for a long time.
"I have the historical information in the back of my head and interpret the way they are playing," says Wain. "If ‘their' character is being really angry or aggressive with a doll, my role is not to say ‘Oh, that poor doll, don't hurt it'. Quite often children have feelings that are trapped and they carry them in isolation. So externalising them is valuable in itself."
Part of his role is to explore relationships, identity, self-esteem and look at responsibility and accountability for the abuse and "take that away from the child".
"Blame, shame and guilt may be attached to the child by the abuser, either subtly or explicitly, and children find that really difficult to let go of," says Wain. "We don't have a magic wand, but we can help children to gain a different perspective about being abused and to hear some very strong messages about them being valuable."
Children are referred to LTFI in various ways. Referrals may come via the Childline helpline, teachers, police or social workers. To be eligible, children must be aged between four and 17, be safe from abuse and have emotional support from a parent or foster carer, with no moves planned. If assessment suggests a child is not safe from further abuse, the case is referred back to local authority children's services.
After being assessed, children are usually offered up to 20 therapeutic sessions, although some may go on to have up to 30 if needed. The last few sessions involve the child and parent/carer together with the whole process, including assessment, usually lasting between nine and 12 months.
The programme is delivered by practitioners working in small teams and is currently on offer at 21 NSPCC centres around the UK. The intervention is underpinned by a guide rather than a manual that must be followed, giving workers more freedom. They use a range of approaches depending on a child's age, learning style and abilities and the stage they are at. As well as creative and play therapies, counselling and work on children's feelings, other interventions include education about grooming and keeping safe, work on boundaries, solution-focused brief therapy and cognitive behavioural therapy.
The majority of practitioners already have several years' experience of direct work with children affected by sexual abuse and many have additional qualifications in fields such as therapy and counselling. All have attended a special six-day LTFI training course, which can be followed up with additional training.
The programme was developed by NSPCC after the charity identified gaps in support for this highly vulnerable group, despite a large body of research showing the damaging impact of sexual abuse in the short and long term.
"Before developing LTFI, we did a mapping survey and found generally services were few and far between," says NSPCC development and impact manager Trish O'Donnell. "If you had a mental health problem and you met the CAMHS (child and adolescent mental health service) criteria, you could get referred to the mental health service, but you couldn't get a service for the experience of being sexually abused."
LTFI is based on evidence of successful interventions, and also the views and experiences of practitioners and young people on what works best. One of the most valuable aspects of the scheme is the fact it is not part of the physical or mental health system, but delivered in the community by social workers, O'Donnell believes.
The programme was launched in 2011 at 18 NSPCC centres in England, Wales and Northern Ireland, and evaluated by the universities of Durham and Bristol.
Their study is believed to be the largest multi-site randomised controlled trial in the world looking at a sexual abuse intervention for children and young people.
The results of the trial, published earlier this year, show therapeutic interventions with sexually abused children can be effectively delivered by trained social care professionals. However, the findings suggest LTFI works best for older children aged eight and over.
The trial involved 242 children - half embarking on LTFI straight away while half were on a waiting list.
Among the group getting the intervention immediately, the proportion of children aged eight and over with severe emotional and psychological difficulties dropped from 73 per cent to 46 per cent after six months.
For younger children, there was no significant drop in trauma levels after six months of LTFI. However, at 12 months, the proportion with severe difficulties had dropped from 89 per cent to 40 per cent, indicating improvements may take longer to achieve or to be recognised by parents and carers in this age group.
The average cost of providing LTFI for a child, including meetings with external professionals, management costs, staff training and supervision, is £2,300. The average cost when a child with a range of mental health problems is seen by CAMHS is about £5,000.
Children and young people who come to LTFI frequently have a wide range of needs and a significant proportion are in care. John Harrison, who manages the team of six practitioners that include Dom Wain, estimates 15 to 40 per cent of their cases are looked-after children.
"They have a diversity of needs, with many having experienced neglect, abuse, separation and loss as well as sexual abuse," he says. "We try to deal with those traumas so they can also deal with their post-sexual abuse needs." Some looked-after children also get help from CAMHS with issues such as self-harm and suicidal thoughts.
It is more unusual for children who are not looked after to have other help at the same time, but sometimes they are also supported by counsellors in schools, voluntary organisations or CAMHS. The NSPCC practitioners work closely with these agencies. "It needs to be carefully planned out with agreed roles around the areas people are working on, and good communication," says Harrison.
Parents or carers are generally offered six to eight sessions, but that can be more in some cases. While the focus of LTFI is on the child, parents have to deal with the fact their child has been abused and with their own trauma. In some cases, they have also been groomed by the abuser to gain access to their child. If a parent - "invariably the mother" - needs more support, practitioners will make referrals to appropriate services.
The NSPCC is pushing for all sexually abused children to be offered therapeutic support via the "It's Time" campaign. O'Donnell hopes other organisations will also be able to provide LTFI in the future. Some agencies are interested, but she is under no illusions about the impact of tight budgets and austerity cuts on their ability to offer services.
In the meantime, the NSPCC is piloting an adapted version of LTFI for children with learning disabilities in services in Luton, Peterborough and Swindon. A slightly different approach is needed for this group, who often take longer to form relationships with the practitioner, need more sessions to reinforce certain messages, and may need to be assessed in different ways.
The programme has certainly made a huge difference to Jane and Mercy. The daughter she once thought of as quiet and reserved is now "Little Miss Chatterbox", says Jane.
"Everybody has seen a difference in her," she adds. "She's been taught a lot - to be independent, to say no, to choose what she does and doesn't want to do."
Mercy still struggles to get to sleep by herself and has nightmares, but Jane says she is much more able to express her feelings and the programme has helped mum and daughter communicate with each other.
"I thought it was just going to be for my daughter, but it ended up being good for us both," says Jane. "That bitterness is gone, that anger is gone and maybe in time you heal when people listen to you. I could easily have gone right down without the support I got."
THERAPY IN ACTION: LOUISE'S ‘GOODBYE' SESSION
Ten-year-old Louise* has had 30 sessions of therapy rather than the usual 20 because her experience was so horrific - she was abused by both parents. She is now in foster care with carers she calls mum and dad.
At previous sessions with NSPCC practitioner Jenny*, Louise revealed her fears that her parents might find her and harm her again. In the last session, Jenny helped Louise make a video to let her foster carers and social worker know about the work she had done and her worries about the future.
Today, Jenny has invited Louise's foster carers, her social worker and the social work assistant to come along as active participants in a final "goodbye" session. "I had an idea of what I wanted to achieve from it and I had emailed them with ideas about it," she explains.
Jenny begins the session by thanking everyone for coming and giving them a plan of how the session will progress. They start by watching Louise's video.
Jenny then suggests they use role-play with hand puppets to demonstrate in a very visual way to Louise how all the adults around her will protect her in the future.
Louise gives out the puppets, allocating a dinosaur puppet to her foster mum. This symbolises the fact that her foster mum could be a fierce protector, explains Jenny after the session.
Using the puppets, the adults address Louise's fears and reassure her. Her carers tell her they will always make sure she is safe and would never let her parents get into their house. A puppet policeman and puppet judge also explain what they would do if Louise ever needs help.
The 15-minute role-play leads into discussions about roles and responsibilities and what should happen next so Louise can see there is a plan in place for her future safety.
For the final 15 minutes, Louise decides to dress up as "the queen" and directs the willing adults to wait on her.
"It was about her trying to regain some control," explains Jenny afterwards. "I think she needed to end the session through play. By that stage, her mindset was about disengaging from the process. She had given me some chocolates and was very keen for me to open them and start sharing.
"When the time came to say goodbye, I told her: ‘You've achieved so much and don't need me any more'."
Louise's foster carers ask her if she wants to give Jenny a hug, but she opts for a fist-bump instead. She skips out of the building for the last time, hand in hand with them and smiling.
LESSONS FROM LETTING THE FUTURE IN
- Keep your support child-centred. Be prepared to listen, use techniques that suit each individual child and include them in making decisions.
- The bond you form with each child is key to their recovery. Find out more about the interests and activities they enjoy, make sure you keep appointments and are on time, and agree how you will work together from the start.
- Help carers feel supported and understood. Be positive about a child's potential to recover and help parents understand children's needs. Consider referring parents to specialist support if necessary.
- Understand and use the child's support network. Do this early on with the child, if possible. Identify roles and responsibilities of professionals involved with the child and implement home and school safety plans.
- Your own welfare is important. Good supervision and peer support are vital. Don't be afraid to ask for advice. Set aside time to reflect on your practice and keep up to date with new learning.
- For more information, advice and resources, go to www.nspcc.org.uk
Source: Someone to Lean On: Advice for professionals giving therapeutic support to children who have been sexually abused, NSPCC