International Journal of Clinical and Experimental Hypnosis

ISSN: 0020-7144 (Print) 1744-5183 (Online) Journal homepage: http://www.tandfonline.com/loi/nhyp20

Storytelling, Hypnosis and the Treatment of Sexually Abused Children Judith W. Rhue & Steven Jay Lynn To cite this article: Judith W. Rhue & Steven Jay Lynn (1991) Storytelling, Hypnosis and the Treatment of Sexually Abused Children, International Journal of Clinical and Experimental Hypnosis, 39:4, 198-214, DOI: 10.1080/00207149108409636 To link to this article: http://dx.doi.org/10.1080/00207149108409636

Published online: 31 Jan 2008.

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Date: 05 November 2015, At: 19:01

STORYTELLING, HYPNOSIS AND THE TREATMENT OF SEXUALLY ABUSED CHILDREN' Downloaded by [NUS National University of Singapore] at 19:01 05 November 2015

JUDITH

W.RHUE

Ohio Llniuersity College of Osteopathic Medicine, Athens

AND

STEVEN JAY LYNN23 Ohio Unicersity, Athens

Abstract: The present article describes an assessment and therapy program for sexually abused children using hypnotherapeutic techniques which center on storytelling. Storytellingpresents the therapist with an opportunity to use comforting suggestions, symbolism, and metaphor to provide the emotional distance necessary to deal with the trauma of abuse. Hypnotherapy proceeds in a stepwise fashion from the building of a sense of safety and security; to imaginative sharing; to the introduction of reality events; to the final step of addressing complex emotional issues of loss, trust, love, and guilt brought about by the abuse. Childhood sexual abuse is a problem of vast proportion. As many as one of every four girls in North America may be sexually victimized before adulthood (Finkelhor, 1979).The problem is not limited to females. In fact, estimates suggest that 9-128 of male children are victims of sexual abuse (Herman, 1981; Russell. 1983).The estimate that between 150,OOO and 400,000 children in the United States are victimized annually (Finkelhor & Hotaling, 1984; Mrazek, 1983) suggests that sexual abuse touches the lives of many children. Statistics are not available for the incidence of abuse on a world-wide basis (Ferrier, Shaller, & Cirardet. 1985), but there is little doubt that children have been at risk for sexual abuse "at all times and places" (H. Parker & S. Parker, 1986). A consensus exists (Briere & Runtz, 1987, 1988; Gold, 1986)that childhood sexual abuse has multiple aftereffects: dissociation, somatization, anxiety, sleep disturbance, tension, sexual problems, anger, depression, guilt feelings, diminished self-esteem, and interpersonal problems. An awareness of the serious repercussions of sexual abuse has kindled interest in a host of treatment interventions (Kolko,1987). Nevertheless, interventions that specifically incorporate hypnotic and imagination-based Manuscript submitted November 21, 1989; final revision received February 18, 1991. 'Portions of this article were presented at the 98th annual meeting of the American Ps chological Association, Boston, August 1980. authors wish to thank Dr. Erika Fromm and anonymous reviewers for their valuable contributions and comments on earlier versions of this article. ?leprint requests should be addressed to Judith W. Rhue. Ph.D., Department of Family Medicine, Ohio University College of Osteopathic Medicine. 325 Crosvenor Hdl, Athens, OH 45701.

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methods have not been reported in the literature. This is noteworthy insofar as hypnotic techniques have been used to treat other traumarelated problems and disorders. These include the treatment of posttraumatic stress disorders (e.g., MacHovec, 1984; Spiegel, 1988);d’issociative disorders (e.g., Kluft, 1983; Ross, 1984); global amnesia (e.g.. Eisen, 1989); traumatic grief (Van der Hart, Brown, & Turco, 1990); the aftereffects of adult rape (Dempster & Balson, 1982; Ebert, 1988; Valdiserri & Byrne, 1982); and adult incest victims (Miller, 1986). To redress this imbalance, the present authors will argue that naturalistic hypnotic techniques, which center on storytelling, can be used in the assessment and treatment of the aftereffects of child abuse. Storytelling is actually a well established method. It was utilized and written about by Despert and Potter (1936) more than 50 years ago, and it is nicely exemplified by R. Gardner’s (1977) psychoanalytic work with children. R. Gardner invited children to make up creative stories which he treated in a manner analogous to adult dream productions. Stories generated by children served as stepping stones for stories scripted by the therapist that framed alternative approaches to problems; interpretations of situations; and personal attributions in a positive, constructive manner. Numerous clinicians have either patterned their work after R. Gardner’s (1977) or modified his techniques (e.g., Aurela, 1987; Brooks, 1987; Davis, 1986; Kestenbaurn, 1985; Lawson, 1987; Levine, 1980). Storytelling, which accesses fantasy and imagination, has fallen under the rubric of “hypnotic” in the psychological literature. Storytelling is client-centered and permissive. Many of the methods described in the present paper can be thought of as naturalistic induction methods. They are “hypnotic” in that they enhance qualities of imagery, absorption, and the involuntary, spontaneous quality of ideation, behavior, and affect. Numerous examples of hypnotic storytelling are presented by G. G. Gardner and Olness (1981), and Milton H. Erickson is well known for his creative use of therapeutic stories and metaphor. Hypnotic storytelling procedures have been used to treat children in acute pain (Kuttner, 1988) and children who undergo difficult medical procedures (J. R. Hilgard & LeBaron, 1984). Storytelling can combine direct and indirect suggestions in creative ways; it has much akin with play therapy and with Porter’s (1975) guided fantasies that are presented to children as bedtime stories. The present authors’ approach synthesizes the therapeutic interventions we have found to be most effective in our work with 32 victims of sexual abuse, 4 to 10 years of age. The methods that will be described can also be used with other interventions and can be used to treat posttraumatic stress disorder, dissociative disorders, and short-term reactions to trauma in childhood, all of which require titrating affect, controlling abreaction, and fortfiing a sense of personal mastery. Dissociative Cognitive Strategies in Sexually Abused Children Because fantasy, imagination, and daydreaming are integral to the child’s cognitive and affective life (Klinger, 1971), hypnotic techniques are

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well suited to this population (London, Morgan, & E. R. Hilgard, 1973). Empirical studies of children have documented a modest association between measures of fantasy and hypnotizability (e.g., LeBaron, Zeltzer, & Fanurik, 1988). This relationship holds for adults; in this population, hypnotizability also has been associated with a propensity for everyday imaginative involvements (see Lynn & Rhue, 1988). With respect to adults, evidence suggests that an association exists between a history of severe punishmentkhild abuse, hypnotizability, and imaginative tendencies (see J. R. Hilgard, 1970; Wilson & Barber, 1983). For example, we (Lynn & Rhue, 1988) recently found that 6 of the 21 fantasizers studied reported childhood physical abuse (e.g., broken bones, bruise), whereas none of the non-fantasy prone Ss reported being abused. Rhue, Lynn, Henry, Bukh, and Boyd (1991) also found that students who reported a history of both physical and sexual abuse were more hntasy prone than nonabused Ss. Although Ss in this study (Rhue et al., 1991) who reported abuse were no more hypnotizable than nonabused Ss, several other studies (Nash & Lynn, 1986; Nash, Lynn, & Givens, 1984) have shown that the majority of Ss who reported being physically abused as children scored as high hypnotizable Ss as adults. Imagination and fantasy serve an active yet functional role in disavowing negative affect, disowning aspects of the self, and, more generally. regulating internal experiences. Lynn, Rhue, and Green (1988) have posited that “dissociative cognitive strategies,” which abused children report invoking to distance or separate themselves from aversive events outside their realm of control, can be thought of foremost as a fantasy-based creative activity. An example of such activity would be imagining that the “core self” is separated from the body that is being subjected to abuse. What has been labeled “dissociation”(Spiegel, 1984) can be thought of in this way. Not only might dissociative imaginal and attentional strategies (e.g., amnesia, distraction, motivated forgetting)serve a defensive function, but repeated acts of abuse may spur imaginative activities that mitigate anxiety and guilt and block the pain of punishment. Of course, not all abused or fantasy prone children exhibit dissociation or have particularly well developed hypnotic abilities (Carlson & Putnam. 1989). Nevertheless, abused children may be particularly well suited to exploit storytelling techniques and benefit from them.

Hypnotherapy and Storytelling with Sexually Abused Children Assessment and general considerations. The very occurrence of abuse, much less the details surrounding it, is often shrouded in a black curtain of secrecy. Children are often reluctant to discuss sexual abuse and minimize its frequency, duration, and graphic details. Nevertheless, the therapist must respect the client’s privacy. To spare the child the emotional pain of disclosing the abuse before he/she is ready to do so, collateral

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information sources, such as social service agencies, may be utilized. If abuse is continuing, it is incumbent upon the therapist to prevent continued trauma to the child and to inform family members and the appropriate authorities. It is not essential that the therapist be absolutely certain that abuse has occurred. Even if it can never be ascertained with certainty that abuse has occurred, the child’s account of abuse may nevertheless carry the weight of narrative truth while lacking the stamp of historical truth (Spence, 1989). The therapist must resist the temptation to focus on ferreting out the “reality” of what occurred, and thereby impose an agenda that disrupts treatment. Because of the danger of pseudomemory creation (Laurence & Perry, 1983), the therapist should exercise caution about suggesting or implying that abuse occurred. Until the child is ready to disclose the Fact or details of abuse, relationship building and symptom reduction are primary treatment objectives. The assessment of the child must also address hidher willingness and ability to profit from storytelling techniques. Children who enjoy imaginative reading or listening to and telling stories and fairy tales are good candidates for storytelling. Intense absorption in make-believe games; the belief that dolls and stuffed animals are alive; imaginary friends, animals, and objects; and pretending, and, in some sense, believing to be someone else (i.e., a fairy tale character), suggest a capacity for imaginative involvements (Lynn et al., 1988)and augur well for involvement in fantasy and storytelling. To provide guidelines for stories, the child is asked about hidher favorite fairy tales, story characters, superheroes, and persons he/ she admires. After a thorough assessment, collaborative storytelling can proceed. We do not routinely measure hypnotizability; it is necessary only that the clients are absorbed in the story. Children are encouraged to immerse themselves fully in the imagined events, and to identify with characters with whom they feel a sense of kinship. To avoid challenging children, direct ideomotor suggestions are rarely used. They are used only when there are definite indications of movement in response to suggested images; specific movements are suggested in order to intensify the observed response and to rat+ the child’s experience. Although children are asked to close their eyes in order to focus on the story, if children open their eyes, this behavior is not discouraged. In fact, some children, particularly those younger than 8 years of age, spontaneously act out aspects of the story or talk in a particular character’s voice. Stories that initially provoked anxiety, but that the child wishes to retell, may be preceded by relaxation suggestions. Building a safe hauen: Thefauorite place. It is essential to build a safe context from which feelings about the abuse can be explored (see Brown & Fromm, 1986). To build a safe haven, the child is encouraged to de-

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scribe his or her favorite place. This may be an actual place or a fantasized, idealized place. What is important is that the child feels safe, secure, and comfortable in this place. Favorite places range from the conventional to the improbable. One client we treated described his favorite place as a large green metal box on wheels that resembled a habitable dumpster; another client described an underyvater cave protected by friendly dolphins. So as not to provide an excessive degree of structure or to create demands for reporting only positive affect, we avoid suggesting that the child feels “happy” in the favorite place. Nor is it stipulated whether the child is alone or with a special companion. It is, however, often suggested that the child fill this place with the trappings andlor creatures that he/ she likes best (e.g., stuffed animals, family pets, imaginary companions, and articles of self-defense). When children are anxious, an imaginary gate or other buffer is suggested to determine who enters and exists. One of the challenges confronting the therapist is to monitor and modulate the child’s affect during the story. It is, therefore, useful to sprinkle direct suggestions for relaxation, comfort, and security into the unfolding narrative. One helphl guide to specific suggestions is the child’s responses to questions such as, “How can you feel even better in this place?” Furthermore, it has been found useful to suggest props or devices. such as magic wands, rings, or magic words with special powers, in order to explore the child’s wishes (“What three wishes would you like to be granted”) or to create certain effects such as relaxation or amnesia for selected events (“When the magic wand touches you, you will forget everything about . . ., it will seem as if you dreamed it all, only to recall it perfectly when the magic wand touches you again.”) New stories and characters are introduced from the safety of the favorite place, and the child is encouraged to suggest various plot endings. Stories begin to take on a more realistic quality, with issues of trust, fear, hurt, guilt, love, caring, and anger introduced. Nevertheless, the child is encouraged to bring imaginary protectors if they are needed. The ualue of metaphor. Brooks (1985) has argued that metaphors contained in children’s stories can be construed as dynamic organizers of information and behavior that “provide a window into the child’s phenomenal world (p. 7621.” Metaphors can be used to cement the therapeutic alliance, to educate the child about the agenda of treatment, and to transfer what is learned to events and problems of everyday life. Metaphor serves as a basis of Brooks’(1981) “creative characters” method. Here, the therapist selects key issues facing the child and then develops characters in the context of a narrative that reflects core therapy issues. Similarly, Kritzberg (1972) has described a “therapeutic storytelling word game” (TaskitITell-A-StoryKit) that uses a stimuIus board. The method stimulates motivation, ideation, and verbal productivity; it promotes the interpretations of stories and the generalization of what is learned to real-life situations.

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The forging of a connection between what happens to the story characters and the child’s own life is a crucial step in therapy: At some point the therapist moves beyond the metaphor to “nitty gritty” real-life problems and issues. To this end, as rapport with the child builds, he/she is encouraged to relate stories of real-life events that have happened to his/her friends or to “imaginary friends.” The childs stories are not questioned; no effort is made to have the child disclose whether described events happened to him/her or to hidher friend. Nevertheless, spelling out the metaphor, in terms of its connection to real-life events, is a treatment objective. To foster this sort of “connection-making,” we generally sidestep directly interpreting the meaning of the stories. Rather, insight is promoted by nondirective questioning (“Do you see any connection between what happened to E. T. and yourself?”), with interpretations made following the childs insightful remarks. This process of connection-making is a treatment objective that permeates all the techniques described in the present paper. Thefaoorite story. When the child is pressured to reveal details of the abuse, resistance can be expected. Specifics about abuse may emerge only gradually, with children testing the therapist’s reaction to symbolic or “actual” accounts of abusive events. To encourage children to talk about themselves and difficult subject matter, we invite them to share a favorite story with us. Fears can be shared and conquered, anger expressed, revenge extracted, sorrow experienced, and loss mourned, if not on a literal, then on a symbolic level. The child can control the imaginal representation of a feared situation and become desensitized to it by way of repetition. If anxiety mounts to uncomfortable levels, suggestions for imaginal separation from the situation may be initiated by the child or the therapist. As the child becomes emotionally secure and can express feelings associated with the abuse with less distancing, direct suggestions are given to promote a stronger, unified sense of self and wholeness. The following example illustrates the fact that the details of abuse often emerge gradually, after considerable rapport building and collaborative storytelling. Teresa4, age 8, for 2 months recounted favorite stories that depicted children who were terrified of being lost or hurt. Finally, at the end of one session, she asked the therapist,“Don’t these stories disgust YOU?” The therapist replied that she was not disgusted and that sometimes children were afraid of bad things happening to them. During the next session, Teresa recounted a usual favorite story, but added a description of how a young girl is molested. Teresa then demanded that the therapist “make up a good story, for goodness sakes” and listened to the therapist’s story tight-lipped without a word. At the following session, 1week later, Teresa said, “That girl in the story last week was my younger sister.” Thereafter, she recounted numerous instances of abuse in her stories, ‘This patient’s name (and others cited in the present paper) have been changed.

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but clearly and repeatedly announced that all of these happened to her “younger sister.” Only after 7 months did she say to the therapist, “A lot of things that happened to my sister happened to me too.” Thereafter, Teresa never mentioned her sister, but gradually began to enter her own stories as a character. Teresa did not have any siblings. Images of personal power and control. Images may be used to alleviate anxiety and foster a sense of personal power and control. These images can be loosely categorized in terms of escape images (e.g., flying horses, magic carpets, rocket ships); protection images (e.g., suit of armor, E.T., 10-foot velveteen rabbit); control images (e.g., chameleon, computer console that manipulates people and feelings, television with control dials); and power images (e.g., “incredible hulk,” favorite superhero). These images can be introduced when children recount stories in which the characters are hurt, molested, or “bothered,” or when children are particularly anxious for any reason. The therapist may also serve as a powerful ally and protector who helps the child brave whatever threat presents itself. The following example illustrates how stories that contain images associated with protection, power, and control, can assist the abused child in confrontingstressful life situations, including mastering situations related to the legal system. Billie, a 9-year-old boy, was scheduled to testify in criminal proceedings court about the sexual abuse perpetrated by his uncle. Billie had testified in a previous hearing and dreaded the questions asked during cross-examination by uncle’s attorney. He said that he felt like he was being cut by each question and felt that everyone could see the cuts. The therapist described a superhero who was always protected from hurtfiil things by an invisible clear plastic shield. Anything that hit the shield simply bounced off and could not hurt the person underneath. This idea appealed to Billie; the therapist had him close his eyes, relax, see the imaginary shield in his mind, and describe it. The therapist then had Billie stand up and imagine putting the shield all around him and zipping it up. Next, the therapist had Billie jump around and clap and sing to see all of the things he could do with the shield on. After allowing Billie to look in the mirror to be sure no one could see the shield, the therapist asked Billie to pretend he was watching a television set showing the courtroom on the screen. He could see himself wearing the magic shield that would protect him, but no one else could see it. In watching the courtroom scene, the therapist asked Billie to have the attorney ask him a question that might have been hurtful in the past. Billie said in an accusatory voice, “You made the whole thing up to get even with your uncle fbr not taking you on vacation, didn’t you?” Billie was delighted in using the magic shield and the television to practice scary things. He always took the magic shield with him when he left the therapist’s office. Sharing responsibility for the story. In addition to using images to improve the childs self-esteem, and to help the child to regain a sense of

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control, we emphasize and reinforce the child’s freedom to chart the course of the story, to “make it what you want.” The child is also invited to select a story from among one or more alternatives for the therapist to tell, or to choose a story in which the child and therapist alternate assuming responsibility for the narrative. The importance of patience and accepting, valuing, and respecting the child’s story is illustrated in the following example: Susan, age 6, would first tell her story, and then have the therapist tell one. She adhered rigidly to this pattern and repeatedly told an angry, violent story in which a helpless child (a young girl) is buried alive by falling furniture as a monster roams through her home looking for her. Over 13 sessions, Susan’s story plot remained invariate, although her characters fared differently. At first, Susan had the little girl die under the furniture before the monster could get her, saying that she was “better off dead anyway.” As the therapy progressed, and Susan’s control and power were suggested in the therapist‘s stories, the little girl began to find weapons and fight the monster, although both characters suffered in these battles. In Session 13, the little girl had grown very strong and was able to perceive the approach of the monster from some distance, and summon the police so that she would not be harmed. Susan was clearly pleased with herself, and had the therapist congratulate her as the monster was taken away. The incongruity of a monster being removed by the police was never discussed, and the next week Susan proposed a new story with less helplessness and violence. The “child as teacher.” Yet another mastery-building method is what the present authors refer to as the “child as teacher.” Children, like adults, enjoy the role of “helper.” Indeed, seeing oneself as being in a position to help another person minimizes feelings of dependence and helplessness and ratifies the perception of oneself as competent. When children teach other children, the “teacher” may learn as much or more than the “student.” Playing the part of a teacher can be a powerful antidote to thinking of oneself as a helpless victim. One way that the child can benefit from assuming the role of “teacher” is to suggest stories that would help other abused children know what to do if someone wants to touch them inappropriately or asks h i d h e r to touch them inappropriately. Relieuing guilt via metaphor and reframing. The legacy of abuse is often a crippling sense of guilt and shame. Sources of shame and guilt are multiple and include: (a)the belief that the child played some part in the abuse (e.g., guilt associated with sexual arousal and the misattribution that the child therefore “wanted it”); (b) the belief that some action or attribute associated with the child (about which he feels guilty) makes adults approach himher sexually (especially reported when there has been more than one abuser); and (c) the feeling of guilt associated with having talked about the abuse and betrayed the abuser. The therapist must identify the source of abuse and work to dissolve the child’s feeling that he/she is the responsible agent rather than the victim of abuse.

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To alleviate this burden of guilt, in story form, we recast the child’s problem as an irresolute dilemma in which the child coped as best as he/ she could under difficult, conflictual, and confusing circumstances. The child interacts with imaginary characters who are in situations analogous to those of the abused child, gives them advice, helps them not to blame themselves, and teaches them about what adults should and should not do. The story also challenges the child’s perception of badness and uses metaphors to promote insight. Examples include conveying the idea that getting rid of guilt feelings is like getting rid of germs, and that children who are recovering from having their tonsils removed require time to recover, just as abused children require time to recover from the effects of abuse. The therapist emphasizes the point that in each case the children will eventually feel better (Rhue & Lynn, 1991). Finally, the present authors have found it useful to tell stories about how other children have coped with dimculties similar to those of the abused child. Promoting good health. Sexually abused children are at risk for physical and psychological problems including vaginal and urinary tract problems, yeast and ear infections, and psycho-physiological illness (Adams-Tucker, 1982; Boekelheide, 1978; Sgroi, 1982). Trauma. including that produced by sexual abuse, has been theoretically linked to immune system suppression, although the evidence is inconclusive (Walker & Bolkovatz. 1988). The storytelling format can be used to provide suggestions for bodily integrity and good health. Also, we use guided imagery and hyperempiric suggestions (Gibbons, 1979) to teach children how to produce a sense of well-being and relaxation to counteract the stress associated with abuse. Achieving appropriote rewards. Finkelhor and Browne (1985) use the term “traumatic sexualization”to refer to developmentally inappropriate and dysfunctionalsexuality that arises from sexual abuse. Sexually abused children are confronted with adult sexual behaviors prematurely. Those who experience pain, as a result of the sexual abuse, may associate fear and sex; the child may require the therapist’s help to separate physical affection, and, later, sexuality, from pain. In the majority of sexual abuse cases, however, the child experiences minimal physical pain; sexual behaviors are instead paired with positive physical sensations, statements of affection and love, and a peculiar specialness - the child learns that sexual activities earn extra attention and material goods. The child may, thus, acquire an inappropriate repertoire of sexual behavior, exhibit confusion about hidher sexual self-concept, and have unusual emotional associations to sexual activities. Storytelling may be used to help the child learn appropriate ways of earning rewards via nonsexual means. Initially, fantasyhrtoon characters may be used in scenarios in which the characters strive, to gain rewards such as a new spaceship or a glowing purple turtle. Gradually, the therapist develops more realistic stories of children whose experiences are analogous to those

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of the abused child. Suggestion and repetition are used to bond positive emotions to age-appropriate methods of coping. Ultimately, sexuality is recast as a gift, not a commodity.

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THE CASE OF

ANN

The following case provides a more extensive example of how a variety of storytelling techniques (e.g., favorite place, images of power and control) can be used to modulate affect, foster perceptions of control and mastery, and facilitate the entry into previously unexplored areas of inquiry. In this case, role-played interaction with the child’s mother is an important aspect of treatment, which is combined with collaborative storytelling and interpretation of feelings. The following is the transcript from portions of Sessions 2 and 15 with Ann, age 8. Ann was a bright, verbal child. She had been sexually abused by her mother’s live-in boyfriend for several months. Evidence of abuse and neglect led to her removal from her mother’s home and subsequent placement with foster parents. The boyfriend confessed to fondling Ann and was sentenced to jail. The foster parents reported that Ann was enuretic, had frequent and frightening nightmares of being chased and stabbed, and sexually manipulated her dolls. Despite the boyfriend’s confession of abuse, Ann denied being abused, maintaining that he had “tried,” but that she had outsmarted him and nothing had happened. In these two sessions, Ann closed her eyes spontaneously. Because she appeared to be intensely absorbed in the stories, no attempt was made to formally test her hypnotizability. Session 2 Therapist: Hello Ann, I’m glad to see you today. Ann: What are we going to do? You said we might tell a story together. How are we going to do that? Therapist: It sounds like you’re ready to begin. Ann: I looked at the books in the library at school and picked out some stories, but you may already know them. Therapist: You really did get a headstart! That was a good idea and I bet that you can use your imagination with those stories you read to make them even better. You said last week that you make up your own stones when you’re playing with your dolls. Ann: Unhuh . . . I don’t want to talk about my dolls. I hate them! Therapist: It sounds like you feel pretty angry at someone. Ann: No, not really . . . Can we please talk about something else? Therapist: OK, we can talk about feeling angry and the dolls when you’re ready. Now, let’s think of our favorite places. I‘ll think of my favorite place, and you think of your favorite place. It doesn’t have to be a real place, an imaginary one will do. Ann: That’s easy. Therapist: Now, let’s use our imaginations to put our favorite places in the middle of an enchanted forest. Then we can take a walk in the enchanted forest and share visits to our favorite places.

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Ann: [Closes her eyes] You can come to mine and have cookies and coke

with me. OK? Therapist: That sounds nice. We’ll share a walk in the enchanted forest and then we’ll go to your favorite place and have cookies. Do you want to describe the enchanted forest or shall I? Ann: You do it. Therapist: OK. Do you want to walk beside me so we can look at everything together? Ann: No, I’ll stay behind you. That way if anything jumps out and gets you I can run away. [giggles] I’m only joking. Therapist: Let’s open our hands so that we can feel the big shiny key that opens the gate. Ann: Are you sure it’s safe? At night it could be dangerous. You don’t know who is in there in the dark. My foster mom had to leave the light on last night because I had a bad dream. Therapist: It seems that you feel better with more light so we can control that. We are the only ones with the magic key and we can make it sunny. You can even have a guard if you want. Ann: I want a giant dragon with big wings that will eat up anyone who shouldn’t be there. Her name will be Silver and she will rip them apart. I saw one on the Saturday morning cartoons. Therapist: Now we are walking through the enchanted forest. Can you see lots of flowers, red ones and yellow ones and white ones? They look so pretty it makes you feel happy. Can you hear the birds singing? Ann: Yes. I can see a robin. It’s building a nest. Can you see it? Therapist: Yes. Is that your favorite place I see up there? Ann: Unhuh, you’re the only one I am going to let in and you can’t tell anyone about it Iwecause [XI [mother’s Iwyfriend] might find out. Therapist: You’re still a little afraid of him even though you know this is a safe place and he won’t bother you any more. Ann: I’m not afraid of him and I don’t want to talk allout him. Let’s have our cookies. Therapist: Will you show me around? Ann: Yes, here’s the living rooin. All of my toys are over here. There are lots and lots of them. Here are my books and my desk so I can do m y homework. We ctn eat our cookies here, but be careful not to spill crumbs or stuff or we might get bugs like we do at home. I know how to fix hotdogs. I ctmked for my mom. Therapist: Do you miss your mom? Ann: Yeah, she got rid of [XI[boyfriend]when she found out. She’s going to get me back again as soon as she gets our house cleaned up and gets some money. . . . Ann continued to deny abuse until Session 15. She developed a strong relationship with the therapist, however, frequently bringing a paper with a good grade or a drawing to t h e sessions. Her enuretic nights became less frequent and she ceased to exhibit sexual behaviors in playing with her dolls. Ann’s nightmares continued to occur sporadically, particularly around the time of visits at home with her mother. Session 15 Therapist: Hi Ann, how are you today? Ann: I’m OK. I visited with my mom this weekend.

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Therapist: How did the visit go? Ann: OK, she’s getting the house cleaned u p and she wants me to come home. Therapist: How do you feel about going home? Ann: I don’t know. It’s hard to talk to her. I don’t want to hurt her feelings. Therapist: Why don’t we pretend she’s here? Then when you’re feeling very safe in your favorite place, you can talk to her and b e sure that it won’t hurt her feelings. Ann: [She closes her eyes] I don’t know . . . maybe. Let’s get the key to the magic gate. Close your eyes. Therapist: OK, I’ll let you lead the way again this week if you want. Ann: [Giggling] This gate creaks. I think we need to oil it. Now, I’ll close it behind us and we can skip. Careful now so that you don’t fall down. OK, we’re here. Therapist: You certainly know the way these days. Ann: I learn fast don’t I? Therapist: Yes, you do. Can you imagine your mom sitting here with us. Maybe she’s sitting ill the big green chair. Ann: Yeah, I can see her. Therapist: What would yo11 like to tell your mom first? Ann: That I’m not inad at her any more for what [XI[boyfriend] did. Therapist: It sounds like you were miid at her for ii while aliout it. Ann: Yeah, if she hadn’t gone to work and left hiin there at night with me. it wouldn’t have happened. He never came in my rooin during the day when she was home, just at night. Therapist: It must h w e been pretty scary for you, Ixit now you’re safe and you can talk about it and not be afraid. Ann: H e said my inom would be real inad ut me if she found out. Therapist: Well, your inom iilready understands what [XIdid. He admitted to the police that he touched you. Is your nioin inad at you now? Ann: No, she’s inad at [XI.She still loves ine. Therapist: Now, let’s talk with your inom. Ann: Hi, Mom. Therapist: Tell your inoin about your feelings. Ann: Mom, I’m sorry that I’ve been a little inad at you. I didn’t want you to leave and go to work when [XI was there, but you went anyway. I was so scared. H e said you would lie mad at me. I’m not mad at you anymore and I don’t want you to be mad at me. Therapist: Is there anything else you want to tell your mom? Ann: Yeah. Mom, please don’t let him bother me ever again. That’s all.

Ann continued in therapy for an additional 25 sessions. During that time she was returned to her mother’s custody. Although she experienced several enuretic nights around the time of her move home, these ceased after the second week. Ann continued to use the magic cottage as her safe place. She gained self-confidence and her grades in school improved dramatically. After the termination of therapy, the therapist occasionally received short letters from Ann, many of which were accompanied by a test paper with a high score. In conclusion, as we have indicated, therapy moves in steps from establishing rapport and a sense of safety and security; to collaborative storytell-

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ing; to the introduction of reality events; to the final step of addressing complex emotional issues of loss, trust, love, and guilt stirred by the abuse. Throughout this process, the therapist emphasizes connectionmaking and is cognizant and respectful of the child’s resistances and needs for support to explore traumatic material. The therapist, however, must avoid taxing the child’s emotional resources by attempting to promote abreactive experiences in cases where there are clear signs (e.g., nightmares, flashbacks, intrusive thoughts) of post-traumatic stress disorder (see Brown & Fromm, 1986 for a thoughtful discussion). With these children, more prolonged therapy, aimed at integration rather than abreaction (see Brown & Fromm, 1986). is advisable. Anger toward the therapist, revealed in story content, symbols, or passive aggressive behaviors, is a notable signal that the therapist is intruding on the child’s defenses. With victims of traumatic abuse, the present authors generally do not attempt to initiate storytelling until a strong therapeutic alliance is established and posttraumatic and dissociative symptoms are in abeyance. The authors prefer to use metaphors with such children rather than direct, authoritative methods. Not uncommonly, therapy may extend to 3 or more years in such cases. Rather than rigidly compacting therapy into a set time frame or number of sessions, an ongoing evaluation of the child’s distress, needs, and strengths dictates the investment and time spent in each step of therapy. In making decisions about termination, the therapist needs to evaluate the child’s symptom picture, level of overall coping, and hislher social and emotional development. The present authors believe that the establishment of “insight” into complex emotional issues is unnecessary and unworkable for many children. When the child is functioningat a developmentally appropriate level, and when the child no longer exhibits symptoms that hamper hisher functioning. termination is appropriate. Nevertheless, follow-up contacts for 1 year or longer are advisable, because additional dissociative reactions to trauma may surface that were not apparent during treatment, and continuous follow-up serves as a check with regard to later sexual abuse. The procedures outlined in the present paper are not meant to be adopted or adhered to in a slavish fashion; rather, techniques and strategies have been presented that can be applied in a flexible, creative manner with children who present with a variety of abuse-related symptoms. Although the present authors have had good success with the treatment described, we have not conducted a systematic investigation of the treatment’s e5cacy. In the absence of a contiolled investigation, it is premature to suggest that our approach is superior to any number of other therapeutic interventions for treating the sexually abused child. At present, the boundary conditions of imagery-based therapies and the limits of their applicability are relatively amorphous and undefined. Moreover, story-

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telling, cannot be profitably used in the absence of a theory-driven understanding of the child’s conflicts and the behavioral and dynamic meaning of the abuse-related symptoms. Nevertheless, it is the present authors’ hope that the hypnotherapeutic procedures delineated is this paper will provide the sensitive clinician with a valuable inroad into the experiential world of the abused child and with a vehicle for intervening in the troubled child’s behalf.

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Das Ceschichtenerzihlen, Hypnose und die Behandlung von sexuell miBbrauchten Kindern

Judith W. Rhue und Steven Jay Lynn Abstrakt: Der vorliegende Artikel beschreibt eine Bewertung und ein Therapieprogrnmm fur sexuell millbrauchte Kinder durch Anwendung von hypnotherapeutischen Techniken, die sich um das Erzahlen von Ceschichten drehen. Das Erzahlen von Geschichten gibt dem Therapeuten die Mbglichkeit, trostende Suggestionen, Symbolismus und Metapher zu gebrauchen, um die emotionelle Distanz zu schaffen, die ndtig ist, um mit dem Trauma des Millbrauchs fertig zu werden. Hypnotherapie verfahrt in schrittweiser Fasson vom Schaffen eines Sinnes der Sicherheit und CewiBheit; zur Einbildungsteilnahme; zur Einfuhrung von Wirklichkeitsgeschehen; zum letzten Schritt des sich an komplexe, emotionelle Problem Wendens, wie Verlust, Vertrauen, Liebe und Scham, die durch den Millbrauch entstanden.

Le conte d'histoires, I'hypnose et le traitement d'enfants abusbs sexuellement Judith W. Rhue et Steven Jay Lynn Rbsurnb: Le present article dbcrit un programme d'bvaluation et d'intervention hypnothbrapeutique, bast sur le conte histoires, utilist dans le traitement d'enfants abusbs sexuellement. Le conte histoires donne nu thbrapeute I'opportunitb de se servir de suggestions rbconfortantes, de symboles et de mbtaphores, permettant de prendre d e la distance bmotionnelle ntcessaire pour traiter ce genre de traumatisme. L'hypnothbrapie procede par btape, d'abord en btablissant un sentiment de stcuritt, ensuite un partage irnaginatif, puis I'introduction des bvtnements de la rbalitb et enfin on procbde au traitement d e sujets bmotionnels plus complexes tels que la perte, la confiance, I'amour et la culpabilitb laisuite de I'abus. qui surviennent ?

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RHUE AND LYNN Narraciones, hipnosis y tratamiento de nilor m e t i d m a aburo sexual

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Judith W.Rhue y Steven Jay Lynn Resumen: Este arHculo describe la evaluaci6n y el pmgrama terapCutico implementado para niims sometidm a abuso sexual; se utilizan t h i c a a hipnoterhpiw centradas en In narraci6n de h m t o h y K r e a l i su evduacih. Lp n a r r d 6 n de una hutorin le otorga al terapeuta la oportunidnd de mar sugertioner de bienestar, simbolismo y metPforas para crear la distancia emodonal nmesaria para tratar el tema del abuso. La hipnoterapin se implementa de UM manera gradual, desde la construeci6n de un sentido de seguridad y confianm, compartir la mponsabilidad de In n n r d n y la introducci6n de 10s acontecimientos de la realidnd, hasta el ppso find de encarar temas emocionalmente complejos de firdida, confinma. amor y culpa generedor por el abuso sexual.