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Can Counselling Support the Resilience of Young People to the Impact of Domestic Violence

Introduction

Question: Can counselling support the resilience of vulnerable children and young people to the impact of adverse events, such as domestic violence and abuse, early in their lives?

In our society we recognise that there are many children who are exposed to adverse factors such as experiencing or witnessing domestic violence and abuse. This may impact on their ability to reach their full potential in life, or render them so scarred that they later become incapable of functioning as adults, without additional support. Yet some children, whom we refer to as resilient, appear to overcome difficulties experienced in early years and progress to develop meaningful relationships and participate in society as successful members of society. 

The aim of this study is to review the research that identifies the factors that appear to impact on the resilience of children to the effects of adversity early in their lives, and consider if there is evidence to support the positive impact of counselling for these young people. The study will focus, where possible, on domestic violence and abuse.

I have chosen this topic as it has direct relevance to my personal circumstances having adopted two children and also my work with children and young people for the charity CLEAR (Children Linked to and Experiencing Abusive Relationships).

Background

For the purpose of this discussion it will be useful to introduce the concepts of adversity, resilience outcomes and interventions, in terms of their definition and context within this essay, and how they may be measured.

Adversity

Common sources of adversity affecting children in the UK population include: poverty, ill health of the child or main carer, problems relating to the family environment - abuse or domestic violence and an impoverished environment with a lack of local facilities (Hooper 2007), (Hill 2007). Within the immigrant population sources of adversity may also include; war, famine and malnutrition and being separated from families and communities. All of these factors may imply that the child is at risk of a poor outcome in terms of future development, but it is also possible that negative outcome may be avoided (Rak 1996).

Risk in itself has multiple, overlapping meanings ranging from the presence of a danger or threats, to risk factors statistically related to the probability of something negative happening” (Hill 2007 p5).

Rutter (1979), (cited Keyes 2004) studied a cohort of children in the UK who had experienced one or more risk factors including marital discord, poverty, large families and parental criminal activity or mental illness. He found that often a single stressor would not have a significant impact on the children’s developmental wellbeing but combinations of stressors or the prolonged duration of a stressor reduced the likelihood of positive outcomes. It was also noted that certain forms of risk tended to occur together, for instance  in families with inter-parental conflict there tended to be a high level of parental psychopathology. This is referred to as the cumulative risk model. Families with co-occurring domestic violence and child maltreatment have high levels of cumulative risk and are ten times more likely to be placed in foster care than those with low levels of risk (Kohl 2005).

As these risk factors may not always lead to negative outcomes it is difficult to place a value on the degree of adversity subjected to an individual child. This has an impact on the meaningful analysis of research looking at the effectiveness of therapies and other interventions to negate the impact of adversity as it is difficult to quantify the degree of adversity experienced by individuals in the study group. For this reason, many studies have focused on the impact of intervention on developmental outcomes as a secondary measure. However, it is generally accepted that the impact of domestic violence or abuse may be considered to be highly traumatic and a significant indicator of adversity for all children.

Resilience

When written in Chinese the word ‘crisis’ is composed of two characters. One represents danger, and the other represents opportunity or crossroads. 

Arnold (1990) (cited Dulmus 2005 p5) reports:

“The way children respond to stress may either promote growth and a sense of efficacy or cause behavioral, social, academic, or psychosomatic problems. Children exposed to stress that increases the risk of an adverse outcome are said to be “vulnerable” to that outcome, therefore resilience is defined in terms of two concepts—vulnerability and competence.”

Resilience has been defined as:

"A set of qualities that helps a person to withstand many of the negative effects of adversity…….Bearing in mind what has happened to them, a resilient child does better than he or she ought to do." (Gilligan 2000)

There are several factors that have been linked to mitigation of the detrimental effects of exposure to domestic violence. Perhaps the most important is a strong relationship with a caring adult. This does not necessarily need to be a family member. In many cases relationship with a professional will suffice (Zinke 2008) (Maclean 2004). 

Other factors that impact on resilience to domestic violence include:

  • Type and history of the abuse
  • Age, gender and developmental age of the child
  • The child’s interpretation of the violence
  • Protective strategies used by the non-offending carer(s)

In a longitudinal study of 205 children over 20 years, Mansten (2000) reviewed the impact of adversity on children in more general terms and discovered additional factors that were linked to resilience in the study group. These were differentiated into internal and external factors and included:

Internal

  • Good intellectual skills
  • Self-efficacy
  • Talents valued by society and self - meaningful roles
  • A sense of meaning in life

External

  • Connections to competent and caring adults
  • Community resources - peer support
  • Good schools

“Longitudinal studies reveal that 50- 75% of children growing up in families with domestic violence, as well as exposure to other risks, defeat the odds and turn a life that appears destined for further hardship into one that illustrates resilience and triumph” (White, 2003, p. 6).

The value of longitudinal studies is that they compensate for changes that occur naturally as the child develops and could otherwise be incorrectly associated with short term changes resulting from an intervention. The difficulties facing the researchers include maintaining contact with study group members for the duration of the study, the latency between commencing the study and completion of data collection and the impact of wholesale changes to the environment and social setting of the study as decades pass.

Measurement of resilience presents similar problems to the researcher in a similar way to the difficulties in trying to put an empirical value on adversity. Grotberg (1997) reviewed  data from 600 children from 30 countries involved in an international resilience project to develop an assessment framework intended to be used to assess the resilience promoting resources available to a child. The action model, rather than a scoring system as such, helps the child to look at their own resources in terms of: I have, I can, and I am, and is used to help areas where the child’s own resilience could be enhanced.

Outcomes

The conclusions of most studies looking at childhood adversity and resilience refer to some measurement of outcome and to what extent this outcome differs from groups not exposed to the same risk factors. 

The standards by which we normally judge how well a child is doing, often refer to developmental tasks (Masten 2012). Toddlers are expected to walk, talk and follow simple instructions. Primary school children are set educational goals and are expected to get along with their peers without causing disruption at home or in the classroom. Youths leave school, hopefully with the necessary skills and qualifications to get work and become financially independent, develop more permanent relationships with others and generally contribute to society. These factors are easy to measure and many can be attributed a numerical value.

In a comparative study between children in care who did well at school with children not exposed to adversity but achieving less favorably Jackson & Martin (1998) demonstrated a startling correlation between academic achievement and positive outcomes later in life. Their study suggests strongly that progress at school may be a useful indicator of a child’s resilience to adversity, and furthermore may represent a valid measure to monitor change brought about by intervention.

From the government’s perspective the Every Child Matters Agenda is a set of reforms supported by the Children Act 2004 and aims for every child, whatever their background or circumstances, to have the support they need to:

  • be healthy
  • stay safe
  • enjoy and achieve
  • make a positive contribution
  • achieve economic well-being.

The strength and value of Every Child Matters as an outcome indicator is that is stretches beyond the more easily measurable indicators such as educational achievement and financial independence and includes being safe and enjoying life which are equally important to those experiencing violence and abuse at home.

Interventions

Yates and Masten (2004) identified three strategies to try to promote resilience in at-risk individuals:

Risk-focused methods. 

These describe approaches that try to avoid the adverse events from occurring. In relation to domestic violence or abuse they may include parenting classes, counselling for parents or more significant child protection interventions to prevent exposure.

Asset-focused approaches. 

These relate to measures taken to improve access to resources that may reduce the likelihood of domestic violence or support the victims in other ways in terms of providing access to local facilities, better living conditions and good quality healthcare. As domestic violence is more common in areas of poverty it is hoped that improving community resources may reduce it's prevalence. This strategy is often more effective where the risk of adversity remains long-term.

Process-focused approaches. 

These aim to nurture and develop individual resources such as self-esteem, relationships with significant adults, spiritual health and positivity about the future.

Counselling traditionally focuses on positive change, helping clients to recognise their inner strength in order to overcome adversity and therefore relates closely to the process focused strategy. Rather than focus on the psychogenetic development of behavioral dysfunction, the salutogenic approach explores with the child their capacity to build a better life for themselves (Hauser 1985). 

Body

Rak (1996) describes the development of a twenty-five item resiliency questionnaire based on previous cited work by Sullivan in 1953 which was designed to enable a counsellor to evaluate both at risk issues and capacity for resilience of the client based on their reported internal and external resources. The counsellor may then choose to initiate strategies to help the child recognise, discuss and begin to understand what has been happening to them, or support their efforts to find ways to buffer themselves from the impact of ongoing adversity.

The resilience promoting factors that may be enhanced by counselling are those identified as intrinsic factors. However, the impact of a successful therapeutic outcome may reach beyond this. It is suggested that sometimes a single good or reparative experience can produce a chain effect that can bring about a series of improvements relating to the CYP’s adversities and circumstances (Rutter 1985). 

The most commonly associated “malleable” factors that may be enhanced through counselling (Gilligan 1997), (Rutter 1999) are generally accepted to include:

  • Emotional security and attachment style 
  • Self-esteem (valuation of self) 
  • Self-belief (confidence of being effective) 
  • Self-efficacy (understanding of one’s strengths and limits) 
  • Social competence 
  • Autonomy, also known as internal locus of control 
  • Capacity for problem solving 
  • Sense of purpose and future, including religious faith 

In a meta-analytic investigation of therapeutic intervention for sexually abused children and adolescents, Hetzel-Riggin (2007) and colleagues analysed twenty-eight peer-reviewed studies comparing the effectiveness of different psychological treatments. They were particularly interested in the impact of the therapies on behavior problems and psychological distress. They found that different types of therapy, cognitive behavioral, individual, and play therapy were clearly beneficial, although some improvement was also seen in those receiving no therapy, indicating a high level of innate resilience in those studied.

Cognitive behavioral therapy was most effective for behavior disorders or poor self image, either when delivered individually or as group therapy. Play therapy was particularly useful for children whose difficulties related to social functioning whereas cognitive behavioral and individual therapy worked best for psychological distress. Long term therapy was associated with better outcomes.

One of the difficulties highlighted was in separating the therapeutic effect from potential changes in the relationship with parents / carers or other significant adults following the onset of therapeutic intervention. The authors noted the difficulty in isolating the impact of external factors on relatively short term studies. 

Whilst the meta-analysis approach can be a useful way of combining the results from several smaller studies which individually may fail to make statistical significance, it is always difficult to ensure that study protocols,methods and designs are similar enough to make such comparison justified. Furthermore, Hetzel-Riggin highlighted that in some cases the exact nature of the therapeutic interventions used or the isolation of control groups from unintentional therapeutic benefit was not always reported clearly.

There are several scoring systems that have been designed to allow quantitative assessment of the mental wellbeing of children who have experienced abuse or other forms of adversity. Those most frequently deployed are tabled below for clarity:

Measure

Domain

Completed by

Description

Child Behavior Checklist (CBCL)

(Achenbach 1992)

Behavioral and emotional problems

Parent or primary caregiver

Assessed internalising and externalising behaviors.

Piers-Harris Self-Report Measure

Psychological health 7-18 year olds

Children

Based on the child's own perceptions, assesses self-concept in individuals ages 7 to 18. It is composed of 60 items covering six subscales

Outcome Rating Scale (ORS)

Miller et al, 2003.

Daily functioning or adaptation

Children & Young People - beginning & end of therapeutic work

4 items. Respondents rate how they are doing, how things are in their family, how things are at school and how everything is going on a 0 to 10 scale, with 0 indicating not doing very well and 10 doing very well..

Emotional Literacy Questionnaire (ELC)

Faupel, 2003.

Resiliency

For children 7 – 16 years of age.

Children, young people and parents -

beginning & end of therapeutic work

25 items categorised into 5 subscales: empathy, motivation, self-awareness, self-regulation and social skills. Respondents rate how much they agree with statements. Total and subscale scores calculated.

Strengths & Difficulty Questionnaire

(SDQ)

Goodman, 2001

Symptoms

Functioning

Resiliency

For children < 7 years of age.

Parent – beginning & end of therapeutic work

31 items categorised into 5 subscales: emotional difficulties, behavioural difficulties, hyperactivity, peer problems and pro-social behaviour. Respondents also asked to rate the impact of symptoms of life. Total symptom, subscale and impact scores calculated.

Children’s Manifest Anxiety Scale

(RCMAS)

Reynolds & Richmond 1978

Measures levels of anxiety in children aged 6 to 19 years

Self-report

37 items - Each item is purported to embody a feeling or action that reflects an aspect of anxiety, hence the subtitle, “What I think and Feel”. It is a relatively brief instrument, which has been subjected to extensive study to ensure that it is psychometrically sound

An earlier review (Finkelhor 1995) of studies, again looking at the effectiveness of treatments for abused children concentrated on twenty nine projects with quantitative measurement of outcomes. Finkelhor’s review was limited to studies that either compared two groups, one receiving treatment and the other not, or comparing two or more groups receiving different treatments. Only studies using quantitative measurement pre and post intervention were included. The only scoring systems mentioned were the Child Behavior Checklist and Piers-Harris Self-Report Measure. 

Finkelhor’s findings were that studies comparing treatment with no treatment supported the positive value of intervention, but those comparing the efficacy of different treatments showed no significant difference.

Peer support and social engagement have also been shown to impact on the resilience of children to adversity (Mansten 2000) and there have been several successful programs using group therapy to help children cope with their experiences of abuse and neglect.

De Luca (1995) evaluated a group therapy program for pre-adolescent girls who had experienced sexual abuse. In this study the authors compared thirty-five girls who had been sexually abused with a comparative group of thirtyfive girls who had not. All had group therapy with ninety minute sessions of structured activities, over nine to twelve weeks. The girls were assessed pre and post intervention using; self-esteem inventory, Children’s Manifest Anxiety Scale, Child Behavior Checklist and child and parent feedback questionnaires. 

The study outcomes demonstrated a sustained and significant improvement in self-esteem and reduced anxiety scores amongst the abused girls in comparison with the control group. There was also a reduction in their internalising behavioral problems initially although this was no longer statistically significant after twelve months. This was a well constructed study which produced results that could be tested for statistical significance as a result of the quantitative data from the scoring systems used and a control group for comparison. The only issue that was not clarified was wether or not the therapists leading the group work were blind to which girls had been abused  and which had not. The relevance of this is probably minimal as most of the beneficial component of therapy would presumably have come from interactions between the group members themselves.

Many of the studies assessing the impact of therapeutic interventions on children subjected to domestic abuse and violence have been focussed on the impact of the therapy in helping to manage specific symptoms or behavioral problems. Cognitive behavior therapy has been researched extensively as it has well recognised effectiveness in this field. 

“Cognitive-therapy is an active, problem-orientated treatment that seeks to identify and change maladaptive beliefs, attitudes and behaviors that contribute to emotional distress.” (Freeman 1995, p16)

As a result, many of these studies use measures that monitor behavioral changes that occur during or at the end of the therapeutic support. The question that remains unanswered is whether or not these benefits were sustained and could therefore be considered to have supported the resilience of the individual to their adversity.

Deblinger (1999) and colleagues undertook a two year follow-up study to determine if the benefits of 12 sessions of cognitive behavioral therapy delivered to 100 sexually abused children suffering post-traumatic stress, was sustained. In their previous study in 1996, the children were randomised into three CBT treatment groups; child only, mother only, mother and child. A fourth control group was assigned to a community support program. All were assessed for externalising behavioral problems, depression and post-traumatic stress disorder using structured interviews, Child Depression Inventory, Child Behavior checklist and a parenting practices questionnaire. The results supported the long term benefits of the intervention in terms of the children’s adjustment and parenting practices.

Children who witness or experience domestic violence are at increased risk of sexual abuse but many suffer from emotional, psychological and other forms of physical abuse or neglect. The impact of these adversities is intensified as one or more of the most significant factors that could support the child’s resilience, that of a caring and loving adult, may be unavailable to them.

In many cases, domestic violence or abuse is not directed directly at the child but at an intimate partner. In these situations the violence towards the child’s parent is not a random act by a stranger but specifically directed by someone with whom the child often has an ongoing emotional relationship. As a result of their victimisation the non-abusing parent is often unable to provide an appropriate level of support to their child who may then develop a post-traumatic stress disorder. 

Cohen (2011) compared the impact of trauma focused cognitive behavior therapy with child centred therapy in a cohort of 124 children with post traumatic stress disorder resultant from experiencing intimate partner violence. Using several outcome measures including structured interviews, Child Behavior Checklist and Children’s Depression Inventory Cohen and her colleagues concluded that whilst both approaches had a beneficial impact, the reduction in hyper-arousal and avoidance symptems was greater in the CBT group. Unfortunately, a high drop-out rate approaching 40% overall limited the validity of this otherwise well planned study.

In the 1940s, Carl Rogers (1951) established a new model of psychotherapy - client centred therapy, which focused on the relationship between therapist and client based upon empathy, congruence and unconditional positive regard. Influenced by this person centred approach, Axline (1969) developed a similar approach for working with children and this became referred to as non-directive Play Therapy. 

Play Therapy is currently defined by British Association of Play Therapists as:

“...the dynamic process between child and Play Therapist in which the child explores at his or her own pace and with his or her own agenda those issues, past and current, conscious and unconscious, that are affecting the child's life in the present. The child's inner resources are enabled by the therapeutic alliance to bring about growth and change. Play Therapy is child-centred, in which play is the primary medium and speech is the secondary medium.”

Kot (1995) investigated the effectiveness of non-directive Play Therapy based on Axline’s model, with  20 children aged between 3 and 10 years, who had witnessed domestic violence. Her studies measured outcomes using the Joseph Pre-School and Primary Self-Concept Screening Test, Child Behaviour Check List and Children's Play Sessions Behaviour Rating Scale and these were compared against a control group. Children in the treatment group were found to have significantly reduced externalising behaviour problems and significant reduction in their total behaviour problems. 

Summary

Children exposed to domestic violence and abuse may suffer direct physical harm, sexual abuse, psychological abuse, neglect or any combination of these. The risks to their emotional and physical wellbeing is affected by the frequency and ferocity of the events, their duration and timescales. Some children develop significant behavioral and developmental difficulties as a result of their exposure but for others the impact is less obvious and their ability to cope with such adversity is referred to as resilience.

Several factors have been identified that may impact on the child's ability to become resilient to adversity, some intrinsic to the child and others linked to external support mechanisms from significant others, schools and communities. 

There are intrinsic factors relating to the child such as self-esteem, the ability to understand and process what is happening to them and to see hope for their future that may be supported by counselling intervention. In addition to this, the counsellor may provide support in the role of a significant adult role model in whom the child can trust, who will offer the unconditional regard, empathy and trusting relationship that is otherwise absent. 

Much of the research relating to therapy for child victims of domestic violence and abuse has focussed on the management of behavioral issues, symptoms of stress, anxiety and depression. The impact of direct sexual abuse has received more attention than other adversities as has cognitive behavioral therapy as a therapeutic approach. Most research findings support the suggestion that counselling therapy can impact positively on the resilience of children and young people to the impact of domestic abuse and violence and in many cases the various modalities applied have been similarly effective. There are however no large longitudinal studies comparing the effectiveness of other approaches with cognitive behavioral therapy and this is probably because of difficulties in maintaining contact and involvement with those concerned. It is also difficult to differentiate the changes innate to the child with those that may have come about from an improvement in environmental and other external factors.

Conclusions

There is a gap in our evidenced based understanding of how therapeutic intervention can best support and strengthen the resilience of children and young people. It would appear that most things we can do will help, at least in the short term, but it is not at all clear whether or not the most important factors relate to the approach used or the relationship between the child and their counsellor. 

In the long term it would be of value to compare the effectiveness of repeated focused short term therapy, long term therapy with the same counsellor, group therapy with equivalent peers or therapy directed at the child and the non-abusing carer or an equivalent supportive adult together. What is certain is that many questions remain unanswered.

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