COGNITIVE BEHAVIORAL GROUP THERAPY FOR

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Treatment Manual for Cognitive-Behavioral Group Therapy for Children with Sexual Behavior Problems Barbara L. Bonner, PhD Center on Child Abuse and Neglect University of Oklahoma Health Sciences Center Department of Pediatrics C. Eugene Walker, PhD Pediatric Psychology Department of Psychiatry and Behavioral Sciences University of Oklahoma Health Sciences Center Lucy Berliner, MSW Sexual Assault Center University of Washington Grant No.

90-CA-1469 National Center on Child Abuse and Neglect Administration for Children, Youth, and Families U. S. Department of Health and Human Services TABLE OF CONTENTS Page Preface 1 Session One 3 Session Two 7 Session Three 10 Session Four 13 Session Five 15 Session Six 19 Session Seven 22 Session Eight 24 Session Nine 27 Session Ten 28 Session Eleven 30 Session Twelve 32 Appendix 34 0 Cognitive-Behavioral Group Therapy for Children with Sexual Behavior Problems Barbara L.

Bonner, PhD, C. Eugene Walker, PhD, and Lucy Berliner, MSW Preface The principles of cognitive-behavioral therapy and its use with children have been well defined in a number of publications (Harris, Wong, & Keosh, 1985; Meyers & Craighead, 1984) and are generally familiar to psychotherapists. The principles attempt to combine two different approaches into a unified system capable of dealing with human behavior, psychopathology, ... more. less.

and psychotherapy. The approach is behavioral in that it is straightforwardly concerned with human behavior and broadly based on learning concepts. Further, this approach emphasizes the need for a scientific basis for treatment, carefully constructed protocols, and rigorous outcome research, all of which have been hallmarks of behavioral approaches compared to other theoretical approaches. The approach is cognitive in that there is emphasis on the complex cognitions of human beings, such as false beliefs, attributions, decision-making processes and so forth, and how these influence behavior as opposed to simple stimulus-response connections. The protocol presented here relies on behavior modification principles for group management and emphasizes cognitive rules, decision making, impulse control, and education. This approach to group treatment of children with sexual behavior problems is highly structured and utilizes a teaching-learning model. The groups consist of 6 to 8 boys and girls ages 6-12. The therapists, a male and female, take a directive role and the children follow the lead of the therapists. Due to the time-limited structure of this program (12 sessions), five major topics are focused on in the treatment 1 program. These include: acknowledging the inappropriate sexual behavior, learning the Sexual Behavior Rules, improving impulse control, receiving sex education, and preventing reabuse of self and others. Various techniques are utilized in the sessions to teach and reinforce the children's learning of the material. This manual presents an outline of each of the 12 group sessions for the children and is accompanied by a separate manual for the parents. The session outlines include the objectives for each session, the materials needed, the topics to be covered, suggested content for covering the topics, and questions for the children's weekly assessment. An appendix is attached that has copies of the handouts used in each session. References Harris, K.R., Wong, B.L., & Keosh, B.K. (Eds.). (1985). Cognitive-behavior modification with children: A critical review of the state of the art. (Special Issue). Journal of Abnormal Child Psychology, 13, 329-476. Meyers, A.W., & Craighead, W.E. (Eds.). (1984). Cognitive behavior therapy with children. New York: Plenum Press. 2 Session One: Children Objectives 1) Introduce the children to each other. 2) Clarify with the children the purpose of the group. 3) Give an outline of how the group will be conducted. 4) Establish group responsibilities. Materials Name tags Folders for child's materials Pillows (optional) Flip chart & markers Crayons, felt-tip pens, pencils cMy Attendance Sheet d handout (See Appendix) Assessment sheets (See Appendix) "Things I Have Talked About and How I Listen" chart (See Appendix) Group Therapy Record (Optional; See Appendix) Rubber stamp of a star and an ink pad (Note: Small stickers can used for this activity.) Introducing Group Members -Provide the children with name tags as they enter the therapy room. -Provide each child with a sticker to put on his/her attendance sheets . Introductions -Have the children sit in a circle on the floor or on chairs around a table. -Ask the children to break into pairs and tell each other their name, age, grade, favorite subject, favorite thing to do for fun, favorite food, favorite TV show, etc. -Have each child introduce her or his partner to the group, telling as many things about that person as they can remember. Something Good & Not So Good -Have the children each tell something good and something not so good that has happened to them during the past week. -The therapists may start this activity in order to model for the group. -Let the children know that this activity will be repeated at the beginning of each session. Description of Group Purpose -Explain that everyone in the group is there for the same reason--they have all broken a sexual behavior rule. For example, touching someone else's private parts would be breaking a sexual behavior rule. -Explain to the children that we will discuss the sexual behavior rules in the next session. This group is a place where they will learn how to not break those rules. Things We'll Be Talking About 3 -Let the children know that there are a lot of things that they will be expected to talk about during the next 12 weeks. Give each child a copy of the chart, "Things I Have Talked About and How I Listen." The items should be written on a flip chart . Read the list or have the children take turns reading the items. 1. Telling who I am 2. Something good that has happened to me 3. Group responsibilities 4. Sexual behavior rules 5. Feelings 6. Sexual behavior rules I have broken 7. Names of body parts 8. Using the Turtle Technique 9. Staying safe 10. Being a good listener 11. Being kind to others 12. Our last meeting with the group Establishing Group Responsibilities -Explain that you want to make this group a safe place where the children can feel comfortable talking. To do that, they each have some responsibilities to remember. -Check to see if they know what the word responsibility means. -As the following responsibilities are discussed, write them on a flip chart. 1. Talking (confidentiality) -Ask the children to tell what cprivate d means. -If they cannot define it, tell them that private is something that is personal, it belongs to you and nobody else. -Explain that the things they say can also be private--the things talked about in here are private. -Let them know that they should not tell other people about something someone else said in the group but that they can tell about something they said if they want to. Practicing the Talking Rule -Have the children practice deciding what is and is not right to tell someone else about the group. (For example: Susie wants to tell her mother about something Susie said in the group, is that OK?; Johnny wants to tell his dad about something Billy said in the group, is that OK?; and so forth.) -Emphasize that even though it would be OK to tell something they said in the group, they do not have to if they don't want to. Practice being asked what they did in the group and responding with phrases such as "I don't want to..." or "I'm not ready to...". Explaining Therapist Responsibility -Let the children know that the therapists also have responsibility about talking. 4 -Things said in the groups will generally not be told to other people, including their parents/caregivers. -Explain that the only time a therapist would tell is if not telling would hurt them or someone else if it was not told. -Explain that their parents may be told the types of things talked about in the group--the topics. For example, that group rules were talked about. Let the children know that their parents may be told whether they participated in the activities or not. 2. Be respectful. -Explain that in this group, being respectful means no interrupting while other people are talking, no hitting, no name calling, and no swearing. -Ask the children to suggest additional rules. -If they can't think of any, an additional rule that needs to be discussed is to stay in the room unless you have permission to leave. Keep the rules at a minimum. Assessment Questions -Each week the children are asked some questions to assess their understanding of the material covered in that session and in previous sessions. -The questions are read aloud. -The children respond by circling their answer on the c Assessment Sheet d handout , which uses a picture of a thumbs up sign for yes, a thumbs down sign for no, and a question mark for I don't know. -Have the children write their name and the session number on the first Assessment handout: Read these aloud and have the children circle the correct answer. Younger children may need assistance with this exercise. 1. It's OK for you to tell what you said in this group. (Yes) 2. It's OK for you to tell what someone else said in this group. (No) 3. If someone asks what you said in group, it's OK to say that you don't want to talk about it. (Yes) 4. It's OK to interrupt when someone else is talking. (No) 5. Everyone in this group is here because they broke a sexual behavior rule. (Yes) -When the children have finished, they pass the sheets to the therapist. The therapist can then go over each question and discuss the correct answers with the group. (Note: This procedure should be followed each week. The children's answers will be checked and the number correct written at the top with a brief note such as "Good job" for those who did well. For children who missed items, a therapist should go over these with the children at the next session to make certain they are learning the information. The sheets are passed back at the next session and the children keep them in their folders.) Things I Have Talked About and How I Listen 5 - Have the children get their chart which contains the list named earlier of the things that will be talked about during the course of the group. -Tell the children that every week they will look at their list and put a star/sticker by each of the items they talked about during that meeting. (Since they have already talked about the first 2 items on the list, they can all put a star by those items with the rubber stamp of star and ink pad.) Folder for Materials -Give each child a folder for his/her materials. -The children will keep their materials in their folders and get them out at the end of each session. -Explain that all of their drawings and papers will be kept in this folder until the group is over. -Explain that after the last session they will be able to take the folder and some of their papers home with them. -Explain that some of the things they do will be kept here. -Remind the children that it is important to come to each session. Activities (If there is remaining time) -Have the children decorate their folders and put their attendance sheet in them. As you prepare the children to return to the waiting room, tell them: - They will be in the playroom while the parents/caregivers are in their group (if parents' group is held after the children's group). -The childcare workers will be there so everyone can play safely. -If anyone needs to use the restroom, their caregiver or a child care worker will take them. A chart, the Group Therapy Record, for documenting child and parent attendance, verbal participation, and behavior is provided in the Appendix. This chart has been useful to review the child's progress quickly and to make brief notes about the child. Therapists may also want to make more extensive notes in the child's therapy file. 6 Session Two: Children Objectives 1) Review the purpose of the group. 2) Define the term "private parts." 3) Teach the Sexual Behavior Rules. 4) Have the children practice applying the Sexual Behavior Rules with visual aids. Materials -Name tags -Attendance sheets/folders -Stickers -Crayons, felt-tip pens, & pencils -Flip chart & markers -Sexual Behavior Rules handout (See Appendix) -Projective Storytelling Cards (See Materials List in Appendix) -Bathing Suit Picture (See Appendix) -Assessment sheets -Rubber stamp of a star and ink pad Introducing New Group Members -Have the children sit in a circle on the floor. -If there are new members, make name tags . -Have the children put stickers on their attendance sheets . Something Good & Not So Good -Remind the children that you will do this each week. Review from Previous Session -See how many of the group responsibilities the children can remember. -Use the flip chart to remind them of those they have forgotten. -Explain the responsibilities for any new members that might be present. Purpose of the Group -Review the purpose of the group. -If the children can't remember, remind them: -Everyone in the group has broken a sexual behavior rule. -They are here to learn the sexual behavior rules and to practice keeping them here, at home, at school, and other places that they go. Introduce Sexual Behavior Rules -Explain that you are going to talk about the Sexual Behavior Rules today. -They may have different rules when they get a lot older, but these are for the rules for now. Define "Private Parts": -Explain "private parts" using the picture of a boy and girl wearing bathing suits. -Everyone has private parts of their body. 7 -The easiest way to remember where private parts are is to think about a bathing suit. -The parts of the body covered by a bathing suit are "private parts." -Answer any questions the children may have. Sexual Behavior Rules -Write the rules on the flip chart, explaining them to the children. 1. It's OK to touch your own private parts when you are alone. -In general, it is OK to touch your private parts when you are by yourself in your room or in the bathroom. -It is not OK to touch your private parts when other people are around, such as in school, on the bus, or on the playground. -Some parents don't want children to touch their private parts at all, even when they are alone, and each child will need to follow their parents' rules. 2. It's not OK to touch other people's private parts. -Not touching other people's private parts includes many things that can't be done such as kicking, pinching, or hurting in any way. - It also means that you can't touch other people's private parts with any part of your own body or with anything else. 3. It's not OK for other people to touch your private parts. -The only time that people should ever touch their private parts is if that person has a very good reason. -Ask them what might be a good reason. -A doctor or nurse who needs to touch them as part of a medical exam is one reason. -A parent who is helping them clean or put medicine on their private parts is another reason. 4. It's not OK to show your private parts to other people. -Give the children the "Sexual Behavior Rules" handout. Applying the Sexual Behavioral Rules -Using the Projective Storytelling Cards (# 87-A7, A12, A17, A19, A20, A21, A22, A25, 88- A8), or others, -Have the children say what they think is happening in each card. -Explain that different people will see the cards differently, and that is OK. -Ask the children if they think a sexual behavior rule might be broken and if so, who they think broke it, how people in the picture feel about that, and so forth. -Ask the children to say whether what is happening is OK or not OK according to the Sexual Behavior Rules. Assessment Questions 8 Give the children an assessment sheet , go over the directions again, and then read the following questions: 1. It is OK for you to tell what someone else said in this group. (No) 2. Everyone in this group is here because they broke a sexual behavior rule. (Yes) 3. It is OK to touch your own private parts when you are alone. (Yes) 4. It is OK to touch other people's private parts. (No) 5. It is OK to show your private parts to other people. (No) Things I Have Talked About and How I Listen -Remind the children that there are a lot of things that will be talked about during the weeks that are left in this group. -If there are any new group members, read the list. Help the children decide which of the things on the list they talked about and help them use the stamp and ink pad to mark those. Activity -Let the children finish decorating their folders . 9 Session Three: Children Objectives 1) Review the purpose of the group. 2) Explore expression of the children's feelings and familiarize them with an affective vocabulary. 3) Define specific private parts. Materials -Attendance sheets/folders -Stickers -Crayons, felt-tip pens, & pencils -Drawing paper -Flip chart & markers -Thermometer #1 handout (See Appendix) -Female Diagram (See Appendix) -Male Diagram (See Appendix) -Projective Storytelling Cards -Assessment sheets - Rubber stamp of star and ink pad Attendance Sheets -Let children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good -Review the week briefly with each child. Review Group Purpose -Ask the children to tell what the purpose of the group is. -If they can 9t remember, remind them that each one of them has broken a sexual behavior rule, and they are here to learn the sexual behavior rules and to learn how to keep them. Tell the children that when they talk in this group about the sexual behavior rules they have broken, that will be a good thing because talking about what you've done in the past will be an important part of learning not to break the rules in the future. -Remind the children that the therapists won't tell about the things the children say in the group unless it would hurt someone if they don't tell. Define Specific Private Parts -Ask for the definition given last week of what private parts are (parts of the body covered by a swimsuit). -Explain: 10 -The children will now learn the specific names of these private parts. Note: Appropriate anatomical terms are used, i.e. penis, breasts. -Even though they may know other names for these body parts, these are the words that will be used in the group. -The private parts for boys and girls are different -Show the female diagram on the flipchart. - Provide the children with female diagram handouts. -As each body part is named, have the children draw a line from the word to that part of the body on the diagram and give a brief description of what each part does. -Show the male diagram on the flip chart. -Provide the children with male diagram handouts. -As each body part is named, have the children draw a line from the word to that part of the body on the diagram and give a brief description of what each part does. -Explain that you will talk more about these body parts and their purposes in a few weeks. Review the Sexual Behavior Rules -Ask the children to name the sexual behavior rules. -After they have named the ones they can remember, show them the list of rules on the flip chart again. -Practice with additional Projective Storytelling Cards . -Describe a situation to go along with each picture and have the children tell what sexual behavior rule is being broken. -Also have them explain how the people in the pictures might be feeling. -Give some verbal examples of sexual behaviors (specific behaviors of each of the children in the group without mentioning any names) and have the group tell if they are OK or not OK and which sexual behavior rule is being broken. -In this exercise, also include some behaviors that would be considered OK, such as giving a cousin a hug, putting an arm around a friend. Feelings -Provide the children with the Thermometer 1 handout. -Each thermometer is labeled with one of the following feelings: mad, sad, happy, afraid, and confused. -Have the children color in the thermometers to show how often they experience the feelings on the thermometers. -For example, if they feel mad most of the time, they would color in the thermometer almost all the way to the top; if they don't feel mad very often, they would only color in a small part of the thermometer at the bottom. -Have each child pick one feeling and tell about a time when he or she felt that way. Assessment Questions 1. You are in this group because you broke a sexual behavior rule. (Yes) 11 2. It 9s OK to break the sexual behavior rules if you know you won 9t get caught. (No) 3. It 9s OK to touch someone else's private parts if they ask you to. (No) 4. It 9s always OK to touch your own private parts. (No) 5. Boys and girls have different private parts. (Yes) After the children are finished, go over the questions and provide the correct answers. Things I Have Talked About and How I Listen -Mark with stamp and ink pad . 12 Session Four: Children Objectives 1) Review the Sexual Behavior Rules. 2) Review the purpose of the group. 3) Acknowledging having broken a Sexual Behavior Rule. 4) Discuss feelings that the children have had when they broke a Sexual Behavior Rule. Materials -Attendance sheets/folders -Stickers -Crayons, felt-tip pens, & pencils -Drawing paper -Flip chart & markers -Thermometer #2 handout (See Appendix) -Assessment sheets -Stamp and ink pad Attendance Sheets -Let children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good -Review week briefly with each child. Review Sexual Behavior Rules -Have the children name the sexual behavior rules. -Display list on flip chart . -Describe some situations (the same ones used last week) and have the children tell which sexual behavior rule is being broken. Purpose of Group -Ask the children what the purpose of the group is. -Explain that the purpose of the group is that they are here to learn what the sexual behavior rules are and how to keep them. -Remind them that last week we said that talking in this group about the sexual behavior rules they have broken will be a good thing. -Ask the children if they remember why. (Talking about what they 9ve done in the past will be an important part of learning to not break the rules in the future.) -Remind them that the therapists won't tell about the things the children say in the group unless it would hurt someone if they don 9t tell. 13 Acknowledging Having Broken a Sexual Behavior Rule -Ask them to tell which sexual behavior rule they broke or to point to it on the flip chart. -If any of the children will not do that, the therapist points to the rule and says that they were told the child broke this rule. -As each child acknowledges breaking a sexual behavior rule, encourage him or her to tell what he/she did specifically, when, and with whom. The children are to be encouraged to self- disclose, but are not to be coerced. Specific questions may be helpful, such as; " Who did you break the rule with?" "What did you do when you broke the rule?" "When did you break the rule?" "Where were you when you broke the rule?" (Note: The words "abuse" and "victim" are not used when describing the child's inappropriate sexual behavior; the focus is on breaking a rule, not "abusing" someone else.) -Praise the children for telling about the rule they broke. -Acknowledge that this may be difficult for them to talk about. Give them a piece of paper and ask them to write a number from 1 to 10 which describes how hard it is for them to talk about this with 10 being very very hard and 1 being not hard at all. -Have them talk about their responses. Feelings when Breaking a Sexual Behavior Rules -Give them a copy of the Thermometer #2 handout . -Ask, cSuppose you broke a Sexual Behavior Rule just now, how would you feel? d -Have the children color in the thermometers to show how much of each of these feelings they would have. (If none of the five feelings are ones that the children would feel, have them fill in their own feeling under the unlabeled thermometer.) -Discuss the children's feelings about breaking a sexual behavior rule. Assessment Questions 1) It's OK to show your private parts to people if they ask you to show them. (No) 2) It's OK to break the sexual behavior rules if an older person says it 9s OK. (No) 3) In this group, you will learn how not to break the sexual behavior rules. (Yes) 4) It's OK to tell about something someone else said in this group. (No) 5) It's OK to let your brother touch your private parts. (No) Things I Have Talked About and How I Listen -Mark with stamp and ink pad . Session Five: Children 14 Objectives 1) Review Sexual Behavior Rules. 2) Encourage acknowledging having broken a Sexual Behavior Rule. 3) Teach the Turtle Technique. Materials -Attendance sheets/folders -Stickers -Crayons, felt-tip pens, & pencils -Drawing paper -Flip chart & markers -Projective Storytelling Cards (See card numbers in Session Two) -Puppet turtles (See Materials list in Appendix) -Turtle Technique handout (See Appendix) -Assessment sheets -Stamp and ink pad Attendance Sheets -Let children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good Review the week briefly with each child. Review Sexual Behavior Rules -Have the children name the Sexual Behavior Rules. -Display list on flip chart . -Describe some situations using the Projective Storytelling Cards. -Have the children tell which Sexual Behavior Rule is being broken. -Also use some verbal examples of sexual behaviors (use specific behaviors of each of the children in the group without mentioning any names), and discuss which Sexual Behavior Rule was broken. Acknowledging Having Broken a Sexual Behavior Rule -Remind the children that talking in this group about the sexual behavior rules they have broken is a good thing. -Ask if they remember why. -Explain that talking about what they have done in the past will be an important part of learning to not break the rules in the future. -Remind the children that the therapists will not tell about the things the children say in group unless it would hurt someone if they do not tell. -Explain that even though they told about breaking the rule before, it is important to do it again. -Ask the children to tell which sexual behavior rule they broke or to point to it on the flip chart . -As each child acknowledges breaking a sexual behavior rule, encourage him or her to tell what they did specifically, when, and with whom. The children are to be encouraged to self- disclose, but are not to be coerced. 15 -If any of the children will not do this, let them know that you will tell which sexual behavior rule you have been told they broke, and encourage them to tell the next time the group does this exercise. -Praise the children for telling about the rule they broke. Turtle Technique Story Tell this or a similar story using the puppet turtle : There once was a turtle named Toby who lived in a pond with his family and a lot of other turtles. He liked to swim and play all day long. He also liked to play with his friends. He especially liked to play with his two best friends, Terri and Tim. In this pond, there was an area that was used only by one turtle at a time when they needed to go to the bathroom. One day Toby saw Terri go back to the bathroom area and he thought, cMaybe I will go and peek around the corner so I can see Terri's private parts. d Just before he started to go over there to peek, he thought that maybe first he better STOP and Wait a second. He then went inside his shell where he knew it was safe to relax . He then spent a few moments thinking: cIs what I'm thinking about doing OK? d He decided that it was not OK because it broke a sexual behavior rule. cWhat will happen if I peek at Terri? d He thought that if Terri found out that he was peeking, it might hurt her feelings, and that he also could get himself in trouble if he did this. cWhat could I do instead? d He thought that he could go and play catch with Tim, or maybe go swimming in his favorite part of the pool. So Toby decided that what he was going to do instead was to go and find Tim to play catch, and he went off to play ball. Turtle Technique -Remind the children that the purpose of the group is to help them learn to not break the sexual behavior rules. -Explain that: -Now you are going to talk about some steps called the Turtle Technique which they can follow in order to help them keep the Sexual Behavior Rules. -The children can use the Turtle Technique any time they think they are about to do something that might not be OK. -Teach this technique while modeling it with a puppet turtle which has a head that may be pulled into its shell. 1. STOP. WAIT. -Have the children imagine a stop sign. -This is their signal to stop what they are doing and ask themselves what they 9re feeling. 16 cLet us imagine a turtle (use puppet) is in a situation similar to one when you want to break a sexual behavior rule. How do you think the turtle might be feeling?" -Discuss the children's feelings. 2. GO IN YOUR SHELL LIKE A TURTLE and RELAX. -Ask the children what turtles do when something bothers them. -Explain: cThey go inside their shells where it is safe. Doing that makes it easier to relax and think. d -Have the children pretend they are turtles and practice going in their shells. -Demonstrate this with the puppet. -Explain that while they're in their shell, they may relax some more by going limp like a bowl of spaghetti or a rag doll. -Have the children practice this, taking some deep breaths to help them relax. 3. THINK. -Tell the children: cAsk yourself, is what I'm thinking about doing OK? d cWhat will happen if I do this? d cWhat could I do instead? d -Explain that now that the turtle is relaxed, this is a good time to think about these things. -Use these questions in relation to the situation that was described earlier for the puppet turtle. -Ask the children to name some things the turtle could do instead, maybe some things to make the turtle feel better if they mentioned unpleasant feelings in the first step. -Write these suggestions on the flip chart. -Make certain that a few suggestions with negative consequences are given so there is an opportunity to talk about how some things might seem like a good idea at first but make us feel bad later or get us into trouble. -Have the children pick something that the turtle can do instead of breaking a Sexual Behavior Rule. 4. DO SOMETHING. -Explain that now that the turtle has picked something to do, he/she needs to go ahead and do it. -Give the children the Turtle Technique Handout. Assessment Questions 1. It is OK for you to touch someone else's private parts if they say it is ok. (No) 2. The Turtle Technique can be used to help you keep the Sexual Behavior Rules. (Yes) 3. Relaxing is part of the Turtle Technique. (Yes) 4. It is OK for a doctor to touch your private parts as part of a medical examination. (Yes) 5. It is OK to pinch your friend's private parts. (No) Things I Have Talked About and How I Listen -Mark with the stamp and ink pad . Activity (time permitting) 17 -Have the children draw a picture of themselves using the Turtle Technique or of something that will remind them of the Turtle Technique. 18 Session Six: Children Objectives 1) Encourage acknowledging having broken a Sexual Behavior Rule. 2) Practice the Turtle Technique. Materials -Attendance sheets/folders & stickers -Flip chart & markers -Projective Storytelling Cards (See card numbers in Session Two) -Puppet turtles -Thumbs up, Thumbs down cards (See Appendix) -Assessment sheets -Chips/Tokens -Award basket with small trinkets, gum, candy -Stamp and ink pad Attendance Sheets -Let children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good Briefly review each child's week. Review Sexual Behavior Rules -Have the children name the Sexual Behavior Rules. -Display list on flip chart . -Describe some situations using the Projective Storytelling Cards. -Have the children tell which Sexual Behavior Rule is being broken. -Also use some verbal examples of sexual behaviors (use specific behaviors of each of the children in the group without mentioning any names), and discuss which Sexual Behavior Rule was broken. Turtle Technique -Remind the children that the purpose of the group is to help them learn not to break the Sexual Behavior Rules. -Explain that: -They may use the Turtle Technique any time they think they are about to do something that might not be OK. -The Turtle Technique can help them to keep the Sexual Behavior Rules and avoid breaking any other rules that they might have trouble with. Rules of the Turtle Technique Game -Each child will get to practice the Turtle Technique in turn with the turtle puppet . -The game is over when every child has had a turn. 19 -After the child gives a step of the Turtle Technique, each child puts a cthumbs up d card or a cthumbs down d card face down on the table. When the therapist says, cTurn them over, d the children turn their cards over. Each child holding out the correct response gets a chip/token. A response is correct if it is a cthumbs up d card when the child correctly states a step of the Turtle Technique, or cthumbs down d when the child incorrectly states a step of the technique. If the child who is going through the steps says the correct step, he or she gets 2 tokens. -At the end of the game, chips are counted and the child with the most chips gets first choice out of the award basket. If the children tie, have the group help choose which of the ones that tied was quieter throughout the game. Allow the quieter child to choose from the basket first. Each child then gets to pick a small treat from the basket for participating. Turtle Technique 1. Stop. Wait. -The turtle imagines a stop sign. -This is its signal to stop what it is doing and ask what it is feeling. 2. Go into the shell and relax. -The child demonstrating the technique with the puppet should make the puppet pull its head back into its shell. -While it is in its shell, it may relax some more by going limp like a bowl of spaghetti or a rag doll. 3. Think. -Then the puppet should ask: c Is what I 9m thinking about doing OK? d cWhat will happen if I break a Sexual Behavior Rule? d cWhat could I do instead? d -Have the child name some things the turtle might do instead, i.e., some things to make the turtle feel better if they mentioned unpleasant feelings in the first step. -Have the child pick something that the turtle can do instead of breaking a Sexual Behavior Rule. 4. Do something. -Now that the turtle has picked something to do, it needs to do it. Acknowledging Having Broken a Sexual Behavior Rule(s) -Remind the children that talking in this group about the sexual behavior rules they have broken is a good thing. -Ask if they remember why. Explain that talking about what they have done in the past will be an important part of learning not to break the rules in the future. -Remind the children that the therapists will not tell about the things the children say in group unless it would hurt someone if they do not tell. -Explain that even though they talked about the rule they broke before, it is important to do it more than one time. -Ask the children to tell which Sexual Behavior Rule they broke or to point to it on the flip chart. 20 -As each child acknowledges breaking a Sexual Behavioral Rule, encourage him or her to tell what they did specifically, when, and with whom. The children are to be encouraged to self- disclose, but are not to be coerced, or scolded for not disclosing. -If any of the children will not do this, tell them which Sexual Behavior Rule you have been told they broke. -Praise the children for telling about the rule they broke. Assessment 1. You are in this group because you broke a Sexual Behavior Rule. (Yes) 2. The first step in the Turtle Technique is to think. (No) 3. The last step in the Turtle Technique is to do something. (Yes) 4. It is important to talk about the Sexual Behavior Rule you broke. (Yes) 5. It's OK for you to touch other people's private parts. (No) Things I Have Talked About and How I Listen -Mark with stamp and ink pad . 21 Session Seven: Children Objectives 1) Review the concepts of the Turtle Technique in a game format Materials -Attendance sheets/folders -Stickers -Turtle Technique Game (An adaptation of the Stop, Relax, and Think Game; See Materials List in Appendix) -Chips/Tokens -Small prizes for all players in the game -Stamp and ink pad Attendance Sheets -Let children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good -Briefly review each child's week. Turtle Technique Game Use an adaptation of the Stop, Relax, and Think Game to practice the Turtle Technique . 1) Roll a die to see who goes first. The therapists have put eight colored (red; white; blue, yellow, red-white; red-blue; blue-yellow; and yellow-white) areas on the floor. 2) From a table in the corner of the room which is the starting point, each child will draw a card from a pile of colored cards that correspond to the colored squares on the floor. -The child will then go to the spot that matches the color or colors on the card. -At each dual-colored area, they will be asked by a therapist to do something else and will receive a token for responding correctly. -If they go to the blue, red, white, or yellow areas, they will draw another card. If they do what the card says, they get a token. 3) Explanation of cards: Blue: - The card describes a situation and the child is to tell how they would feel if that happened to them. White: - The card tells things that can be done in order to relax and the child going to that area must do what the card says to do. Yellow: -The card either asks for information or describes situations for which the child is to come up with a plan to handle that situation. Red: 22 - The card tells the child to roll an eight-sided die to select an activity that the rest of the group will do over and over again until the child says stop. 4) Areas with 2 colors: - The child will have a task to do. If the child does the task, then he/she may continue and draw another card, but if the child doesn't answer, then he/she loses that turn. If they do what the card says, they get a token. The tasks are as follows: Red/blue -Pick a feeling: mad, sad, happy, or afraid. -Tell about a time when you felt that way. Red/white -Say something someone might say to encourage themselves when they feel down. Yellow/white -Pick someone in the group and tell one thing you like about that person. Blue/yellow -Keep yourself from smiling or laughing while the rest of the group does funny things to try to make you laugh or smile (group members may talk or move around but may not touch the player). After doing what is required on a given square, the child returns to the starting point and picks another card. Play until the allotted amount of time has expired, but try to make certain that everyone has had an equal number of turns. Let the children count their tokens . Provide a small prize to all the children for participating, allowing the child with the most tokens first choice of the prizes . Assessment 1. When using the Turtle Technique, it is important to remind yourself about the bad things that could happen if you break a rule. (Yes) 2. Relaxing is part of the Turtle Technique. (Yes) 3. It is OK to touch someone else's private parts if they are the same age as you. (No) 4. It is ok for your parent to put medicine on your private parts. (Yes) 5. It is ok for you to touch your friend's private parts. (No) Things I Have Talked About and How I Listen -Mark with stamp and ink pad . 23 Session Eight: Children Objectives 1) Increase the children 9s knowledge and understanding of the private parts and their functions. 2) Clarify appropriateness of time, person, and language used when the children talk about sex. Materials -Attendance sheets/folders -Stickers -Crayons, felt-tip pens, & pencils -Flip chart & markers -Drawing paper -Book: Where Did I Come From? (See Materials List in Appendix) -Male & Female body parts diagrams -Assessment sheets -Stamp and ink pad Attendance Sheets -Let children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good Sex Education -Explain to the children that today you are going to talk about parts of their body and they will learn more about them. -Let them know that you are also going to talk about how babies are made. -Tell the children that you are going to go through a book called, Where Did I Come From? -While summarizing the book, let the children look at the pictures that go with the story. -After going through the story, let the children know that: 1. You will talk some more about body parts and their purpose. 2. You are going to use the names for body parts that doctors use, even though they may have heard some different names for these body parts. 3. Not all body parts are the same for boys and girls. 4. Their bodies don't look exactly like the bodies of adults right now, but their bodies will change as they get older. 6. The changes take place during a time called puberty which occurs around the ages of 9 to 14. -See what body changes the children can name that take place during puberty. Male and Female Body Parts -Have Female Diagram on the flip chart and give the corresponding handout to the children. -Point to each part and either name it or have the children give the name. -After naming a body part, have the children find that word on their handout and draw a line to the correct part of the body. -Also talk about the function of each of the body parts named. 24 -Repeat the above process using the Male Diagram , along with the corresponding handout. -Suggested Sex Education Content -Males and females have different parts to their bodies. -These different parts make it possible for a man and a woman to make a baby. -Body parts to discuss: 1. Breasts- Provide milk for a baby 2. Uterus- Place in the mother's body where the baby grows 3. Vagina- A girl 9s or woman 9s private part where the baby comes out 4. Penis- A boy's or man's private part that he uses to urinate and where sperm comes out 5. Testicles 3 Produce the sperm necessary to make a baby 6. Scrotum- External sac that holds the testicles -Babies are made by grown-ups, a man and a woman. -Sperm leaves a man's penis and enters a woman's body through the vagina. -The sperm and the egg combine to make a baby. -The baby starts out very small and grows inside the mother for 9 months. -After about 9 months, the baby is ready to come out of the mother's body. -The mother pushes the baby out through her vagina, using the muscles in her stomach to do the pushing. -While inside the mother, the baby has been getting food through a tube attached to the baby's stomach, but after birth, the tube isn't needed so the doctor snips it off (it doesn't hurt). That's how we all got a belly button. Talking About Sex Explain that you have talked about sexual things in the group, and that it is important to talk about when is the right time to talk about such things. Discuss the following suggestions. 1. Ask questions to someone that you know well and trust (such as a parent). 2. Ask questions when the person you are asking is not busy. 3. Find a time to talk when there are not a lot of other people around. -Ask: cWhen is it a good time to ask your parents about sex? d 4. Usually, it is better not to ask other children about sex. Many times adults (parents) want to be the ones to talk to their children about sex, rather than having children talk to each other about it. -Ask: cWhy might it not be a good idea to ask other children about sex?" 25 Assessment 1. It is OK for you to have sex with someone. (No) 2. A baby is made when the egg and sperm combine. (Yes) 3. The vagina is the part of the woman 9s body where the baby comes out. (Yes) 4. A boy's private part is called a penis. (Yes) 5. A baby grows in the mother's uterus. (Yes) Things I Have Talked About and How I Listen -Mark with stamp and ink pad . 26 Session Nine: Children Objectives 1) Review the concepts of the Turtle Technique Materials -Attendance sheets/folders -Stickers -Turtle Technique Game -Chips/Tokens -Assessment sheets -Small prizes for all players of the game -Stamp and ink pad Attendance Sheets -Let children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good Briefly review each child 9s week. Review Turtle Technique -Have the children each say a step of the Turtle Technique ; go around the circle until the whole group says all of the steps with minimal assistance two times. Turtle Technique Game Use the adaptation of the Stop, Relax, and Think Game to practice the Turtle Technique (see description from Session Seven). Assessment 1. The turtle is supposed to think while it is relaxed in its shell. (Yes) 2. It is OK for you to touch another person's private parts if they give you permission. (No) 3. You know how to help yourself keep the Sexual Behavior Rules. (Yes) 4. It is OK for you to touch your best friend 9s private parts. (No) 5. It is OK to break a Sexual Behavior Rule. (No) Things I Have Talked About and How I Listen -Mark with stamp and ink pad . 27 Session Ten: Children Objectives 1) Review private parts, their functions, and puberty. 2) Teach abuse prevention principles. Materials -Attendance sheets/folders -Stickers -Pencils -Female and Male Diagrams -Private Zone book or a similar book on prevention (See Materials List in Appendix) -Projective Storytelling Cards (See card numbers in Session Two) -Assessment sheets -Stamp and ink pad Attendance Sheets -Let children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good Briefly review each child 9s week. Private Parts Review -Present the Female Diagram . -Have the children name the private parts that you talked about in Session Eight. -Have the children name the functions of each of the private parts. -Repeat with the Male Diagram . -Ask the children what the name is for the time that girls begin to change into women and boys begin to change into men. -Have the children list the different changes that occur during puberty. Abuse Prevention -Tell the children that you are going to talk some more about the Sexual Behavior Rule stating that it's not OK for other people to touch their private parts. -Ask the children if they know what they should do if someone does try to touch their private parts. -Read the book Private Zone aloud to the children. -After reading the book, ask the children to name things they could do if someone tried to touch their private parts and write these on the flip chart . Prevention Guidelines : Teach the children the following prevention guidelines. -Even adults need a good reason to touch your private parts. -It's OK to say you'll do it yourself (taking a bath, using medicine). -Say no. -Yell! -Tell someone--never keep it a secret. 28 -Keep telling people until someone believes you. -Use the Projective Storytelling Cards and have the children tell what they would do in each of those situations if they were the child and the other person were trying to touch their private parts. Be sure to use some cards that show situations that would be appropriate (a doctor in an exam, changing a baby's diaper, helping a small child get dressed, etc.). Assessment 1. If someone touches your private parts when they aren't supposed to, you should tell someone. (Yes) 2. Adults need a good reason to touch your private parts. (Yes) 3. It is OK for other children to touch your private parts. (No) 4. If you use the Turtle Technique, it will help you keep the Sexual Behavior Rules. (Yes) 5. I have said which Sexual Behavior Rule I broke.(Yes) Things I Have Talked About and How I Listen -Mark with stamp and ink pad . 29 Session Eleven: Children Objectives 1) Review the Sexual Behavior Rules 2) Review the Private Parts 3) Review the Turtle Technique Materials -Attendance sheets/folders -Stickers -Flipchart -Male & Female Diagrams -Assessment sheets -Stamp and ink pad Attendance Sheets -Let the children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good Briefly review each child 9s week. Review the Private Parts -Show the children the Female Diagram . -Ask the children to list the private parts and name their functions. -Repeat with the Male Diagram . Review the Sexual Behavior Rules -Ask the children to help you list the Sexual Behavior Rules. Write them on the flipchart . Review the Turtle Technique -Split the children into two groups with one therapist per group. -Present different scenarios and ask a child what he or she would do. Be sure that all the Sexual Behavior Rules are included in the different scenarios. -Have the children take turns explaining what they would do in accordance with the steps of the Turtle Technique. Assessment 1. The last step of the Turtle Technique is to come out of your shell and do something. (Yes) 2. If you have a question about sex, it is a good idea to ask another child to find out the answer. (No) 3. It is OK to show your private parts to another person if you are by yourselves. (No) 4. It is best to ask your parents questions you have about sex. (Yes) 5. It is OK for you to touch another child's private parts in the bathtub. (No) Things I Have Talked About and How I Listen 30 -Mark with stamp and ink pad . 31 Session Twelve: Children Objectives 1) Discuss issues related to saying goodbye 2) Review the Sexual Behavior Rules 3) Review the Private Parts 4) Review the Turtle Technique 5) Assess the children 9s understanding of the topics covered in the group Materials -Attendance sheets/folders -Have materials removed from the children 9s folders that will remain in their case files; other materials can be taken home in their folders. -Stickers - cMy Group d handout -Assessment sheets -Certificates of Achievement (See Appendix) -Prize basket and prizes Attendance Sheets -Let the children put stickers on their attendance sheets . -Remind them about the stars they will earn for participating. Something Good & Not So Good Saying Good-bye Give each child a copy of the handout called cMy Group. d Read each statement aloud and assist the children with writing in the answers they want to provide. Afterwards, discuss the different responses everyone gave. Final Assessment 1. Private parts are the parts of your body covered by a bathing suit. (Yes) 2. It is OK to break a Sexual Behavior Rule if you know you won 9t get caught. (No) 3. It is OK to touch someone else 9s private parts if they ask you to. (No) 4. The first step in the Turtle Technique is cdo something. d(No) 5. If someone touches your private parts when they aren't supposed to, you should tell someone. (Yes) 6. When using the Turtle Technique, it is important to remind yourself about the bad things that could happen if you break a rule. (Yes) 7. It is OK to touch someone else 9s private parts if they are the same age as you. (No) 8. Relaxing is a step in the Turtle Technique. (Yes) 9. A baby is made when the egg and sperm combine. (Yes) 10. It is OK to touch your private parts when you are alone. (Yes) 32 Things I Have Talked About and How I Listen -Mark with stamp and ink pad . Presentation of Certificates -Let the children know how pleased you are that they came to the group and present them with certificates that recognize their participation and achievement. Final Prize Basket -Allow children to choose out of the prize basket in the order of those with the most stars to those with the least stars. -Remind the children that they may take their folders home. Let them know that you kept some of the things that were in their folders so that you can remember them. 33 APPENDIX 34 Session One: Children My Attendance Sheet Name: ______________________________________________ 1 2 3 4 5 6 7 8 9 10 11 12 Sessions 1-12: Children 35 Assessment Sheet Name: Session: 36 Things I Have Talked About And How I Listen Name________________________________ Session1 2 3 4 5 6 7 8 9 10 11 12 1. Telling who I am 2. Something good that has happened to me. 3. Group Responsibilities 4. Sexual Behavior Rules 5. Feelings 6. Sexual behavior rules I have broken 7. Names of body parts 8. Using the Turtle Technique 9. Staying Safe 10. Being a Good Listener 11. Being Kind to Others 12. Our last meeting with the Group Session One: Children 37 GROUP THERAPY RECORD Name: Date: Therapist: Date WED 1/6 WED 1/13 WED 1/20 WED 1/27 WED 2/3 WED 2/10 WED 2/17 WED 2/24 WED 3/3 WED 3/10 WED 3/17 WED 3/24 Child Attendance (Y/N)* Child On Time (Y/N)* Verbal Participation** Behavior in Group*** Parent Attendance (Y/N) * Yes/No; If late, indicate amount late (e.g., -5) ***1 2 3 4 5 Very poor Poor Acceptable Good Excellent **Verbal Participation: 1-Very Poor: Is unwilling to attend to group activities or to participate verbally; 2-Poor: Listens bu t does not enter into discussion even when called upon; 3-Satisfactory: Participates when called upon; 4-Good: Participates when called upon and makes appropriate spontaneous comments ; 5-Excellent: Participates actively and provides leadership to the group. ***Behavior in Group: 1-Very Poor: Disruptive and distracts other children frequently; 2-Poor: Pays limited attention and distr acts other children; 3-Satisfactory: Attends and does not bother others most of the time; 4-Good: Participates in activities and rarely distracts others; 5-Excellent: Actively participates and serves as a role model for other children. DATE COMMENTS: 38 Session Two: Children SEXUAL BEHAVIOR RULES 1. It 9s OK to touch your private parts when you are alone. 2. It 9s not OK to touch other people 9s private parts. 3. It 9s not OK for other people to touch your private parts. 4. It 9s not OK to show your private parts to other people. 39 Children with Sexual Behavior Problems Materials List 1. Projective Storytelling Cards: Northwest Psychological Publishers, Inc. P.O. Box 494958 Redding, CA 96049-4958 (916) 223-4735 2. Hand puppets: Folkmanis Puppets 1219 Park Avenue Emeryville, CA 94608 (510) 658-7677 (510) 654-7756 FAX 3. Where Did I Come From? by P. Mayle, 1973. Lyle Stuart, Inc. 120 Enterprise Ave. Secaucus, NJ 07094 4. Stop, Relax, and Think Game: The Center for Applied Psychology P.O. Box 1587 King of Prussia, PA 19406 (215) 592-7273 (215) 923-5455 FAX 5. Private Zone (1982): Frances S. Dayee Warner Books, Inc. 666 Fifth Avenue New York, NY 10103 40 Session Two: Children 41 42 43 44 45 Session Four: Children TURTLE TECHNIQUE 1. STOP. WAIT. 2. Go in your shell like a turtle. RELAX. 3. THINK. 4. DO SOMETHING. Turtle Technique Story There once was a turtle named Jamie who lived in a pond with her family and a group of other turtles. She liked to swim and play with her friends. She also liked to play with her friends. She especially liked to play with her two best friends, Susie and Carol. In this pond, everyone had a special bookbag where they kept their own belongings, things that only belonged to them. One day, Jamie saw that Carol was away from her special place and that Carol had a beautiful pencil sticking out of her bookbag. She wanted to see it up close and she really wanted to have a pencil just like that one. She started to go over to the bag and she was going to take the pencil. Just before she got there, she felt she better Stop and Wait a second. She then went inside her shell , where she knew it would be safe to relax . She then spent a few moments thinking : " Is what I 9m thinking of doing OK? " She decided that it was not OK because it would be breaking a rule that she should not steal other people 9s things. " What will happen if I do this? " She thought about how it might make Carol feel bad if she didn 9t have her pencil anymore and that she might get herself in trouble if she did this. " What could she do instead? " She thought that maybe she could go and play jump-rope with Susie, or maybe go swimming in her favorite part of the pool. " So . . . Jamie decided that what she was going to do instead was to go and find Susie to play jump-rope, and she went off to play. 46 This story works best when using a puppet that has a head that can be pulled into its shell. They can practice the following steps: 1. Stop-Wait " Have the child imagine a stop sign. " This is the signal to stop what they are doing and ask themselves what they 9re feeling. " cLet us imagine a turtle (use puppet) is in a situation similar to one when she wants to take something that is not hers. d " How do they think the turtle might be feeling? 2. Go in your shell like a turtle, and relax. " Ask the child what turtles do when something bothers them. " Explain: " cThey go inside their shells where it is safe. Doing that makes it easier to relax and think. d " Have the child pretend he/she is a turtle and practice going into his/her shell. " Demonstrate this with the puppet. " Explain that while he/she is in the shell, he/she may relax some more by going limp like a bowl of spaghetti or a rag doll. " Have the children practice this, taking deep breaths to help them relax. 3. Think " Tell the child: " cAsk yourself, is what I 9m thinking about doing OK? d " cWhat will happen if I do this? d " cWhat could I do instead? d " Explain that now that the turtle is relaxed, this is a good time to think about these things. " Use the questions in relation to the situation that was described earlier for the puppet turtle . " Ask the child to name some things the turtle could do instead, maybe some things to make the turtle feel better if they mentioned unpleasant feelings in the first step. " Make sure that a few suggestions that might have negative consequences are given so there is an opportunity to talk about how some things might seem like a good idea at first but make us feel bad later or get us into trouble. " Have the child pick something that the turtle can do instead of breaking a behavior rule. 4. Do something: " Explain that now the turtle has picked something to do, he/she needs to go ahead and do it. 47 48 Session Twelve: Children Name ________________________ Date_________________________ My Group 1. Now that the group is almost over, I feel 2. The hardest thing I did in the group was ______________________________________________________________________________ 3. I wish the group 4. If I were the group leader, I would 5. The thing I like best about the group was 6. Here is what I would like to say to the group: Adapted from Mandell, J.G., & Damon, L. (1989). Group treatment for sexually abused children. New York: Guilford Press. 49

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