Background Information
Childhood sexual abuse affects children and adults across ethnic, socioeconomic, educational, religious, and national lines (Bein, 2011). Childhood sexual abuse often goes unreported, but of reported cases from 22 countries in 2009 an estimated “overall international figure” can be determined. Based on these data, 7.9% of males and 19.7% of females faced sexual abuse before the age of 18 years (Singh et al., 2014). Many researchers have determined Post Traumatic Stress Disorder (PTSD) as a core manifestation of sexual abuse trauma because of the high frequency with which this disorder and related symptoms appear in sexually abused children (Kaplow et al., 2009).
Symptoms of childhood sexual abuse related PTSD can extend far into adulthood and can include withdrawal behaviour, distressing memory intrusions, emotional disturbance, re-enactment of the traumatic event, avoidance of circumstances that remind one of the event, and physiological hyper-reactivity (Sinanan, 2015). Pharmacotherapies are available to treat the severe symptoms of PTSD for childhood sexual abuse; however, they are often inadequate or unwanted by the survivor (Chivers-Wilson, 2006), and other methods of treatment may provide superior relief for the survivor.
Expressive therapy is an umbrella term that includes art therapy, music therapy, drama therapy, dance/movement therapy, and writing/poetry therapy (Frydman, 2018). PTSD survivors may show benefits from expressive therapies, such as music therapy (Landis-Shack et al.,2017) and art therapy (Puent. 2016).
Examination of Empirical Studies
Two empirical studies examining the role of music therapy in the treatment of survivors of childhood sexual abuse and two empirical studies examining the role of art therapy in the treatment of survivors of childhood sexual abuse were selected.
Study 1: Art Therapy: An Approach with Working with Sexual Abuse Survivors
Brooke (1995)’s study’s purpose was to determine the effectiveness of art therapy, specifically in its ability to improve self-esteem in a group of childhood sexual abuse survivors. Childhood sexual abuse survivors consistently have low self-esteem. Self-esteem can be defined in a variety of ways; in this study Franklin (1992)’s definition of self-esteem was implemented: “self-evaluation and having a strong appreciation of one’s self.” The hypothesis of the study was that the implementation of art therapy will significantly improve these survivors’ self-esteem.
The participants in the study were adult women who had been sexually abused as children, who presented low levels of self-esteem. They were all white and their socioeconomic class was middle class. All of the participants attended the Raleigh Women’s Center, which is a United Way organization that administers peer counseling, support groups, and financial and legal counseling. The research design of the study was a control-wait design, with 6 participants being assigned to a treatment condition and 5 participants being assigned to a control condition. The treatment condition engaged in group art activities designed to improve self-esteem. A group counsellor guided these art activities, and gave positive feedback on artwork, work habits, and the subject’s behavior. All of the artwork was created by the subject’s choice of medium from the options of crayon, watercolor, chalk, or pencil. The subject’s subsequently depicted self-portraits, family portraits, dreams, their symbolic monsters, their wishes, and then they engaged in free collage. The study took place over the course of 8 weeks, and the art therapy sessions were two hours per week.
The subjects participated in a pre- and post-intervention self-report measure of self-esteem, the Culture-Free Self-Esteem Inventory(SEI) scale, which includes subscales of general self-esteem, social self-esteem, and personal self-esteem. There are 60 items on the scale that have yes/no answers. At the conclusion of the intervention, the treatment group’s global scores of self-esteem increased significantly greater than the control group. The treatment group’s increases in self-esteem were mainly evident in the general and social self-esteem subscales. The treatment group subjects’ communication skills increased in that at first the subjects could barely discuss, if at all, their sexual abuse, and the art facilitated increasing disclosure and verbalization of their trauma. The treatment group subjects’ reported feeling more trusting and willing to take risks. They also developed friendships with members of their group.
Study 2: Pulling Out the Thorns: Art Therapy with Sexually Abused Children and Adolescents
Pifalo (2002)’s study examined a total of 13 females from ages 8 to 17 years old who were all survivors of childhood sexual abuse. All of the participants were referred to the study by therapists, and it was ensured that each participant was not at further risk for any abuse through their respective safety plans. The hypothesis of the study was that a 10-week cycle of art therapy sessions with objectives targeted at prominent issues of sexually abused children and adolescents would result in a reduction of the symptoms associated with such trauma, including anxiety, depression, posttraumatic stress, anger, dissociation, sexual preoccupation, and distress.
The research design of the study was quasi-experimental. All of the subjects participated in group art therapy that was designed to be developmentally appropriate by splitting up the 13 subjects into three smaller groups: a Little Girls’ group, a Latency Age girls’ group, and an Adolescent Girls’ group. The Little Girls’ group consisted of participants who were ages 8-10 years old. The Latency Age girls’ group included participants of ages 11-13. The Adolescent Girls’ Group consisted of participants who were ages 14-17. The group art therapy sessions included drawing, painting, three-dimensional clay work, and construction of puppets, combined with verbal processing of the issues relevant to childhood sexual abuse. The group sessions encompassed “The Circle of Believers” format, in which the subjects in the group collectively verbalize their belief of every fellow group member’s story. Each group session occurred once a week for an hour and a half, for 10 weeks and the subjects participated in no other interventions during this period of time. The intervention was based off of psychological theory and was designed to specifically target issues of concern to victims of sexual trauma including: a sense of isolation, low self-esteem, depression, rage, inability to trust, feelings of betrayal, feeling responsible for what happened, stigmatization by peers, siblings, and other family members, feelings of worthlessness, feeling “marked” or damaged, a loss of bodily integrity, a lack of the sense of a cohesive self, dissociation, numbing, inability to access or express true feelings, repression, and inappropriate sexual development including sexual acting out.
All subjects were pre- and post-intervention tested with the Briere Trauma Checklist for Children (TSCC), which is designed to assess children who have experienced many kinds of trauma, particularly childhood sexual abuse. It is a child self-report measure of traumatic symptomology with 12 subscales, which include measures of hyper-response, under-response, anxiety, depression, anger, posttraumatic stress, dissociation, dissociation-overt, dissociation-fantasy, sexual concern, sexual preoccupation, and sexual distress. At the conclusion of the intervention, the participants’ symptoms decreased across all of the subscales of the TSCC in comparison to their pretest scores. The most significant reduction of symptoms was evident in the subscales of posttraumatic stress, anxiety, and dissociation-overt.
Study 3: Music Therapy with Sexually Abused Children
Robarts (2006)’s case study examined a survivor of childhood sexual abuse who was 7 years old at the onset of the study. The subject had been sexually abused by two different men in the household, one being the mother’s partner, and the assaults were extreme and persistent. The subject displayed all the major symptoms of PTSD listed in the DSM-IV, including dissociative states, persistent symptoms of increased arousal, poor capacity to self-regulate, a distorted development of the sense of self, persistent avoidance of stimuli associated with the trauma, numbing of feelings and persistent re-experiencing of the event.
The type of music therapy that was utilized was Poiesis Music therapy, which employs a technique of improvisation of song-poems. The therapist modulates music directly based on the subject’s emotions and behaviors, in an effort to develop experiences of self-regulation, healthy attachment, and a capacity for play. The subject participated in this therapy from the age of 7 years to 14 years, once weekly, initially lasting 30 minutes, and from the 4th year on of therapy the sessions increased to 40 minutes.
For the first two years of the music therapy, the subject attended psychotherapy. The subject participated in daily 15 minute sessions with her learning mentor at the end of each school day for the duration of her engagement in music therapy. From the age of 11 and on, the subject’s progress in school performance was outlined in an Individualized Education profile.
Within the first three years of music therapy, the participant changed from being a very disturbed, easily re-traumatized and dissociating child to a child who could respond and assimilate to new experiences, particularly basic sensory experiences that were formerly easily overwhelming for the patient. The therapy enabled the participant to express feelings of anger, despair and sadness less impulsively and more coherently. Throughout the course of the intervention, the self-harming, screaming, and completely passive and remote behaviours of the participant were reduced and the participant became able to participate in group activities at school. The subject’s expressive language became increasingly more fluent and clear. The musical therapy facilitated working through trauma with normal sensory and play experiences, which resulted in a gain in the subject’s basic sense of body boundaries and physical safety. The subject’s capacity for developing relationships was increased through the development of trust stemming from the musical therapeutic experience of predictability and variation. The child engaged in musical sensory experiences and structures, linking touch, hearing, sight, being and being with, which enabled the subject to examine the cause and effects of her actions and alter her impulses. The subject’s self-regulation of emotions had increased and the subject developed a capacity to explore and feel safe in new experiences and the capacity to sing and speak about herself in the present, without constant dissociation and flashbacks. The results of the subject’s individual educational profile confirmed that the subject was increasingly emotionally stable, exhibited less impulsive shifts in mood, had improved sustained attention, had improved eye contact, had developed the ability to mentalize, and used more expressive language.
Study 4: The Healing Function of Improvised Songs in Music Therapy with a Child Survivor of Early Trauma and Sexual Abuse
Robarts (2003)’s subject was a survivor of childhood sexual abuse, who was 11 years old. The participant experienced sexual abuse perpetrated by her paternal grandfather and her biological brother along with his friend. The subject presented all the major symptoms of PTSD in the DSM-IV criteria, specifically: dissociative states, persistent symptoms of increased arousal, a poor capacity to self-regulate, a distorted development of the sense of self, a persistent avoidance of stimuli associated with the trauma, numbing of feelings, and a persistent re-experiencing of the event. The subject was in an in patient program where family therapy, individual sessions with a nurse/therapist/keyworker, and special schooling were part of her regular treatment in addition to music therapy.
The type of music therapy implemented was poietic music therapy, which is a creative improvisational therapy, and follows the same methodology of Study 3 (Robarts, 2006). The instruments available for use in the music therapy sessions were a wide range of percussion instruments, including simple wind instruments, and a grand piano. For one month the sessions occurred once per week and then the sessions increased to twice per week for 13 months. As a result, the participant’s confidence greatly increased, along with her capacity to mentalize and her sense of self-worth.
DEFINITION OF CHILDHOOD SEXUAL ABUSE
Due to the heterogeneous presentation of childhood sexual abuse, it can be challenging to compare the data presented in childhood sexual abuse studies. It is necessary to identify what was considered sexual abuse in the studies because different definitions have different limitations, strengths, and applicability. All of the aforementioned studies (Brooke, 1995; Pifalo, 2002; Robarts, 2006; Robarts, 2003) didn’t provide an explicit definition of childhood sexual abuse nor the type of childhood sexual abuse that the subjects experienced, which weakens the reliability of these studies. However, it was specified in study 3 (Robarts, 2006) and study 4 (Robarts, 2003) that the sexual abuse occurred within the home of the survivor, which is likely due to childhood sexual abuse being more likely to occur within the home for female victims (Singh et al., 2014). Study 4 (Robarts, 2003) involved incest, which may impact the severity of the effects of the childhood sexual abuse. In study 3 (Robarts, 2006) and study 4 (Robarts, 2003), it was particularized that the subjects experienced multiple incidents of sexual abuse for more than one year and there were multiple perpetrators of the sexual abuse. The varying presentations of childhood sexual abuse may account for the variability in the outcomes of these expressive therapies for the survivors.
PARTICIPANTS
All of the studies (Brooke, 1995; Pifalo, 2002; Robarts, 2006; Robarts, 2003) examined solely female participants, which is likely due to childhood sexual abuse being more prevalent among females than males (Singh et al., 2014). This fails to account for gender differences, and therefore weakens all of these studies. Only one study, study 1(Brooke, 1995), stated the race and socioeconomic class of the participants, which strengthens that study. All of the studies varied in the age of onset of treatment, which makes them difficult to compare. Study 2(Pifalo, 2002), Study 3(Robarts, 2006), and Study 4(Robarts, 2003)’s participants were all under the age of 18, while study 1’s participants were adult survivors. The variance in age may impact the effectiveness of these expressive therapies.
PRESENCE OF PTSD
Of these four studies, two studies specifically diagnosed the subjects with PTSD: study 3 and study 4(Robarts, 2006; Robarts, 2003). The participants of these studies each met the same diagnostic criteria for PTSD and the major symptoms of PTSD displayed by the two cases were the same. The other two studies (Brooke, 1995; Pifalo, 2002) did not explicitly diagnose the subjects with PTSD, however in study 2(Pifalo, 2002) symptoms of trauma were examined, and it remains evident that the subjects of study 1 and study 2 have undergone severe trauma, that is comparable to study 3 and study 4.
COMPARISON OF METHODS/RESULTS
The research design and methodology employed in these studies face several limitations and varied greatly. Study 3(Robarts, 2006) and study 4(Robarts, 2003) were case studies, which inherently have several limitations. Case studies are limited in their applicability, reliability, and validity. Examining one participant fails to discount for individual differences that may have influenced the results. Study 1(Brooke, 1995) employed a control-wait design and Study 2(Pifalo, 2002) implemented a quasi-experimental design. Study 1’s design is stronger than study 2’s because of the presence of a control group. Overall, Studies 1 and 2 were stronger than studies 3 and 4 because of the presence of more than one participant, but the sample size of studies 1 and 2 were small, which weakens their applicability and validity.
Study 4 and study 2 examined an overlapping age group, which facilitates the comparison of trans-expressive therapies. A strength of study 2 is that it accounts for developmental considerations by grouping participants by their age, which increases its validity. A weakness of study 1 was the wide range of ages of subjects in the study, which hinders the validity of the study. A notable limitation of studies 1, 3, and 4 (Brooke, 1995; Robarts, 2006; Robarts, 2003) that may have impacted their results was the presence of other therapies during the administration of the expressive therapy, which decreases the reliability of the outcomes resulting from the corresponding expressive therapies implemented.
All of the studies differed in the length and frequency of expressive therapy administered. The studies employing music therapies, study 3 and study 4 (Robarts, 2003; Robarts, 2006), were conducted for at least a year and once per week, which strengthens these studies. The studies employing art therapies, study 1 and study 2(Brooke, 1995; Pifalo, 2002), were conducted for similar lengths of time—for 16 and 15 total hours of intervention, respectively. However, due to study 1 employing more time of intervention than study 2, the implications of that study are stronger in that regard. Of these four studies, varying forms of expressive therapy were implemented, including music therapy and art therapy. All of these techniques involved the expression of the self.
Studies 3 and 4 (Robarts, 2006; Robarts, 2003) employed music therapy involving poesies techniques. The poesies techniques employed in studies 3 and 4 encompassed the exact same improvisational methodology. A weakness of this methodology is its basis on the subjective interpretation of the subject’s behavior. An aspect of studies 3 and 4 that can be considered both a weakness and a strength is that the experimenter was the same in both studies, which can be considered a weakness because of the potential presence of experimenter bias, but can also be a strength in that the methodologies were likely conducted in a comparably similar manner and the resulting changes in behavior were likely subjectively interpreted in the same way.
Studies 3 and 4 both resulted in a reduction of PTSD symptoms, but, significantly, in study 3 (Robarts, 2006), the subject developed the capacity to sing and speak about herself in the present, without constant dissociation and flashbacks. Both of these studies resulted in increased self-confidence, metallization, ability to express the self, self-regulation and sense of self worth. Study 3 was stronger than study 4 (Robarts, 2003) because study 3 provided an individualized education profile 3 years into the music therapy, which was an additional measure of the improved functioning that the subject experienced, showing that progress was evident in more than one setting. A major weakness of study 3 and study 4 is that the psychological changes were not measured with a standardized method, and instead were based on observed changes, which impairs the implications of the studies.
Studies 1 and 2 (Brooke, 1995; Pifalo, 2002) employed different art therapies. Both studies implemented group art therapy, which can be both a strength and a weakness. It can be a strength because of the benefits group sessions can have on this population of people such as building trust and facilitating friendships. However, it can also be a weakness of these studies because it weakens the implications of art therapy being a suitable intervention for these survivors, since the positive outcomes of these studies could be attributed to the group sessions instead.
A strength of study 1(Brooke, 1995) was that the participants had freedom in choosing which method of art they got to utilize, as it is beneficial for childhood sexual abuse survivors to assert themselves. A limitation of study 1 is the quantitative measure implemented because it solely measures self-esteem and monitoring progress of other psychological mechanisms, specifically related to trauma, would increase the validity of the implemented art therapy as a suitable intervention for this population. Additionally, the quantitative measure used in study 1 may be a weak measure of self-esteem because it offers only yes/no answers, perhaps a scale that has a range of responses will facilitate a more accurate measure of self-esteem. The quantitative measure used in study 2(Pifalo, 2002) strengthens the study because it is a very reliable scale and assessed trauma symptoms, which is very relevant to these survivors. Another strength of study 2 was that the group sessions had a specific organization, the “circle of believers”, that is particularly beneficial for childhood sexual abuse survivors. Overall, the outcomes of the intervention implemented in study 2 were stronger than the intervention of study 1.
All of the studies (Brooke, 1995; Pifalo, 2002; Robarts, 2006; Robarts, 2003) are not methodologically rigorous enough to draw definitive conclusions, but do provide a “proof of concept.”
DISCUSSION
Examination of the selected literature yielded empirical evidence that suggests that music and art, when employed as a therapeutic tool via music therapy or art therapy, may address and improve functioning of childhood sexual abuse survivors and associated PTSD symptoms. However, further empirical study is required before music and art therapy can be included among the canon of evidence-based treatments for children who were sexually abused due to the limited extent to which these therapies have been determined effective.
AREA FOR FUTURE REASEARCH
Several questions remain that warrant further study. To better understand the impact of music and art therapy on childhood sexual abuse survivors, a larger sample size of subjects could provide more information as to these therapies’ possible benefits. The study should account for gender differences by including male and female participants. The study should employ music therapy and art therapy, in order to compare their results and determine which of these two expressive therapies is most beneficial for these survivors. The age of the participants and length of therapy should be controlled for as well. Additionally, the type of sexual abuse, relation to the perpetrator, and the number of incidents of sexual abuse could be accounted for to further strengthen the implications of art and music therapy. The implementation of a physiological measure, such as a measure of salivary cortisol levels, in conjunction with multiple standardized psychological measures could further clarify the impact of these expressive therapies for childhood sexual abuse survivors and strengthen the validity of the therapies.
A group music therapy intervention should be studied in the future to see if that provides additional relief to this population, along with a study examining art therapy without group sessions to determine if it is effective on its own in providing relief to this population. In addition, study 3(Robarts, 2006) and study 4(Robarts, 2003) should be replicated utilizing the newer DSM-5 to ensure its implications are valid.
Conclusion
Individuals who have experienced childhood sexual abuse could gain from further research into music therapy and art therapy as treatment options to improve functioning. Increased knowledge about the direct impacts of music therapy and art therapy on childhood sexual abuse survivors could also increase the number of tools available to clinicians who aim to offer better holistic care.