Sexual violence against children is a serious problem that has gained the attention of researchers over the past decades. The literature reflects the importance of developmental issues salient in early victimization ( Cole & Putnam, 1992, Finkelhor 1994). Each individual’s experiences and consequences to this form of abuse are unique, but it seems there are some common short and long term reactions with it’s survivors. These children may experience such psychological problems as, “anxieties, fears, depression, angry and destructive behaviour, phobic reactions and deficits in intellectual, physical and social development.” (Green, 1993, p.892).
Early identification of sexual abuse victims appears crucial to reduction of suffering, enhancement of psychological development, and for healthier adult functioning (Bagley, 1992; Bagley, 1991; Finkelhor et al. 1990; Whitlock & Gillman, 1989). Despite an increased focus on child sexual abuse in the recent decade, many gaps remain in our knowledge. Many of the studies hitherto published suffer from few children being included, and from a high dropout rate in cases with protracted treatment periods. In addition, comparability is limited by the great variations between different studies in terms of gender and age structure, input symptomatology and treatment focus.
Reference groups are often lacking, due to ethical considerations. As yet few writers have employed a more experimental design and compared different treatments. Prospective longitudinal follow-up studies of sexually abused children and treatment outcome studies are urgently needed (Green 1993). In the last few years there is an encouraging growth in the number of experimental studies. Those with sexually abused children randomly distributed between treatment group and control group have presented a fairly unanimous picture, namely that of the treatment groups developing significantly better than the control groups. Many of these studies support the cognitive behavioural therapy as having a better effect on a number of different problems.
Briere and Elliot (1994) described three stages of victim response including : (1) initial posttraumatic stress, painful emotions, and cognitive distortions; (2) development of coping behaviours; and (3) long term consequences. Briere and Elliot (1994) suggested that after the initial reactions to abuse, children begin to develop coping behaviour. Hartman & Burgess (1998) identified five patterns that may emerge including an integrated pattern, an avoidant pattern, symptomatic pattern, identification with the abuser, and psychotic pattern. Several authors have reported the long-term effects of childhood sexual abuse. Briere & Elliot (1994) argue that for many children, the coping behaviours are not enough to overcome the negative consequences of sexual abuse.
For these individuals, long-term, chronic symptoms may be present in adulthood. Briere & Runtz (1993) suggest that there are strong evidence for the psychological toxicity of childhood sexual victimizartion, thus childhood sexual abuse is damaging both at the time of the occurrence and in the long-term. Newmann et al., (1996) in their meta-analysis of the research noted that children who were sexually abuse (females) report symtomatology of low self-esteem, depression, dissociation, anxiety, and post-traumatic stress disorder. The cognitive difficulties related to PTSD include impaired self-concept and self-esteem, negative perception of self and others and the future ( Briere 1989).
In addition to the cognitive difficulties, many survivors report emotional after-effects which include anxiety, depression, interpersonal problems, and suicide ideation. Beitchman et al (1992) using 32 studies of clinical and nonclinical samples they noted that children who were sexually abused they show sexual dysfunctions, anxiety, depression, and suicide ideation in later adulthood. Maker & Buttenheim (2000) reported problems of interpersonal discord, low self-esteem, parenting difficulties, and substance abuse ( Davis & Petretic-Jackson 1999). Messman-Moore & Long (2000) found a greater vulnerability of later victimization for individuals with a history of childhood sexual abuse, whilst Beitchman et al suggest that the presense of penetration and perpetrator identity ( e.g. the victim’s father or stepfather) increase likelihood of long-term consequences for childhood sexual abuse survivors.
There are several modalities of psychological treatment that have demonstrated positive benefits for child victims of sexual abuse. These include individual psychotherapy, group-based psychotherapy, and treatments that involve the entire family. When treatment for this population is trauma-focused, structured, and targets the specific symptoms of sexual abuse, it can be effective at reducing short-term and long-term effects. Individual treatment usually involves the child and a therapist meeting together for an hour a week
Central to cognitive-behavioral therapies and Relapse Prevention is the belief that sexual abuse is something that does not “just happen.” The overwhelming majority of the time there are identifiable behaviors in which offenders engage prior to offending. Successful treatment involves educating the sexual offender about this process of sexual offending and facilitating an understanding of his particular pattern of offending. Within this conceptualization, it is important to teach sexual offenders how to identify circumstances that place them at greater risk for re-offending. Based on the offender’s understanding of his behavior, he can then learn to identify problematic behaviors early in this cycle, modify his behavior, and consequently reduce the liklihood that he will re-offend. Other important areas of treatment include accepting responisiblity for offending, developing victim empathy, and correcting faulty thinking patterns.
In our focusing therapy emerging from the summary evaluation of the approaches by previous studies and findings emerging from the meta-analysis of the previous studies (refer to appendix 1 &2), we will attempt to employee the Experiential approach and in particular the EFT-AS therapy for adult survivors of child abuse developed by Paivio and Paterson (1999) and utilised by Paivio & Nieuwenhuis, 2001. Paivio & Nieuwenhuis (2001) study, had numerous strengths according to both efficacy and effectiveness criteria. The authors clearly defined their target symptoms and used reliable and valid measures. Both patient self-report and interview measures were used, involving both patients and therapist raters. They utilized assessor or therapist training in their manualised, replicable, specific treatment program.
Most of the previous studies listed on appendix 1 and 2 except the Experiential Therapy by Paivio & Nieuwenhuis (2001) utilizes a no treatment control group. This is important because without a comparison group it remains unclear whether a treatment is more efficacious than none at all. Thought many of the studies mentioned in the met-analysis, appendix 1 and 2, used treatment manuals or specified techniques, only one of them provided a detailed description of how treatment faithfulness was measured reliably (Paivio & Nieuwenhuis 2001). For the remaining approaches and studies mentioned in the meta-analysis did not measure treatment faithfulness, it is unclear exactly what, how, and when interventions were being implemented.
Research on the treatment of sexually abused children according to Finkelhor and Berliner (1995), is still in its infancy. Sexual violence against children and adults is a serious problem reported by many researchers over the last past few decades. The individual of such an abuse is characterised by the self-trauma theory of childhood abuse (Briere 1997). The self-trauma model’s integration of self-psychology, attachment theory, and cognitive-behavioural interventions has been emphasised in the literature on treatment with this population. Research also reveals the importance of developmental issues important in early victimization (Cole ; Putman, 1992; Finkelhor 1994).
Beitchman, Zucker, Hood, Dacosta, and Ackman (1991) reviewed the short -term effects of childhood sexual abuse using 42 studies of clinical and non-clinical populations. They described several symptoms commonly reported by samples of sexually abused children including sexualized behaviour, conduct problems, academic problems, depression, low self-esteem, and suicidal ideation. They noted that these symptoms are characterized of most clinical populations of children, and it is difficult to determine whether or not childhood sexual abuse actually has a direct impact on symptomatic distress.
There are behaviors that children who have been victimized exhibit:
Changes in eating habits
Changes in sleeping habits
Difficulty at bath time
Difficulty at bed time
Regression in behaviors
Self destructive behaviors
Increase in accidents
Fall behind in school
Plays violently with dolls
Hartman ; Burgess (1989) identified five patterns that may emerge in children sexual with such an abuse, including an integrated pattern, an avoidant pattern, symptomatic pattern, identification with the abuser, and psychotic pattern. Briere and Elliot (1994) suggested, that the children begin to develop copying behaviours after their initial reactions to abuse, however, many children, adopting this coping behaviours are not enough to overcome the negative consequences of sexual abuse and they develop long-term chronic symptoms even present in adulthood.
Beitchman et al (1992) reviewed the long term effects of childhood sexual abuse using 32 studies of clinical and non-clinical samples. He registered those adults who were sexually abused as children tend to show evidence for sexual dysfunctions, anxiety, depression, and suicidal ideation. They also noted that variables such as duration of abuse, presence of penetration, and perpetrators identity increase the likelihood of long-term consequences for childhood sexual abuse survivors.
Maker ; Buttenheim (2000) reported problems of interpersonal discord, low self-esteem parenting difficulties, and substance abuse. Messman – Moore ; Long 2000 found a greater vulnerability to later vivtimization for individuals with a history of childhood sexual abuse. Many adults who enter psychotherapy have experienced some form of sexual abuse in their childhood even if they do not present with abuse as the primary issue for therapy. For example Wurr and Patridge (1996) reported a childhood sexual abuse prevalence rate of 46% among adults in an acute inpatient population. Lombardo and Pohl (1997) registered a childhood sexual abuse prevalence rate of 71% in their sample of patients in a psychiatric outpatient clinic.
Sexually abused children are not a homogeneous group requiring identical treatment (Beutler, et al., 1994). Because the consequences of child sexual abuse vary widely in severity, duration, and form, it is unlikely a single treatment program will be suited to all children (Beutler, et al.).
Beutler, L. E., Williams, R. E., ; Zetzer, H. A. (1994). Efficacy of treatment for victims of child sexual abuse. The Future of Children: Sexual Abuse of Children 4(2), 156-175.
Various therapeutic approaches have been utilized in the treatment of adult clients with a history of child sexual abuse (Paivio ; Patterson 1999, Stalker ; Fry 1999). Despite the various therapeutic approaches few investigators have reported on the efficacy or effectiveness of their approach. While group psychotherapy has been shown to be effective at symptom reduction and improvement in functioning, most researchers and clinicians recommend concurrent individual psychotheraphy for survivors of childhood sexual abuse (Westbury ; Tutty 1999). Nevertheless even with the awareness that individual treatment for these cases is an important aspect of recovery. There seems to be limited information on the effectiveness of these treatments.
Research has described a number of different standards for evaluation of psychotherapy outcome studies. Foa and Meadows (1997) “gold standard” for treatments, employees one set of parameters in an efficacy methodology outcome study. They recommended the following; clearly defined target symptoms, reliable and valid measures, uses of blind evaluators, assessor training, manualized, replicable, specific treatment programs, unbiased assignment to treatment, and treatment adherence. Seligman (1995, as cited in Price et al. 2001), previously reported a closely match parameters with Foa and Meadow’s (1997), description of the standards used in efficacy studies. However, Seligman notes that such standards fail to consider many “real world” practices, causing a failure to accept apply the results of efficacy studies and generalize them to clinical practice.
Price et al (2001) outlined the importance of effectiveness studies versus efficacy critics. They suggest that effectiveness studies allow for the “real world” practices such as the use of individuals who actually present for treatment (rather than recruited volunteers). Effectiveness studies also allow therapists to utilize self-corrective measures in the adaptation of treatment to meet the individual needs of the patient, including the length of time changes necessary for treatment.
Measures of effectiveness do not only rely on measures of specific symptoms but also need to include some assessment of general functioning and quality of life, as well as the clients’ degree of satisfaction with the treatment. Finally, effectiveness studies avoid the statistical significance and consider more the clinical outcomes. As Seligman (1995, p.969) notes that the approach assesses “the effectiveness of psychotherapy as it is actually performed in the field with the population that actually seeks it.”
Across all of the psychotherapy interventions it appears that the data largely support the effective use of individual psychotherapy for adult survivors of childhood sexual abuse (refer to appendix 1 ; 2). Studies have shown a decrease in specific symptomatology for adults reported as being sexually abused in childhood. Depressive symptoms decreased for a majority of victims as measured by the BDI in three studies ( Chard, Bennett et al., 1997, Clarke ; Llewelyn 1994, Jehu et al., 1986).
Five other studies indicated a decrease in anxiety or other trauma -related symptoms for many victims as measured by Client Perception Scale (CPS), Impact of Events scale (IES), TSC-40, and Postraumatic stress scale (PTSS) ( Chard, Bennett, et al., 1997; Paivio ; Nieuwenhuis, 2001; Paivio ; Paterson, 1999; Stalker ; Fry, 1999, as cited in Price, et al 2001). A significant improvement on symptoms of “unfinished business,” were reported by Paivio ; Bahr (1998) in their studies, and resolution of past issues by Paivio ; Nieuwenhuis, 2001, Paivio ; Paterson 1999).
Interpersonal functioning was also affected by some types of interventions, as measured by improvements in self-control and self affiliation on the Stractural Analysis of Social Behaviour-Intoject Affiliation subscale ( Paivio ; Bahr, 1998; Paivio ; Nieuwenhuis, 2001, Paivio ; Paterson 1999). Paivio and Nieuwenhuis (2001) also demonstrated improvements in interpersonal interactions as measured by the Inventory of Interpersonal problems (IIP). A secondary result related to interpersonal functioning shown in three studies was that development of a positive therapeutic alliance early in treatment was associated with positive outcome ( Paivio ; Bahr, 1998; Paivio ; Nieuwenhuis, 2001, Paivio ; Paterson 1999).
Finally, global symptomatology as measured by the Global Severity Index of the SCL-90R( Derogatis 1983 as cited in Price 2001) was reduced for child sexual abuse survivors in a number of studies. ( Paivio ; Bahr, 1998; Paivio ; Nieuwenhuis, 2001, Paivio ; Paterson 1999). Overall, it seems clear from these positive results that individual psychotherapy can be effective for adult survivors of childhood sexual abuse. Some studies also conducted follow-up assessments between 3 and 12 months posttreatment (Paivio ; Neuwenhuis 2001). Paivio and Nieuwenhuis (2001) reported that participants maintained treatment gains on all measures at the 9 – month follow up, also with no significant changes between posttreatment assessment and follow- up.
Experiential approaches include existential, humanistic, and feminist therapies. As described by Elliott and Greenberg (1995), experiential therapies focus on relationship principles such as empathic attunement, threrapeutic bond, and task collaboration, as well as task facilitation principles such as experiential processing, growth/choice, and task completion. One common technique used in experiential therapy is the empty-chair technique, derived from Gestalt therapy, which consists of the client expressing him or herself by talking directly to an empty chair that represents the person with whom they have unresolved conflict. In a series of studies using experiential therapy for interpersonal issues including child abuse, Paivio and Bahr (1998) described a therapy aimed at resolving “unfinished business” with a significant other. The authors defined unfinished business as painful interpersonal situations that remain unresolved and continioue to interfere with current functioning.
They indicated that unfinished business comes from the chronic repression of emotion and unmet needs in a relationship and implemented experiential procedures such as the empty-chair technique to resolve these issues.
The EFT-AS approach to therapy for adult survivors of child abuse developed by Paivio and Paterson (1999) and utilised by, (Paivio ; Nieuwenhuis, 2001), posits three mechanisms of change; (1) accessing and modifying trauma memories that generate maladaptive experiences, such as fear and shame; (2) accessing constricted adaptive emotion, such as anger and sadness, in order to access the adaptive orienting information inherent in these emotions; and (3) providing a corrective interpersonal experience with the therapist. This focus on expression of affect and corrective emotional/relational experience shares some common principles with psychodynamic-interpersonal psychotherapy as well ( Blagys ; Hilsenroth 2000).
Paivio ; Nieuwenhuis (2001) described EFT-AS as including the following specific interventions; empathetic responding; experiential and imagery techniques and encouraging integration of traumatic experiences through imaginal confrontation. For our individual case in this study we will adopt similar guidelines as Paivio ; Nieuwenhuis (2001), EFT-AS consists of 20 sessions and following a specific treatment manual developed for adult survivors of child abuse. The client was only undergoing this therapy and did not take any psychoactive medication, or was in a crisis state, which included problems with severe substance abuse, violent relationships, and self-harm behaviour. In addition the client was selected by scoring above 0.60 (t=40) on the GSI of the SCL-9O-R (Derogatis 1983).
While the overall results for the use of individual psychotherapy with adult survivors of childhood sexual abuse are promising, the literature remains incomplete. Few Studies provided an adequate description of the sample in the metanalysis, omitting details such as DSM clinical diagnoses/comorbidity and sample selection. The two studies we have decided to adopt their EFT-AS approach to therapy for adult survivors of child abuse, indicated that their sample consisted of referred or recruited victims (Paivio ; Nieuwenhuis, 2001; Paivio and Paterson , 1999). Also this studies included participants who had experienced other forms of childhood interpersonal trauma.
Future research should concentrate its efforts on continuing to clear the impact of various interventions on important variables that have been related to long-term sequelae of childhood sexual abuse, such as depression, anxiety, interpersonal and general distress. Findings from the psychotherapy outcome for adult survivors of child sexual abuse must be compared to a control group of psychologically distressed adults. Research needs to incorporate the efficacy criteria of utilising reliable and valid measures of clearly defined target symptoms, while also including measurements of general functioning.
Using the model of many of the existing outcome studies, treatment should be aided and informed by a manual. However, flexibility in terms of clients need must also be considered to provide psychotherapy in a optimally responsive manner ( Price., et al 2001). Limitations can also constrained by using assessment and treatment stategies for adult survivors of childhood sexual abuse based on an existing theoretical model of childhood abuse. Briere’s (1997) self-trauma theory integrates self-psychology, attachment theory, and cognitive-behavioural approaches within a developmental perspective in the conceptualisation of trauma. In summary, incorporation of efficacy and effectiveness criteria as well as the utilisation of current theoretical models of childhood trauma can yield maximum results .
Green, A.H.(1993) ”Child Sexual Abuse: Immediate and long-term effects and intervention”, Journal American Acabemy Child Adolescent Psychiatry, vol. 32, no.5, pp.890-902
Briere, J.N., & Elliott, D.M.(1994). Immediate and long-term impacts of child sexual abuse. Future of Children, 4 (2), 54-69.
Briere,J.N.(1997). Treating adults severely abused as children; the self-trauma model. In: D.A.Wolfe, R.J.Peters, & R.D.Peters (Eds), Child abuse:new directions in prevention and treatment across the lifespan(pp.177-204). Thousand Oaks, CA: Sage Publication
Briere, J., & Runtz, M. (1989) The Trauma Symptom Checklist (TSC-33). Early data on a new scale. Jornal of Interpersonal Violence, 4, 151-163.
Briere, j. (1989) Therapy for adults molested as children. New York: Springer.
Blagys, M.D., & Hilsenroth, M.J. (2000). Distinctive features of short-term psychodynamic-interpersonal psychotherapy; a review of the comparative psychotherapy process literature. Clinical Psychology; Science and Practice, 7 (2), 167-188.
Cole, P.M., Putnam, F.W. (1992). Effect of incest on self and social functioning; a developmental psychopathology perspective. Journal of Consulting and clinical psychology, 60, 174-184.
Derogatis, L.R.(1983). SCL-90-R administration, scoring, and procedure manual. Towson, MD; Clinical Psychiatric Research.
Finkelhor, D. (1994). Current information on the scope and nature of child sexual abuse. Future of Children, 4 (2), 31-53.
Finkelhor,D., & Berliner, L (1995) Research on the Treatment of sexually abused children; A review and recommendations Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1408-1423
Foa, E.B., & Meadows, E.A.(1997).Psychosocial treatments for posttraumatic stress disorders: a critical review. Annual Review of Psychology, 48, 449-480.
Foa, E.B., Riggs, D.S., Dancu, C.V., & Rothbaum, b.o.(1993) Reliability and validity of a brief instrument for assessing posttraumatic stress disorder. Journal of Traumatic Stress, 6, 459-473.
Green, A.H., (1993). Child sexual abuse: Immediate and long-term effects and intervention. Journal of the American Academy Child and Adolescent Psychiatry, 32(5), 890-902.
Hartman, C.R., & Burgess, A.W. (1989). Child maltreatment: theory and research on the causes and consequences of child abuse and neglect. In: D.Cicchetti, & V.Carlson (Eds, Sexual abuse of children: causes and consequences (pp.95-128) New York, NY: Cambridge University Press.
Maker, A.H., & Buttenheim, M. (2000). Parenting difficulties in sexual -abuse survivors: a theoretical framework with dual psychodynamic and cognitive-behavioral strategies for intervention. Psychotherapy, 37(2), 159-170.
Messman-Moore, T.L., & Long, P.J. (2000). Child sexual abuse and revictimization in the form of adult sexual abuse, adult physical abuse, and adult psychological maltreatment. Journal of Interpersonal violence, 15 (5), 489-502.
Newumann, D.A., Houskamp, B.M.Pollock, V.E., & Briere, J. (1996). The long-term sequelae of childhood sexual abuse in women: Ameta-analytic review. Child Maltreatment, 1, 6-16.
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Stalker, C.A., & Fry, R. (1999) A comparison of short-term group and individual therapy for sexually abused women. Canadian Journal of Psychiatry, 44(2), 168-174
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The majority today recommend cognitive behavioural therapy, above all for traumatised children. In Sweden and many other countries, this form of therapy has been mainly used for adult patients and to only a slight extent with children. The fact of cognitive behavioural therapy having begun to be applied to this target group, i.e. sexually abused children and young persons, is to be viewed in the light of modern knowledge concerning the functions of the brain in connection with trauma and extreme stress.
Without any doubt, the form assumed by the development of treatment during the 1980s and 1990s has been to develop treatment programmes and models based on multidisciplinary, specialised units, all of which have emerged in response to a growing need of therapeutic help for sexually abused children and young persons and to a growing need for development of science and methods in this field. This process also has the support of recommendations made by the Council of Europe to its member countries. In the light of international experience, development of more treatment centres in addition to BUP-Elefanten is to be recommended, and it should be possible for centres of this kind to be established at least in the three metropolitan regions of Stockholm, Gothenburg (Gï¿½teborg) and Malmï¿½
The treatment of sexually abused children and young persons is an important field but a difficult one to master. Like all other forms of psychotherapy, it presents a multiplicity of theories, treatment models and programmes.
Three emphases in treatment programmes
Cohn (1979) writes that programmes for sexually abused children and young persons have three identifiable approaches: a lay or voluntary approach, mainly offering peer counselling and supportive groups, a group approach offering group therapy and training, and a approach based on social work and mainly offering individual counselling/treatment. MacFarlane (1983) also identifies a fourth systematic approach based on the importance for effective treatment of co-operation between public authorities and mediation. Keller et al (1989) write that in practice the majority offering treatment have adopted an eclectic treatment model which is often based on the humanist model of family treatment developed, for example, by Giaretto (1982). This model combines voluntary efforts in the form of counselling and support with professional individual treatment and group therapy in a co-ordinated multidisciplinary activity.
In a survey in 1986, Keller et al (1989) identified upwards of 2,250 different programmes in the USA. Of these, 553 replied to a questionnaire. Most of these programmes were either part of a private organisation (43 per cent) or (30 per cent) of a public activity such as medical care or social welfare. Over 88 per cent of the units concentrated their attention on the victim and the victim’s family, and most of them had a family-oriented treatment programme. More than half of them (56 per cent) offered individual, family, pair (child-parent, parent-parent) and group treatment. Only a fraction of the units offered only individual treatment (3 per cent) or group treatment (3 per cent). There was a wide variety of techniques, such as insight therapy, play therapy, behavioural modification, picture therapy and more educational techniques such as psycho-educative treatment, heterosocial skill training, anti-recidivist techniques and cognitive treatment. Only 27 per cent of the programmes had post-treatment follow-up routines.
Sex Abuse Project, Ackerman Institute for Family Therapy, USA
The Ackerman Institute’s model is based on two schools of theory in family therapy: social constructionism and feminism (Sheinberg, 1992).
The Ackerman Institute itself describes its therapeutic approach as a multimodal programme, meaning that various modalities, such as individual, group and family therapy, are integrated in the treatment (Sheinberg, True, Fraenkel, 1994). The programme is client-driven, which means that all the time it is framed according to the individual child’s unique experience. In the programme-driven models which are often used in group treatment, for example, different themes are worked through in a structured manner, it being known that they are usually of great importance to children who have been subjected to abuse.
The treatment is based on the assumption of people having “multiple self-images”, depending on the context and relations in which they see themselves (Gergen, 1991). Accordingly, in the therapy the child and other members of the family are offered different experiences by alternating between different therapy contexts or modalities. This working approach has been developed into a recursive flow of information whereby information from one therapeutic context – individual therapy, for example – is introduced into another context, e.g. family therapy, and then back again in a continuous flow. By making different questions, subjects, difficulties, conflicts etc. migrate between the different modalities, greater understanding is achieved of the unique experiences of each member of the family.
No scientific evaluation of the therapeutic outcome has been presented.
Great Ormond Street Sexual Abuse Team, UK
Treatment by this team has been influenced from many quarters, not least by parallel developments in family therapy. Bentovim (1987, 1988) describes, on the basis of a family-systemic model, how a behaviour of sexual abuse can start and continue. The family can be meaningfully described and understood through seven different levels, viz:
1. Elements of interaction.
2. Cycles of interaction.
3. Active meaning systems.
4. The dimensions of family life in sexual abuse.
5. The formulation of the family.
6. The potential for treatment, actual and ideal.
7. The generalities of family life.
The Great Ormond Street programme has made an important difference to European developments in this field. The programme has attempted to integrate two main approaches – family therapy and group therapy – within the framework of clear co-operation with social services and criminal welfare. Great importance is attached to an initial assessment of each individual case.
The programme has been evaluated through a follow-up study (Bentovim, van Elburg, Boston, 1988), in a descriptive study and in a treatment study (Monck et al, 1996). The latter is presented in the fourth section, Treatment evaluation, of the present report.