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Working with sexually abused children

Gregory K. Moffatt November 25, 2013

BearMateo (not his real name) sat on the floor in my office playroom. Each week in therapy, he routinely played with a small plastic doll and every time, without fail, he placed objects in the doll’s mouth. This day, however, he did something more aggressive. His eyes wide and his face full of rage, he took a Tinker Toy, an apparent phallic symbol, and repeatedly jammed it into the doll’s mouth. “He doesn’t want it in his mouth,” Mateo said into the air, “but he’s going to get it in there anyway!”

A male babysitter had sexually violated Mateo several months earlier. I’m confident, in part based on Mateo’s playroom behavior, that the babysitter had forced himself into Mateo’s mouth. Fellatio wasn’t the only violation forced upon Mateo, but it was the most brutal. Recovery for Mateo would take months.

Those sessions occurred more than 25 years ago. Mateo was one of the first seriously abused children to enter my private practice, and I’ve never forgotten him. Unfortunately, he represents only one in a very long line of abused children I have seen over a nearly three-decade career. In some ways, each child is different, responds to abuse differently and progresses at her or his own pace, but the stages of counseling with this population generally are predictable.

Stages of therapy with abused children 

Stage one: Trust. No matter how much parents tell me their children are shy or “won’t talk to a therapist,” I’ve never failed to gain these children’s trust within the first session or two, often within the first few minutes. More than once I’ve been shocked at how quickly children have divulged deeply hurtful and frightening information to me, almost as though it was ready to explode from them at the first opportunity that someone took to listen. Other times, however, it has not been so easy. Hundreds of children have come through my office doors, and I have learned to use the tools of my trade to create an environment of safety.

Play therapists have an advantage over more traditional counselors in these first visits. My office is full of toys, puppets, books, crayons and sandboxes, along with literally thousands of miniatures. As we begin, my first question is usually “Would you like to play for a while?” Only rarely have I come across a child who didn’t want to play.

I want to give the child as much control as possible throughout therapy, but it is especially important during these first sessions. A therapist I greatly respect taught me the phrase, “You can do about anything you want to in here. If there is something you can’t do, I’ll tell you.” I have used that opening line for years, and it has never failed me.

But children will test that statement. When I said this during Mateo’s first visit, he asked skeptically, “Can I dump all the toys out of the toy box?” He rested his hand on the rim of the large plastic tub that contained many of my toys.

“If you need to,” was my response. As I have learned to expect when such a question is posed, Mateo turned the box up on end and dumped everything out. I sat quietly and smiled at him. He smiled back. I had passed his first test for me.

Mateo called me Greg from our first session. I hadn’t earned my Ph.D. at the time, but even now, I don’t like children referring to me as “doctor.” That term is too easily equated with shots or unpleasant experiences. “Greg” is just fine with me when parents will allow it. That also helps begin to create a context of “us” rather than a view that the child is there to be “treated.”

I have to be very careful how I move when I’m with children such as Mateo. Sexually abused children do not interpret movement in the same way that other children do, especially when that abuse has been repeated over many weeks or months. What most children would regard as an innocuous touch may easily be interpreted by sexually abused children as an invitation or command for sex. In the case of physically abused children, they will flinch if I move too quickly to reach for my pen, scratch my ear or adjust my sitting position on the floor (something I have to do often as I get older). Flinching is an unconscious protective reaction that these children have learned. The quick fists of abusers have surprised them before, so these children learn to be vigilant for punches and backhands. The body remembers.

Stage two: Symptom reduction. Once I’ve built trust with the child, I can begin stage two. During this part of therapy, I want to accomplish two things. First, I want to reduce the negative symptoms that brought the child to my office in the first place. If he or she isn’t sleeping or eating, or is having trouble paying attention at school or getting along with siblings, I work with the child and guardian(s) to address these symptoms.

Mateo regularly acted out sexually. He masturbated in public. He exposed himself to other children on his school bus and in his classroom. Most troubling, he forcibly fondled other children, especially younger girls who were too small or too confused to say no. We had to address these behaviors immediately. I almost always use behavioral modification tools to intervene when behaviors are as serious as these.

The second thing I want to accomplish is to provide the child with skills to manage or prevent his or her issues. I worked with Mateo to recognize his urges and to develop ways to manage them. I have two recliners in my office — one adult sized and one child sized. These are the “thinking chairs.” Mateo and I sat in the thinking chairs, both of us staring at the ceiling.

“I’m wondering what we could do when our body parts feel funny,” I said, referring to the urge to masturbate.

“Maybe I could go to my room,” Mateo said, interestingly turning my use of “we” into “I.” Children are surprisingly intuitive and insightful when adults take the time to listen to them. Going to his room was a good idea — one of many that Mateo came up with during the course of our therapy. When the child discovers a solution, he or she is more likely to believe it will work and, hence, more likely to implement it.

Stage three: Facing demons. Abreaction is a term I learned from Lenore Terr, a writer and psychiatrist in San Francisco. Abreaction means that the child is reliving or replaying the abuse in therapy. We all do this in everyday life. When something significant happens to us, we have the need to talk about it —reliving it through conversation.

Imagine that you saw a car accident happen in front of you on the way to work. You would tell your workmates when you arrived. You would think about it during the day. You might call your spouse and relate the event. This would go on until you had “talked it out.”

Young children don’t have the vocabulary or cognitive ability to talk it out. Instead, they act it out in dramatic play, through the pictures they draw or in the activities they engage in in my sandbox. They literally replay their traumas.

When Mateo was forcing the Tinker Toy into the doll’s mouth, he was abreacting. He was abreacting when he fondled children on his school bus, and his masturbation was also a form of abreaction. Like an interested workmate or an understanding spouse listening to your story of the auto accident, I help children work through their stories over and over until they achieve a resolution.

One child in therapy with me abreacted to a perpetrator by repeatedly burying a little toy man in a wad of play dough each day that we worked together. In subsequent sessions, the child left more and more of the little man uncovered by the play dough. By our last session together, only the toy’s feet remained covered. “I see the man is almost free,” I said to the child. Confidently, the child smiled at me and said, “That’s OK, I can handle him.” This little boy had worked through the trauma of his abduction and abuse. His therapy was almost done.

Stage four: Wrapping up. Once symptoms have abated to a point where the child can cope, when he has the tools to deal with stressors in his life and the invasive thoughts and dreams that haunted him have faded away, the child is ready to work toward closure.

After 10 months of therapy, Mateo’s parents reported to me that his autoerotic behavior was under control and he rarely engaged in that behavior in environments where it was inappropriate. He was no longer exposing himself or talking sexually with other children, and he hadn’t touched another child since our first visit. His abreaction in therapy had trickled into almost nothing. His outbursts and temper tantrums were greatly reduced, and his parents now had the skills they needed to work with Mateo without my assistance. It was time to talk about closure.

Stage five: Termination. Saying goodbye to Mateo was hard for me. When growth happens as it should in therapy, it is rewarding and exciting. It is hard not to take ownership of it, but the truth is, Mateo was responsible for that growth, not me.

In the last session with each of the children I work with, the child gets to choose what we do. This allows the child to have control of his or her final hour with me and the work we have done together.

Mateo selected what many children subsequent to him have chosen. “I want to draw something,” he said.

I nodded but otherwise said nothing. Spilling crayons onto the floor in front of him, he worked intently, drawing on the paper while I watched. I was afraid to move because I didn’t want to break his concentration. When he finished, he took a deep breath, smiled at me and handed me his drawing. Two stick figures were holding hands, the sun bright in the upper part of the page and flowers standing like sentinels on either side of them. One figure looked like Mateo, who always drew himself wearing a baseball cap. The other figure was an adult.

“Tell me about your picture,” I said with interest. But I already knew what he was going to say. It was just what I had hoped for.

“This is me,” he said, pointing to the smaller figure with the ball cap. Then, pointing to the other figure, he added, “… and this is my mom.”

He was ready to go. There would be days in the future when Mateo’s abuse would still haunt him, but for now, he had worked through his abuse, his support system was in place, and it was time for me to say goodbye.


Kids like Mateo are the reason I chose counseling with children as my career path. During my residency and internships, I sat with adults, many of them in their 50s and 60s, while they shared unresolved traumas dating back to childhood. I thought it was tragic that decades earlier, they had been set on a path that permanently affected their lives. Those traumas had set a course for the careers they would choose, the people they would marry and how they would cope with life.

For almost all of these individuals, no one had been there to help them at the time of their trauma. If they had received intervention those many years earlier, their lives would have turned out very differently. My hope for children like Mateo is that the time they spend with me will address issues that, left untreated, could lead to years of dysfunctional relationships and unhealthy habits.

There is nothing more satisfying than working with a child like Mateo. Boys and girls bring their stories to me day after day. The first time they come into my office, they are often broken and fragmented. They sometimes stare at me with wide eyes, wondering if it is even possible to overcome the painful experiences that life has dealt them. Yet at the same time, they are very hopeful and willing to take a chance on me. Most of them leave as completely new creatures. Even though their experiences will always remain with them, I can have confidence that they will not be in a counselor’s office 40 years in the future, crying because of the abuse they suffered. That is something we can take care of now, and that is why each day I face the challenges of this population with courage and hope.



Click here to read Gregory K. Moffatt’s related article on complications related to working with sexually abused children. In the article, he discusses confidentiality and mandated reporting, hidden agendas, assessment versus therapy, evidence-based therapy, preparing for court and staying healthy as a counselor when working with this population.



Gregory K. Moffatt is a licensed professional counselor and professor of counseling and human services at Point University in Georgia. Contact him at

Letters to the editor:


  1. Keith Myers

    Dr. Moffatt,

    I really enjoyed your article. Thought it was practical and insightful. I will pass this along to my practicum students that I’m supervising as well as other clinicians working with this population.

    Thanks for all your work,

  2. Greg

    Thanks, Keith. Just saw this comment. I have a new article coming out in CT and was seeing if it was up yet when I saw your note. Thanks so much.


  3. linda kates

    I too am an adult Survivor of sexual child abuse my granddaughter who is 11 was sexually abused not that long ago and I’m looking for counseling for her and maybe still for me if 53 she is in Colorado close to Colorado Springs if you have any one there that could cancel my 11 12 year old granddaughter that would be awesome I would really appreciate any contact info you can give me thank you very much

    1. Brittnie

      Me to my son has been abused by his 13yr step brother ty for the info I really appreciate it honestly I’m out of my depth and never thought anything like this would happen to my son I always keep such a close eye on him. I just never thought another child would do this.

  4. Unknown

    I wanted to know if you were abused as a child and tried to reach out but when being confronted as a child or pre teen by your Mom while the abuser that you respected and loved as a father questioned you while the abuser my step dad was in the house. I didn’t think my mom would believe me because I she loved him. I have been raised with my abuser and told myself he never attempted to do that most of my life. I blamed myself and I also was ashamed .More so I found out he wasn’t my bio dad I think when I was in the fourth or fifth grade . I tried my whole life to be normal but it is hard to be normal when you have seen what grown people are capable of . The survival in me still loved this man who played a father figure. I would block it out in order to move on so I could have a father . Even now with my own children it’s like I have to keep saying it to my Mom

  5. Unknown

    I have nothing to gain but I guess my Mom didn’t want to believe me the old loving pure of heart person died that day and I have adapted to survival and means of loving those who do not love me the way I deserve. I haven’t reached out for help because I don’t want to be looked at as a crazy when I want certain jobs it’s hard enough to come from nothin to something. Everyone needs a support system. My family was all I had and even though my Mom let me down she never apologized even now or recognize that happened to me . I could cry a river but I always pretended to be strong so I don’t appear weak . Even now I don’t have any friends and most of the time I only talk to my family when I really need something. A lot of that is because of that situation with my step dad. It took until I had my first child to really realize how much I’ve subpressed to function on a day to day because I had been living with this so long I think I reacted that way so I wouldn’t loose what was being taught to me by someone that was suppose to treat me like his own blood

  6. Johnathan McFarland

    What can I do if I want my child to receive therapy and the other parent does not? The “abuser” is in the other parent’s family and that parent may feel like their guilt translates to them, or not. Can I take my child to a therapist without the other’s permission?

  7. Johnathan McFarland

    I just left a comment, but I live in Eastern Missouri, St. Louis City. My story is too broad, but we need help. I have sacrificed my life to protect my children and the state of Missouri is taking a long time to help my child. Please excuse me for saying this, but it seems like no one is listening and that could be my fault. I have encephalamalcia from a car accident and subsequent coma and written language is so much easier for me than communicating verbally. Which is why I am saying that I think my wife’s family is planning my death.
    Sorry again.

  8. Helen

    This sounds just like my son! 18 month of play therapy and a different child! It’s been 12 month since play therapy stopped but the last 3 week he has take a turn! He is 10 year old he has acted out and dealt with so much throughout his play therapy but now he is going backwards. This must of been a safe place for him to express as he is Telling me I need mike! (His play therapist)

  9. Deanne Richards

    Gregory, Hello my name is Deanne I’m so worried that my grandson will grow up to continue the abuse. He has been physically, mentally, and sexually abused as well as had great losses in his life he is 12 now! And living with me. He is getting help from the local C.A.C. office but I’m worried it’s not enough help, please advise, what I should look for how I can help, I doubt myself and my ability to help him in the right ways, I too am a victim of abuse, that I never was helped with and feel as tho my fears worries and emotions will get in my way of helping him!

  10. Felicia A Marrow

    I have guardianship of my 9 year old step daughter, she has been with me for 3 years now. About a year ago she started opening up to me about the abuse she endured at the hands of her addict mother and her boyfriend. I have got her into local programs but she is still struggling. I know that this is going to be a long hard road for her but I really need help finding her a counselor that she can trust and speak to on a regular. If you know anyone in my area please help me and my daughter get the help she needs so desperately

  11. Mohini Krsna Summers

    Thank You so very very much. Truly, this work is some of the most important on the planet! As an adult survivor of lineage sexual abuse, I am sensitive to this subject. It seems some of the ways a human deals with these horrendous violations is massive suppression of the memory, depending on the situation and age of abuse. I believe this is the unfortunate case with both of my parents, who did there best to love me appropriately. Now I have a 5 yr old friend, I am her god-auntie to and help her grandparent to raise her for now,. Her mama, is very unwell and I believe based on my own experiences that she has suffered sexual child abuse. She shows all the signs of negative, non-life affirming coping, and is a homeless drug addict. No one helped her with her sexual abuse, now a young child is with out her mother. These traumas must end in the family of humanity. In the mean time as we bring the reality of this evil into the light, compassion, education, and protection of innocence, must become a priory in the family of humanity.

    Your work is VERY courageous, not every one can do it. I thank you deeply!!
    Blessings of Love, Freedom and Thriving Life for you and your dear ones, ALWAYS


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