COUNS-EDU The International Journal of Counseling and Education Vol.6, No.2, Dec 2021, pp. 55-62 | p-ISSN: 2548-348X- e-ISSN: 2548-3498 http://journal.konselor.or.id/index.php/counsedu DOI: 10.23916/0020210633620 Received on 07/22/2021; Revised on 08/16/2021; Accepted on 09/20/2021; Publishedon:11/19/2021 55 Communicating using storytelling method to children experienced sexual abuse and harassment Vista Nurasti Pradanita 1 , Yunias Setiawati 2 , Sasanti Yuniar 2*) 1 Child and Adolescent Psychiatry, Rumah Sakit Umum Daerah Dr. Soetomo Hospital, Surabaya, Indonesia, 2 Departement of Psychiatry, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia * Corresponding author: sasantiyuniar@yahoo.com Abstract Every year, sexual abuse against children is increasing. Globally, it is estimated that 3-31% of children had experienced sexual abuse. This harms children, including the impact of physical injury, neurobiological impact, and psychiatric, such as depression, anxiety, eating disorders, PTSD, drug abuse, self-harm, suicidal thoughts, and attempted suicide. To help children who are victims of sexual abuse, a special approach is required to ease the communication to children. Since children communicate using symbols, thus storytelling, which is part of the Play Therapy technique, is the right method to communicate awareness to children. With an approach using the storytelling method, hopefully, children will be able to understand the very situations, recognize and express their emotions properly, and minimize the negative impact after the abuse. Keywords: Child sexual abuse, storytelling, psychiatric impact, therapy How to Cite: Pradanita, V., Setiawati, Y., & Yuniar, S. (2021). Communicating using storytelling method to children experienced sexual abuse and harassment. COUNS-EDU: The International Journal of Counseling and Education, 6(2). doi:http://dx.doi.org/10.23916/0020210633620 This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©2021 by author. Introduction Sexual crimes toward children still exist, both in Indonesia and around the world. The number of incidents of child sexual abuse worldwide is statistically unclear, but it is estimated that around 3-31% of children had experienced sexual abuse (Vrolijk-Bosschaart et al., 2008). In Indonesia, the cases of sexual crime against children increase every year. According to data from the Witness and Victim Protection Agency, in 2019 there were 350 cases of child sexual abuse. These cases increased by 70% compared to the previous year (Lokadata, 2020). Sexual abuse of children often occurs in places where children should be protected and feel safe, such as at home and school (Ocviyanti et al., 2019). Most of the abusers of children's sexual abuse are adults who should protect and be trusted by children, such as teachers, parents, and even family relatives. The Indonesian Child Protection Commission (KPAI) reported that in 2019 there were at least 35 cases of sexual abuse and harassment of minor students done by teachers and school principals, sadly this happened in the school environment. Child Sexual Abuse (CSA) is sexual activity involving adults and children, which is usually for the stimulation or sexual satisfaction of the abusers. This is because children do not fully understand the sexual activities and inappropriate things between them; also most children have trouble expressing rejection and understanding sexual consent (Seshadri & Ramaswamy, 2019). Sexual harassment is one of the wrong treatments or maltreatment of children and can harm the victims’ mental stability, causing mental disorders due to the trauma. The National Comorbidity Survey reports that there is a relationship between victims of sexual abuse during childhood and the onset of http://dx.doi.org/10.23916/0020210633620 COUNS-EDU  Vol.6, No.2, Dec 2021 Available online: http://journal.konselor.or.id/index.php/counsedu Pradanita, V. N., et al. Communicating using storytelling method ... | 56 Indonesian Counselor Association (IKI) | DOI: 10.23916/0020210633620 psychiatric disorders in adulthood. It was reported that 78% of women and 82% of men who were sexually abused in childhood experienced a mental disorder at least once in their lives, increasing the risk of drug addiction in adult life. Childhood trauma also leads to suicidal thoughts and a higher risk of suicide case in adulthood. Someone who has experienced sexual abuse as a child has a higher suicide risk than those who have never experienced it (Shrivastava et al., 2017). It is not easy to recognize child sexual abuse. Many factors make it difficult to identify, including children who are unable to speak up because they were threatened not to tell others, fear, feel ashamed, limited communication ability or expressing verbal language, fear of being blamed, and children’s limited knowledge about understanding inappropriate things that sexual-related. If this sexual abuse and harassment did not communicate clearly between children as a victim and their guardian, it can be dangerous for the children's further life. Various studies have reported that children who are victims of sexual abuse can experience symptoms of internalization and externalization. Symptoms of internalization that are suffered by victims are PTSD (Post Traumatic Stress Disorder), depression, nightmares, eating disorders, sleep disorders, and anxiety disorders. In addition, symptoms of externalization that often be found are aggressive behavior, delinquency, and inappropriate sexual behavior during childhood (Guerra et al., 2017). According to Piaget, children communicate using symbols to express their thoughts and emotion. Storytelling can "understand" this way of communicating as well as provide a lot of value in the therapeutic relationship between doctors or counselors and patients (Mendoza & Bradley, 2021). Storytelling is an appropriate method or "tool" suitable to communicate with children. This method is considered can help children process their thoughts, especially processing traumatic events for them, recognize existing distortions, and help them to better understand the happened situations while minimizing the negative impact as a result of the traumas. Review Child sexual abuse According to the WHO, the definition of child sexual abuse is the involvement of a child in sexual activity that they do not fully understand and without consent. This violates the law or social values of children protection in society (Vrolijk-Bosschaart et al., 2008). Sexual abuse of children is sexual activity between children and adults or other children that are unable to hold responsibility for their sexual-related action. Sexual harassment is also intended to satisfy someone's sexual desires without the consent of the other party. Sexual abuse and harassment included the inducement or coercion towards children that involves physical contact including penetration or non- penetration (Cattanach, 2008). The child protection agency in the UK reported that sexual harassment is the coercion toward children or minors to perform sexual activity without their consent. Some sexual abuse towards children is not even considered a violent action due to most children do not fully understand sexual activity and harassment. Therefore, the abusers do the sexual abuse by sugar-coating their sexual activity by doing the trick to lure children (Thapar et al., 2015). Type of child sexual abuse Child sexual abuse can be divided into 2: physical or contact sexual abuse and non-physical or non- contact sexual abuse. 1. Physical or contact sexual harassment Non-penetrating physical sexual harassment can be: touching genital parts, forced kiss, and inappropriate sexual activities that children should not do. The abuser takes so many negative benefits without consent, such as touching, kissing, masturbating, and so on. Penetrating physical sexual harassment is penetrating the abuser's genital to victims’ genital organs, anal sex, or oral sex. 2. Non-physical or non-contact sexual harassment Non-physical sexual harassment is inappropriate sexual behavior toward children. For example, making sexual comments about a child's body, supporting a child to behave sexually inappropriately, and teasing with inappropriate words and sentences related to sexuality. COUNS-EDU  The International Journal of Counseling and Education Vol.6, No.2, Dec 2021 Communicating using storytelling method ... | 57 Indonesian Counselor Association (IKI) | DOI: 10.23916/0020210633620 Non-verbal harassment can be showing the genital parts to be seen by children. In another case, checking children's bodies sexually when they are naked, forcing children to watch inappropriate content, such as videos and pictures that contain pornography (Vrolijk-Bosschaart et al., 2008; Cattanach, 2008; Thapar et al., 2015). Sex demographics in children A sexual abuser is divided into two types: (1) A known person. The children's sexual abusers may include family members, caregivers, or others who are not related to the family but are well-known to the child. This includes teachers and school staff. (2) An unknown or unknown person. The children predators can be a person who is completely unknown by the children before. Sadly, there are fewer sexual incidents committed by strangers than by people that are well-known by the children. The child predator in targeting young children, mostly toddlers, will force or coerce the victims using threats. They will persuade children with the things that children usually like, such as candy, ice cream, or toys, so that children are feel invited to be cooperative in sexual acts. The abusers also provide fake attention or affection so that children want to join in sexual activities. This method is generally also followed by excitement and "secrecy" in their sexual activities. The abusers usually trick the children not to tell others by persuading them (Seshadri & Ramaswamy, 2019). The children predators are dominated by adult males (85-95%) most of whom target pre-pubertal children. Female sex offenders are less frequent and usually target boys. Teenagers can be abusers of children younger than them; most of them are minor boys or teenage boys who target younger girls that can be harassed. Sexual activity done by teenagers is considered sexual if the abuser is older than the victim, or by using threats and violence (Thapar et al., 2015). Based on age, sexual intercourse can occur at a younger age but the frequency and level of sexual harassment increase with age. In general, it can happen to boys and girls but is mostly experienced by girls (Thapar et al., 2015). Sexual abuse impact on children Sexual abuse leaves a severely harmful impact on children, especially when the abuser comes from their closest circle, such as family, relatives, close friends, schools, etc. A child would not fully understand the sexual activities or consent, but later, especially when there is no professional help to heal the trauma, they will develop the mental disorder tendency. A child will grow older to fully grasp what had happened to them. They will have difficulty accepting themselves. Most of them will feel guilty, fearful of adult and sexual activities. This case will be worse if the adults around them point out that the sexual harassment was the children's fault. It will make the self-esteem of the child hit rock bottom, they feel “dirty” and “disgusting” (Cattanach, 2008). Not all children who experience sexual abuse were able to speak up and show emotional problems directly after the incidents, some of them can experience psychiatric disorders later in life after their adulthood. The severity of the symptoms that appear depends on the interaction of several aspects of the victim's personality, social environment, and gender experienced (Guerra et al., 2017; Thapar, 2015). Sexual abuse is a traumatic experience that has a very bad impact on a child. There are three impacts of sexual abuse on children. 1. Physical impact Sexual abuse of children significantly affects the physical health of the children. Sexual abuse also can harm children resulting in physical injuries, such as fractures, lacerations, head injuries, genital injuries, and anal organs injuries. There can also be disorders of the gastrointestinal system, gynecological reproductive system, sexually transmitted diseases, such as including HIV, and other physical complaints (Vrolijk-Bosschaart et al., 2008). 2. Psychiatric impact The psychiatric effects of sexual harassment do not always appear immediately after the incident. In most cases, children do not understand what they have been through, and may not even realize that they are victims of sexual abuse. Behavioral or emotional changes in child victims of sexual abuse are usually related to anxiety and depression. This condition can be COUNS-EDU  Vol.6, No.2, Dec 2021 Available online: http://journal.konselor.or.id/index.php/counsedu Pradanita, V. N., et al. Communicating using storytelling method ... | 58 Indonesian Counselor Association (IKI) | DOI: 10.23916/0020210633620 caused by sexual harassment, but can also be caused by other maltreatment such as parental conflict, bullying, learning difficulties, loss, and bereavement. Emotional and behavioral changes in a child that may indicate sexual abuse include: Eating disorder, Mood swing refuses to go to school, Age-inappropriate sexual behaviour, Avoiding or fearing certain people, or feeling afraid all the time, Nightmares sleep disturbances, bedwetting, Fussy, clingy (especially to people they trusted), separation anxiety, Dissociative reactions and hysteria symptoms, Decreased school or academic performance, The presence of body pain that can not be explained medically (somatic complaints). Some of the symptoms of psychiatric disorders that can appear in later life (teenagers or adulthood) include depression, PTSD, attempted suicide or self-harm, drug abuse, panic disorder, antisocial personality disorder, inappropriate sexual behavior, low self-esteem, and difficulty achieving goals. good academics (Vrolijk-Bosschaart et al., 2008; Seshadri & Ramaswamy, 2019; Thapar et al., 2015). 3. Neurobiological impact Child sexual abuse is a stressful experience (early life stress) and can cause psychosocial problems in children. These encourage are regulated on the hypothalamic-pituitary-adrenal (HPA) axis which is a stress pathway (Juruena et al., 2018). Children’s brains that experience stress at such a young age will develop neurodevelopmental disruption, which probably leads to neurological injury. In early childhood and adolescence, important brain structures are formed, therefore a traumatic event will be remembered by the child for life. The traumatic or stressful event leads to high production of cortisol levels. High cortisol levels can cause damage to the hippocampus. High levels of cortisol reduced gray matter in the frontal and temporal regions of the brain and increased amygdala reaction to threats, high basal levels, and a blunted cortisol response to stressors (Shrivastava et al., 2017; Thapar et al., 2015; Juruena et al., 2018). Other effects of child sexual abuse are the impaired neurotransmitters serotonin and dopamine. Serotonin is a system that responds to stress and activates anxiogenic and anxiolytic pathways involved in complex neuronal communication in brain areas. Disruption of the serotonin system plays an important role in the emergence of PTSD symptoms in child victims of sexual abuse as well as predisposing them to depression and aggressiveness in later life (Shrivastava et al., 2017). Storytelling A story is a narrative that tells about an incident to someone in a place and at a time. Storytelling itself has existed since the beginning of the emergence of "language". This illustrates the human need to convey his experiences to others. The existence of storytelling transcends the boundaries of culture and era in every human civilization that exists in any culture (Mendoza & Bradley, 2021). Storytelling is generally conveyed by telling the characters that having moral values to be delivered, as a tool to give advice and problem-solving. Generally, storytelling is beautified with illustrations and subjective interpretations (Mendoza & Bradley, 2021). Children are more like to stories, especially fairy tales, to grasp and absorb moral values, advice, and metaphorical insights contained in a story, where they may "reject" if they are advised with the same values from other people without storytelling. In their book, Schaefer and Cangelosi (2016) include storytelling as a form or technique in play therapy. This technique is considered one of the "best of all time" or all-time best techniques to be applied to children. Albert (1992) states that through a story, a child will be able to "discover" the reality of their social existence, psychological conditions, and habits or culture and be able to explore (explore) these situations with a changing and more developed perspective. COUNS-EDU  The International Journal of Counseling and Education Vol.6, No.2, Dec 2021 Communicating using storytelling method ... | 59 Indonesian Counselor Association (IKI) | DOI: 10.23916/0020210633620 Types of storytelling Schaefer and Cangelosi, (2016) divide the types of storytelling into 3, namely: 1. Child storytelling (for children aged 3-12 years) Storytelling will stimulate children to create personal sounds, show their unique way of thinking, and will be able to show their feelings. The stories told by children will reflect their conscious and unconscious experiences, emotions, and desires. A 3-year-old child will tell stories using short sentences but must be assisted by questions and assistance from adults to trigger their responses. They are already able to use the phrases “once upon a time” and “the end”. At this age, telling children stories about certain issues is a way for children to understand the world. In general, the theme of the story involves simple activities, such as eating, sleeping; and the presence of a kind-hearted character. The age of 4 years is the peak of imagination of a child with a dominance of violence such as monsters, death, and accidents. It is their way of dealing with the fear and urges of aggression within them. At the age of 8 years, a child's way of thinking has developed. They can apply the principles of a story to real life. Children in this age can express the beginning of the story which contains the characters in the story, the story background, the problems or issues that rise within the story experienced by the main character, and the end of the story or problem-solving. The techniques used so that young children can express themselves in storytelling are:  Staters (opening): for example using the word "Once upon a time", "Once upon a time in a very far away land..."  Prompts: when telling stories, children generally need support or encouragement to continue the story. The therapist may ask "So, what happened?". The therapist's tone of voice should indicate curiosity. At the end of the story usually, the child will say "finished" or "the end".  Inquiries (affirmations): affirmations are useful for the therapist to clarify after the story is over. It aims to clarify ambiguities in children's stories and understand the connection between stories and problems that the children have. 2. Mutual storytelling (for children aged 8-14 years) This technique was developed by child psychiatrist Richard Gardner (1971), which involves both children and therapists. This method can correct incorrect cognitive understanding in children. The focus of this method is the repetitive correction of cognitive distortion. Gardner gives an example of his methods neither where he asks a child to come up with a story that is neither on television nor what they have heard on the radio. The children were asked to tell the stories that they made themselves. The story includes the beginning, middle, and end of the story and ends with a lesson or moral value. After the child tells their story, then Gardner tells them a story that provides learning or moral values. He tells stories with the same characters, storylines, and backgrounds as children's previous stories. This method aims to introduce more adaptive solutions to conflicts or problems faced by children in the story. For example, a 6-year-old boy told a story about a mother bear and her baby who were hungry so they both went into the forest to look for honey. They found a beehive full of honey. The Mother Bear took the beehive and began to eat honey. Because of hunger the Mother Bear finished the honey and forgot the Baby Bear that was also hungry. The baby bear just sits and cries. The moral of the story that the children wanted to express was: in this family, everyone only cares about himself. The therapist then retold the first part of the story and then continues with “Mother Bear fell asleep after eating. Feeling hungry, the Baby Bear walked through the forest and headed for Aunt Bertha’s house. In Aunt Bertha’s house, the baby bear was fed milk and honey by Aunt Bertha herself. In this case, the therapist wanted to express that: if the children are being neglected by the adults, or their parents, another capable and caring adult will take care of them. COUNS-EDU  Vol.6, No.2, Dec 2021 Available online: http://journal.konselor.or.id/index.php/counsedu Pradanita, V. N., et al. Communicating using storytelling method ... | 60 Indonesian Counselor Association (IKI) | DOI: 10.23916/0020210633620 3. Therapist storytelling (for children aged 3-12 years) Stories that have a therapeutic purpose (therapeutic story) is an effective method because it is not supposed to make children feel threatened (non-threatening story). It is more flexible, easier to remember, and provides problem-solving, and provides healing processes. In this method, the first step to creating a story is choosing or determining a therapeutic metaphor and/or appropriate tools related to the children's problem. For example, to a child who is grieving due to the closest person loss, the therapist can tell a story about a rabbit that has lost his father or brother. A child grieving due to the divorce of his parents can be told a story about a baby dog that lost its mother. Metaphors and aids can help enrich the storyline. The story should portray children's emotions and contain children's favorite subjects, such as favorite animals, toys, superheroes, and or cartoon characters. The storyline is just as important as a positive ending because, in the process, the storyline helps build tension in the story, involving several events and tasks for the child. Stories should be age-appropriate and provide an indirect “lesson”. Methods in therapeutic storytelling Storytelling can be a very useful “tool” for the interaction between children and therapists. The therapist can create a story with a variety of techniques and modalities, such as using bibliotherapy, sand tray, and cognitive-behavioral approaches (Mendoza & Bradley, 2021). Bibliotherapy Bibliotherapy is a therapeutic modality that uses books as a medium of communication between therapists and children. Mostly, the books are about fairy tales or children's stories. Through children- friendly stories, a child can portray himself with the characters in the story and learn many things through the story. With this method, one can understand the story not only from reading it but also by discussing the feelings, thoughts, relationships, causes, and consequences experienced by the characters in the story. According to Schaefer and Cangelosi (2016), there are four therapeutic elements in bibliotherapy: 1. Universalization: the story should make children feel that the characters in the story have the same or similar problem like them, without the feeling that the characters are the reflection of the children themselves. The story should make the children many people have similar problems, thus they would not feel alone. 2. Psychological safety: stories should create a sense of security that allows children to face difficulties indirectly because confronting children with an exact example of their problem will harm their mental health and worsen the stress. Characters in the story that are often used are animal characters because the children will feel safer that the characters are completely different from them and help the children understand the whole story. 3. Problem-solving: the problem-solving told in the story should overcome the problem that the main character had, so the children can reflect on the problem solving on their own. 4. Theory of mind: stories can help children to understand the mental or mental conditions of others so that they can develop children's ability to empathize and have an understanding of the social environment. Sandtray The sand tray technique is one of the storytelling methods to communicate. Children can "draw" in the sand at the same time by telling about the characters in the story. In addition, children can concretely tell stories using the miniatures contained in the sandbox as well as use them as symbolic representations13. Cognitive-behavioral approach In the counseling context, storytelling can be combined with existing counseling models such as trauma-focused cognitive-behavioral therapy (TF-CBT). Although there are many variations of combining storytelling with counseling sessions, the "story" is the main thing that strengthens the connection between therapist and child. COUNS-EDU  The International Journal of Counseling and Education Vol.6, No.2, Dec 2021 Communicating using storytelling method ... | 61 Indonesian Counselor Association (IKI) | DOI: 10.23916/0020210633620 Discussion In writing and telling a story, imaginative, symbolic, and metaphorical languages are often used. Mendoza and Bradley (2021) illustrate a storytelling model that can be used in counseling practice for traumatized children. In the storytelling model, there are two spectrums, the story spectrum and the degree of control spectrum. Those two spectrums are used to "construct" storytelling into counseling practice. These two spectrums are useful for assessing and deciphering the story told by children (story spectrum) and determining story effect towards children (degree of control spectrum). Figure 1 To succeed in counseling therapy, the goal is to direct children on both spectrums (Figure 1.), as well as transforming fictional stories into narratives about the trauma they experienced (story spectrum) and developing children's abilities to express and understand the moral story (degree control spectrum). Hopefully, the child can tell the traumatic thing with full confidence and the ability to control himself. In the spectrum of stories, fictional storytelling provides a secure feeling and prevents traumatic remembrance that may arise, because the story emerges from the perspective of the story characters or as a third person. Therefore, children will feel safe, feel less alone, and understand that the characters in the story are related to their real-life story without feeling confronted. As a child develop their interest in the story spectrum, they will incorporate vivid images of their experiences into the story. Children will be able to portray themselves into the character of the story if the characters are related to them (similar character or similar story) (Pehrsson, 2008). As the children begin to portray themselves in the story, the therapist needs to monitor for signs of anxiety in the child. The two spectrums are supposed to work consecutively as they are useful for estimating and facilitating the progressive improvement of each other. Conclusion Sexual harassment and abuse can be done not only by adults but also by minors. The abusers can be anyone, unknown people to the victim or people that the victim is close with or trusted. It can be done by anyone and happen to anyone, men and women. The abuser can be considered physical and non-physical sexual activities. Children who are victims of sexual abuse need special treatment. To dig the information deeper from the victim, therapists are forbidden to force the children to talk if they do not want to. The therapist should use a playful approach to make children easily express their thoughts, feelings, and emotions through symbols. Storytelling, which is part of play therapy, can help children safely understand and digest what is happening to them. Storytelling can make children feel less alone and portray the moral values to their life to prevent negative effects in the future (later life). 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