Farrel Greenspan Registered Psychologist, MC

Understanding the roots of anger: How childhood experiences impact emotional processing

Web3 Editor — Thu, 01 May 2025 20:00:24 +0000

It’s not easy coming in and booking a counselling session with someone you’ve never met before, but at Greenspan Psychology, our expert Edmonton Psychologists will ensure that your visit is as smooth and comfortable as possible. Childhood experiences can greatly influence an individual’s emotions and how they process them, including anger. Childhood trauma, abuse, neglect, or unstable family dynamics can lead to difficulties regulating emotions and managing stress, which can trigger anger. Additionally, observing angry behavior and learning it as a means of coping or communicating can also contribute to an individual developing an anger response. The formation of an individual’s beliefs, coping mechanisms, and self-esteem can also be shaped by their childhood experiences, all of which can impact how they experience and process emotions, including anger. However, it is important to note that everyone experiences emotions differently, and not all anger stems from childhood experiences. It is widely recognized that our early years play a crucial role in shaping who we become as adults. Childhood experiences serve as the foundation upon which our emotional landscape is built. Understanding this connection between our past and present is essential to unraveling the roots of our emotions and developing healthy ways to process them. In this blog, we aim to shed light on the intricate link between childhood experience and processing anger. Anger, a powerful and primal emotion, has the potential to affect our well-being, relationships, and overall quality of life. By delving into the depths of our early experiences, we can gain insight into why and how anger manifests within us, allowing us to cultivate healthier responses and pave the way toward emotional healing. Throughout this exploration, we will examine the significance of childhood experiences, including family dynamics, parenting styles, and traumatic events, in shaping our anger responses. We will also explore the influence of attachment styles, social learning, and cognitive processes in understanding how childhood experiences continue to impact our emotional lives.

The Nature of Anger

Anger is a primal and universal emotion experienced by all human beings. It is a natural response to perceived threats, injustices, or frustrations. Anger, when expressed appropriately and managed effectively, serves a functional purpose in our lives. At its core, anger is an emotional response that signals our boundaries being crossed or our needs being unmet. It motivates us to take action, set limits, and protect ourselves or others. Anger can provide a surge of energy and determination, empowering us to address the challenges we face. However, uncontrolled or unresolved anger can have detrimental effects on our well-being and relationships. When anger escalates beyond our control, it can lead to aggressive outbursts, strained relationships, and even physical or psychological harm. Chronic anger can contribute to high levels of stress, increased risk of cardiovascular problems, and mental health issues such as depression and anxiety. Understanding the underlying causes of anger is crucial for effectively managing and processing it. Anger is often a surface-level emotion that masks deeper feelings such as hurt, fear, or vulnerability. By delving into the roots of our anger, we gain insight into the core emotions and unmet needs that drive it. This understanding enables us to respond to anger in healthier and more constructive ways, promoting personal growth and improved relationships. Exploring the underlying causes of anger requires self-reflection, self-awareness, and a willingness to examine our past experiences. Childhood experiences play a significant role in shaping our emotional responses, including anger. By unraveling the influence of these experiences, we can gain valuable insights into the triggers and patterns that contribute to our anger reactions.

The Significance of Childhood Experiences

Childhood experiences lay the foundation for our emotional development, including how we process and express anger. The formative years of our lives shape our beliefs, perceptions, and coping mechanisms, influencing how we navigate the complexities of emotions throughout adulthood. The early environment in which we grow up significantly influences our emotional responses. Children who grow up in nurturing, supportive, and emotionally attuned environments are more likely to develop healthy emotional regulation skills. Conversely, those raised in chaotic, neglectful, or hostile environments may struggle with managing their anger. The dynamics within the family unit and parenting styles play a pivotal role in shaping how children learn to understand and express anger. Families that encourage open communication, empathy, and constructive conflict resolution provide a positive model for healthy anger management. Conversely, families where anger is expressed explosively, or emotions are invalidated, can contribute to difficulties in anger processing. Childhood trauma, neglect, or abuse can have a profound impact on anger-related issues in adulthood. When children experience traumatic events or live in environments where their emotional and physical needs are consistently unmet, anger can become a coping or defense mechanism to protect themselves. Unresolved trauma can result in heightened anger responses, difficulties in emotional regulation, and a tendency to perceive threats where none exist. Understanding the role of childhood trauma, neglect, or abuse is crucial in addressing anger-related issues. Trauma-informed therapy approaches can help individuals explore and heal from past wounds, develop healthier coping mechanisms, and reshape their beliefs and responses around anger. It is important to note that while childhood experiences have a significant impact, they do not determine an individual’s entire emotional landscape. With self-awareness, support, and therapeutic interventions, individuals can learn new ways of understanding and expressing anger, breaking free from the patterns that were established in childhood.

Attachment Styles and Anger

Our early attachment experiences shape our fundamental beliefs about relationships and influence how we regulate and express emotions, including anger. Attachment theory offers insights into the dynamics between caregiver and child, and how they impact emotional development throughout life. Attachment styles refer to the patterns of emotional bonding that individuals develop based on their early relationships. There are four primary attachment styles: secure, anxious-preoccupied, dismissive-avoidant, and fearful-avoidant. These styles form a blueprint for how individuals perceive themselves, others, and how they approach relationships.

Secure Attachment: Individuals with a secure attachment style tend to have a balanced approach to anger. They feel comfortable expressing their anger assertively while maintaining respect for others. They can effectively manage their anger and seek resolution through healthy communication
Anxious-Preoccupied Attachment: Individuals with an anxious attachment style may struggle with anger due to heightened fears of rejection or abandonment. They may suppress or internalize anger to avoid conflict, but it can build up and lead to explosive outbursts or passive-aggressive behaviors
Dismissive-Avoidant Attachment: Individuals with a dismissive-avoidant attachment style often downplay or dismiss their anger. They may avoid confrontation and prefer to withdraw or detach emotionally. This can result in difficulties in recognizing and addressing anger constructively
Fearful-Avoidant Attachment: Individuals with a fearful-avoidant attachment style may experience intense and conflicting emotions around anger. They may oscillate between suppressing anger due to fear of rejection and displaying explosive anger as a defense mechanism

Insecure attachment styles, such as anxious-preoccupied, dismissive-avoidant, and fearful-avoidant, are associated with difficulties in anger management. These individuals may struggle with regulating anger due to underlying fears, insecurities, and challenges in effectively communicating their needs. Moreover, individuals with insecure attachment styles may have experienced inconsistent or inappropriate responses to their anger during childhood. This lack of validation and support can hinder the development of healthy anger management skills, leading to a pattern of maladaptive responses in adulthood. Understanding our attachment style can provide valuable insights into how we relate to and express anger. Recognizing the patterns influenced by our attachment history allows us to work towards developing more secure attachment styles, enhancing emotional regulation, and fostering healthier ways of managing anger.

Emotional Modeling and Social Learning

Children are incredibly perceptive and much of their emotional development is influenced by the behaviors and emotional expressions they observe in their caregivers and the broader social environment. Emotional modeling and social learning theories shed light on how exposure to anger and conflict during childhood shapes the way individuals express and interpret anger in adulthood. Children learn by observing and imitating the behaviors they witness in their caregivers, particularly their emotional expressions. Caregivers serve as powerful role models, shaping the child’s understanding of emotions and providing a template for how to express and regulate them. This process of emotional modeling and social learning lays the foundation for how individuals navigate anger in their own lives. Exposure to frequent or intense displays of anger or conflict in childhood can significantly impact how individuals express and interpret anger in adulthood. Children who grow up in environments where anger is expressed explosively or violently may internalize these patterns, leading to similar anger responses later in life. Alternatively, some individuals may suppress or avoid expressing anger altogether due to a fear of replicating the negative behaviors they witnessed. Family and cultural norms surrounding anger expression also play a pivotal role in shaping individuals’ anger responses. Some families or cultures may encourage open and direct expression of anger, while others may emphasize the importance of suppressing or avoiding anger altogether. These norms influence an individual’s beliefs about anger, determining whether it is perceived as acceptable or taboo. It is crucial to recognize that individuals carry these learned emotional responses and cultural norms into their adult lives, impacting their relationships, well-being, and overall emotional regulation. However, it is essential to understand that these learned patterns are not fixed, and individuals can develop healthier ways of managing anger through self-reflection, therapy, and adopting new strategies. By raising awareness of the impact of emotional modeling and social learning, we can gain insight into the origins of our anger responses and challenge any maladaptive patterns we may have adopted. This process allows us to develop a more conscious and intentional approach to expressing and interpreting anger, promoting healthier and more constructive ways of managing this powerful emotion.

Cognitive Processes and Anger

Our cognitive processes, which is how we interpret the world around us, play a significant role in how we express and regulate anger. The way we think about situations, ourselves, and others influences the intensity and duration of our anger responses. Understanding the impact of cognitive processes on anger is crucial for developing healthier ways of managing this complex emotion. Cognitive processes shape our perception, interpretation, and comprehension of events. When it comes to anger, our thoughts and beliefs about a situation can intensify or mitigate our emotional response. Cognitive processes also influence how we attribute causes to events and how we interpret the intentions of others, which further shapes our anger reactions. Negative thinking patterns, such as catastrophizing, overgeneralization, or personalization, can contribute to heightened anger responses. These patterns involve distorted thinking that amplifies the significance or negative aspects of a situation. Cognitive biases, such as confirmation bias or attribution bias, can further skew our perception of events, leading to heightened anger or misdirected anger toward others. Beliefs formed during childhood can have a profound impact on our cognitive processes related to anger. If a person grows up in an environment where anger is consistently expressed through aggression or violence, they may develop distorted beliefs that aggression is an effective or necessary means of communication. Similarly, individuals who experienced trauma or abuse may develop beliefs of worthlessness or a constant need to defend themselves, leading to heightened anger responses. Childhood experiences significantly contribute to the development of maladaptive cognitive patterns related to anger. Early interactions and the messages received from caregivers or significant others can shape core beliefs about oneself and others, which in turn influence cognitive processes related to anger regulation. Understanding these cognitive patterns allows us to challenge and modify them, fostering healthier ways of managing anger. Cognitive-behavioral therapy (CBT) techniques, such as cognitive restructuring, can help individuals identify and reframe negative thinking patterns and replace them with more realistic and adaptive thoughts. By exploring and addressing the connection between childhood experiences and maladaptive cognitive patterns, we can gain insight into the origins of our anger responses. This self-awareness empowers us to actively challenge and reshape our cognitive processes, leading to healthier expressions and regulation of anger.

Healing and Recovery

Addressing and healing anger-related issues rooted in childhood experiences requires a comprehensive approach that combines self-reflection, therapeutic interventions, and the cultivation of healthy coping strategies. By engaging in this process of healing, individuals can begin working towards emotional well-being and forging healthier relationships with themselves and others. Working with a skilled therapist or psychologist specializing in anger management and trauma can provide invaluable support throughout the healing process. They can help guide individuals in exploring the roots of their anger, developing personalized coping strategies, and facilitating emotional growth and resilience. There are many trauma-focused therapeutic approaches to recognizing and healing from anger-related issues including Eye Movement Desensitization and Reprocessing (EMDR) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). These approaches can help to process traumatic memories and develop healthier ways of coping with anger triggers. Mindfulness-Based Approaches, such as meditation or mindful breathing, can cultivate self-awareness and provide tools for managing anger in the present moment. Mindfulness helps individuals observe their anger without judgment, allowing them to respond rather than react impulsively. Engaging in self-reflection is vital for understanding one’s triggers, emotional responses, and patterns of anger. It involves exploring the impact of childhood experiences and identifying any unmet needs or unresolved emotions. Self-care practices, such as setting boundaries, prioritizing rest and relaxation, and engaging in activities that promote well-being, can provide a foundation for emotional healing. Developing healthy coping mechanisms is crucial in managing and processing anger. This may include engaging in physical activities like exercise or sports, journaling, practicing deep breathing exercises, or seeking support from trusted friends or support groups. Engaging in creative outlets, such as art, music, or writing, can also provide a healthy means of expressing and processing anger. Healing from childhood experiences and transforming anger responses takes time and effort. It is essential to approach the journey with patience, self-compassion, and kindness towards oneself. Progress may not be linear, and setbacks may occur, but with perseverance and support, individuals can gradually develop healthier emotional regulation strategies. Remember, the journey towards emotional well-being is unique to each individual. It is essential to find approaches and techniques that resonate personally and work in collaboration with a professional to tailor a treatment plan that suits individual needs. If you’re dealing with anger-related issues, contact us today for a FREE consultation and begin your recovery journey with our expert Edmonton Psychologists.

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Helping a Spouse with Depression

Administrator — Thu, 27 Apr 2017 22:19:29 +0000

Helping a Spouse with Depression

The post Helping a Spouse with Depression appeared first on Farrel Greenspan Registered Psychologist, MC.

What treatments are available for Childhood Sexual Abuse, and how do they compare?

Administrator — Thu, 27 Apr 2017 21:57:56 +0000

Farrel Greenspan, Andreia G. Moretzsohn, and Peter H. Silverstone Department of Psychiatry, University of Alberta, Edmonton, AB, Canada Published in International Journal of Advances in Psychology, 2013 (in press) ABSTRACT Child sexual abuse (CSA) is frequent, with rates for significant abuse estimated at 15-20% of the female population and 8-10% of the male population. Such CSA frequently leads to significant short-term and long-term sequalae including a multitude of psychiatric conditions including post-traumatic stress disorder, anxiety disorder, and depression. However, treatment of CSA remains unclear, with even the most widely recommended types of treatment, cognitive behavioural therapy (CBT) and trauma-focused cognitive behavioural therapy (TF-CBT), having not always been found to be statistically beneficial in some studies of adult survivors. Furthermore, treatment of children and youth has been even less well researched. Many types of treatment have been recommended, including CBT, TF-CBT, eye movement desensitization and reprocessing (EMDR), play therapy, art therapy, and pet therapy. The aim of this review is to examine the various treatments recommended for CSA to date, and determine whether one specific treatment or a combination of treatments, may be the most appropriate therapeutic approach for child and youth victims of CSA. INTRODUCTION Child sexual abuse (CSA) is a highly prevalent social problem that impacts many children aged from 2 – 17 regardless of race, socioeconomic status or ethnicity. Estimates of the rate of CSA from retrospective prevalence studies report a wide range, from 2% – 45% (Finkelhor, 1994; Bolen & Scannapieco, 1999). A recent review of 39 retrospective prevalence studies concluded the most frequently reported rates for girls aged 2 – 17 are between 10% – 20%, and for boys being slightly below 10% (Pereda et al., 2009). This estimate is consistent with an earlier review estimating the rate for girls at 15% and boys at 7% (Gorey & Leslie, 1997). Nonetheless, it needs to be recognized that the “true” incidence of CSA is difficult to accurately report as the vast majority of all victims of CSA never report it (Finkelhor et al., 2005). There are sometimes significant psychological impacts from CSA, although it should be noted that not all CSA victims exhibit symptoms, with approximately 40% of CSA victims being asymptomatic (Kendall-Tackett et al., 1993; Finkelhor & Berliner, 1995). For the majority of individuals, however, there are frequent short-term and long-term psychological, emotional, physical, and social consequences including anxiety disorders, depressive disorders, eating disorders, sleep disorders, post-traumatic stress disorders (PTSD), substance abuse, depression, sexual promiscuity, sexual perpetration, academic underachievement, and increased risk of suicide attempts (Costas & Landreth, 1999; Corcoran & Pillai, 2008; Chen et al., 2010; Misurell et al., 2011). Of these conditions, the most frequent psychiatric diagnosis is PTSD, although only 36% of CSA survivors meet the diagnostic criteria (Berliner & Elliott, 2002). Thus, many victims do not receive a psychiatric diagnosis despite significant symptomatology. This difficulty in establishing a diagnosis makes comparing possible treatment approaches more difficult. For these reasons attempts have been made to describe the full developmental effects in a proposed diagnosis of Developmental Trauma Disorder, which more fully captures the consequences of interfamilial, early, chronic and often extreme exposure to trauma (Kolk, 2005; Goodyear-Brown et al., 2012). It is possible that forthcoming changes in the Diagnostic and Statistical Manual, 5th Edition (DSM-V) will address some of these diagnostic issues. Despite the lack of a clear consensus about diagnosis, there are a number of different treatment models which have been proposed as being useful to treat survivors of CSA. Of these, the most widely studied is cognitive behavioural therapy (CBT), although a recent review noted that “CBT may have a positive impact on the sequalae of child sexual abuse, but most results were not statistically significant” (Macdonald et al., 2012). However, Gillies et al., (2012) found in their review that the best effectiveness of evidence for treating PTSD in children resulted from CBT interventions. When CBT is used to address CSA symptoms it is sometimes focused differently and can be termed Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Other treatments have also been suggested as being effective, and these include eye movement desensitization and reprocessing (EMDR), play therapy, art therapy, and pet therapy, and there is some evidence for each of these approaches improving symptoms related to CSA (Deblinger et al., 2001; Eggiman, 2006; Jaberghaderi et al., 2004; Cohen et al., 2005; Pifalo, 2006). In addition to individual therapy, a variety of group therapies have also been reported as being effective in reducing CSA symptomatology (Kruczek & Vitanza, 1999). Nonetheless, to date there is no gold standard treatment that exists to treat the wide range of possible symptoms that survivors of CSA may face. To date there has been one review considering a broad range of treatments for PTSD in children (Gillies et al., 2012). PTSD may manifest as a result of CSA. However, the review does not explicitly focus on PTSD resulting from child sexual abuse and includes sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Also, rarely considered are the potential benefits and weaknesses of individual therapy compared to group therapy, and also to determine whether a specific therapy may be best, or if combinations of treatment approaches may yield better outcomes. This latter approach is used in several fields in medicine, where combination therapies are well accepted, but has not been widely examined in psychiatric research. Another aspect that is not commonly considered is how different treatments might have different benefits depending upon the age at which CSA was suffered, and the nature of the CSA. Additionally, the age at which individuals decide to seek treatment, or have treatment offered to them, may impact outcomes since it has been suggested that early intervention is beneficial in children, possibly since in part disruptive behaviours may increase the risk of peer rejection (Reiss & Price, 1996; Bagwell et al., 2011; DeSocio & Hootman, 2004). Therefore, the objective of this review is to examine the current evidence for the effectiveness of various interventions including various forms of CBT therapies, EMDR, play therapy, animal-assisted therapy, and group therapies for youth survivors of CSA. We hope this review will help provide evidence-based guidance to clinicians who are treating children and youth who have been sexually abused. It should be noted, however, that there are large gaps in the research literature to date, which makes categorical advice difficult to give. METHODOLOGY We searched the PsycINFO and PubMed databases from 1970 to 2012 inclusive for potentially relevant articles, using the search terms “Child Sexual Abuse” combined with either “Treatment”, “Therapy”, “TF-CBT”, “Play Therapy”, “EMDR”, “Pet Therapy”, “CBT”, or “Psychotherapy”. Our initial search gathered approximately 200 articles. We then examined all articles which considered youth or children, and then further examined the references from all these articles to give a more comprehensive review of the current literature. It is important to note that the information in the published literature does not allow a formal meta-analysis to be carried out comparing all of these potential approaches. Treatments and Interventions Cognitive Behavioural approaches Cognitive behavioral therapy (CBT) has been suggested for use in adolescences for over 25 years (Adams, 1986). Over the past 10 years a variation on this therapy, trauma-focused cognitive behavioural therapy (TF-CBT) has been proposed as more appropriate for youth, particularly in the short-term aftermath of child sexual abuse (Cohen, 2003). The core difference is that in TF-CBT therapy gradual exposure to the child’s traumatic experience is central to the treatment process (Cohen & Mannarino, 2008), while exposure to traumatic events is not a requirement of standard CBT treatments. For this reason, studies examining these two treatment approaches are discussed separately. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) TF-CBT is an intervention designed to decrease problems associated with childhood trauma such as CSA (Cohen & Mannarino, 2008). TF-CBT focuses on the trauma narrative and overcoming fears and anxieties related to the trauma history. The acronym PRACTICE has been used to describe TF-CBT and stand for Psychoeducation and parenting skills, Relaxation skills, Affective regulation skills, Cognitive coping skills, Trauma narrative and cognitive processing of the traumatic events, In-vivo mastery of trauma reminders, Conjoint child-parent sessions, and Enhancing safety and future developmental trajectory (Cohen & Mannarino, 2008). A review of TF-CBT outcomes in 9 studies found that it significantly improved a variety of symptoms related to CSA, as measured by standardized behavioral questionnaires and checklists. Thus, there has been reported to be a reduction in PTSD symptoms (Cohen et al., 2007; Cohen et al., 2011; Feather & Ronan, 2006; Feather & Ronan, 2009), a reduction in anxiety (Cohen et al., 2005; Cohen et al., 2011; Deblinger et al., 2011; Mannarino et al., 2012), fewer behavioural problems (Stovall-McClough, 2004; Deblinger et al., 2011; Mannarino et al., 2012), decreased sexualized behaviour (Cohen et al., 2005; Deblinger et al., 2011; Mannarino et al., 2012), decreased child depression (Mannarino et al., 2012; Deblinger et al., 2011; Cohen et al., 2005; Stovall-McClough, 2004), reduced fear (Mannarino et al., 2012; Deblinger et al., 2011), reduced feelings of shame (Mannarino et al., 2012; Deblinger et al., 2011; Stovall-McClough, 2004), reduced dissociation (Cohen et al., 2005), increased coping skills (Mannarino et al., 2012; Deblinger et al., 2011; Feather & Ronan, 2006, Grasso et al., 2011), and increased credibility and trust (Stovall-McClough, 2004). In addition, there have been positive parental effects with studies demonstrating reduced parental depression (Mannarino et al., 2012; Deblinger et al., 2011), less parental distress surrounding their children being sexually abused (Deblinger et al., 2011; Mannarino et al., 2012;), and increased positive parenting practices (Mannarino et al., 2012; Deblinger et al., 2011). However, while research to date has demonstrated that TF-CBT treatment for adolescents who have suffered from CSA improves a wide range of symptoms, there has been considerable variation between studies in terms of outcomes measured, and this can make it difficult to compare results. For example, some researchers measure anxiety while others measure depression, even though it is quite possible that TF-CBT may improve symptoms of both conditions. Additionally, there is not a clear understanding of whether specific aspects of various treatments are more or less helpful. Additionally, the effects of age and gender upon success of treatment, and the most advantages time at which TF-CBT occurs following CSA, remain uncertain and these are all areas which need further research. For this reason it is recommended that future studies administer a wider range of measures to better understand the full therapeutic benefits of TF-CBT, and more closely examine issues such as age, gender, and timing. It would also be helpful if there were consistent measures used in all studies to allow for comparisons to be made between them. In conclusion, of treatments studied to date, TF-CBT is the one with the greatest amount of research-based support for use in CSA. Nonetheless, there remains much that is unclear about the best approach and timing for individual patients (Feather & Ronan, 2009), as well as lack of clear evidence of effectiveness over the longer-term (Feather & Ronan, 2006), although there is some 12-month data (Mannarino et al., 2012). Also lacking is reliable information about comparative or combination therapies, so that it is difficult to be definitive about the best approach to use with TF-CBT, or whether or not it can usefully be combined with other treatments, for example art therapy or EMDR. Cognitive Behavioral Therapy (CBT) There have been several studies that have examined the use of CBT in improving the symptoms caused by CSA. In 6 CBT treatment studies there is evidence of reduced behavioural problems (Deblinger et al., 1999, Deblinger et al., 1990; Stauffer & Deblinger, 1996), decreased sexualized behaviour (Stauffer & Deblinger, 1996), reduced depression (Deblinger et al, 1999, Deblinger et al., 1990; Habigzang et al., 2009), decreased PTSD symptoms (Deblinger et al, 1999; Habigzang et al., 2009; King et al., 2000), decreased anxiety (Deblinger et al., 1990; Habigzang et al., 2009; King et al., 2000), increased coping and safety skills (Deblinger et al, 2001), the ability to shift feelings of guilt and challenge beliefs and perception in regard to sexual abuse (Habigzang et al, 2009), increase trust and credibility (Habigzang et al, 2009) and reduced levels of fear (King et al., 2000). There is also evidence that CBT can reduce parental distress (Deblinger et al., 2001; Stauffer & Deblinger, 1996). Thus, findings from CBT studies are comparable to those of TF-CBT studies, and it remains unclear if one approach is consistently better than the other. Again, studies are lacking around issues of gender, sex, timing, and standardized outcomes as well as possible combinations. Longer-term follow-up studies are also lacking. It is also unclear if other forms of CBT may be effective in this patient population, particularly for younger children. Thus, recently a game-based cognitive behavioural therapy (GB-CBT) group program has been proposed for younger children who have experienced CSA (Misurell et al., 2011). Preliminary findings suggested improvements in both internalizing and externalizing symptoms, and a reduction in sexually inappropriate behaviours. It remains to be determined if variants of CBT may prove to be more helpful than more traditional CBT approaches in a younger population. Eye movement desensitization and reprocessing There is currently little research on the effects of eye movement desensitization and reprocessing (EMDR) in adolescents who have experienced CSA. This is in contrast to studies using EMDR in adult populations, where it has been used to treat adult survivors of CSA (Edmond et al., 1999; Edmond & Rubin, 2008; Rothbaum, Astin & Marsteller, 2005). To date, there has only been one study which compared EMDR with CBT in a sample of sexually abused Iranian girls (Jaberghaderi et al., 2004). The findings from this study found that both treatments had large positive effects in terms of reduction of PTSD symptoms, with some smaller additional benefits on reducing behavioural problems. Although there were no statistically significant differences between the two treatments, self-reports generally favoured the use of EMDR over CBT. Additionally, the group treated with EMDR required fewer sessions than the CBT group. This is similar to findings in adults with PTSD, where both treatments were effective, but EMDR led to a more rapid recovery (Nijdam et al., 2012). It should be noted that currently there is also little research on the possible combination of EMDR and CBT, either in adults or in terms of youth who have experienced childhood sexual abuse. A number of studies have found EMDR decreases post-traumatic stress related symptoms in adolescents (Ahmad et al., 2007; Chemtomb et al., 2002; Fernandez, 2007, Greenwald, 1994; Hensel, 2009; Oras et al., 2004; Tufnell, 2005; Adler-Nevo and Manassis 2005). It would be presumed that, since CSA survivors demonstrate such stress- related symptoms, studies would have examined how EMDR benefited youth who have experienced CSA. However, there have been no studies specifically examining the effectiveness of EMDR in the CSA population, and so it isn’t clear if this effectiveness of EMDR in traumatized youth also applies to traumatized youth who have experienced CSA. One of the reasons for concern that EMDR may not be as effective is that in the studies of EMDR in youth to date, the patient population experienced primarily extra-personal trauma resulting from natural disasters (Chemtomb et al, 2002; Fernandez, 2007; Greenwald, 1994). The trauma of these events is different to the interpersonal trauma experienced from CSA. For example, issues of trust, space and boundaries are not violated when children have been exposed to natural disasters. Thus, there is a definite need for future research to be conducted to determine whether or not EMDR can be used to reduce traumatic symptoms in adolescents who have experienced CSA. Play Therapy and related treatments For over 30 years it has been proposed that Play Therapy may be an important component of treatment, particularly for younger children (Delson and Clark, 1981). It is suggested that Play Therapy allows traumatized children to work through their problems in part because Play Therapy doesn’t rely strictly on verbal communication, and thus it is able to address some issues in a way that talk therapy cannot (Miles, 1981; Bratton et al, 2005). Since it has been proposed that disclosure of CSA is an important part of the therapeutic and healing process (Arata, 1998; Paine & Hansen, 2002; Schönbucher et al., 2012), it has been suggested that Play Therapy may help since children may lack the appropriate emotional and intellectual capabilities to disclose such abuse verbally, but may do so during play (Scott et al, 2003; Corder et al, 1990). Studies of the use of Play Therapy in children who have experienced CSA show a significant reduction in internalizing problems, such as anxiety and trauma, as well as in reframing feelings of self blame, shame and embarrassment and a reduction in nightmares (Corder et al., 1990; Pifalo 2006; Rocha & Prado 2006). Additionally, following Play Therapy children were more verbal about their experience (Corder et al., 1990; Rocha & Prado, 2006), and they showed increased intellectual understanding of the abuse and developed skills to recognize and avoid future abuse of themselves and others (Corder et al., 1990). Other positive findings from Play Therapy include reports of a reduction in externalizing behaviours, particularly a reduction in aggressive and psychopathic symptoms, antisocial and sexually inappropriate behaviours and anger (Pifalo, 2006). Although most of the articles reviewed support the efficacy of Play Therapy one study found no statistically significant improvement in self-esteem, self-concept, social competence or adjustment, although the authors did note that the “children’s sense of competency increased over time and during the course of this therapy modality” (Scott et al., 2003). It has also been noted that researchers are unable to describe Play Therapy as a particularly effective method of treatment, since most Play Therapy research compares this to the absence of intervention (Bratton et al., 2005). It is clear that there are several questions regarding Play Therapy that remain. These include the optimal treatment length, best age of intervention, a more standardized interventions and outcome measurements to allow studies to be compared, comparison to other treatments, and possible use in combination with other treatments as first proposed (Delson and Clark, 1981). Thus, before being able to confidently recommend Play Therapy as a treatment modality, more research is required. Animal therapy The first clinical use of animal-assisted therapy (also sometimes referred to as “Pet Therapy”) is credited to the child psychologist, Boris Levinson in 1961 whose primary rationale for introducing animal-assisted therapy was to use the animal as a motivator for patients resistant to therapy (Reichert, 1998; Hamama et al., 2011; Cirulli et al., 2011). It has been suggested that the presence of an animal contributes to a positive, friendly and safe perception of a situation (Friedmann et al., 1983; Parish-Plass, 2008). It has been proposed that this perception might facilitate a child’s disclosure of the abuse, with the animal acting as a “bridge”, enabling a better and more therapeutic connection between the child and therapist (Eggiman, 2006; Ewing et al, 2007). Several studies have explored the possible benefits of animal-assisted therapy, but several issues arise when comparing studies, including significant differences in the animal used, and the method, timing, and length of any interactions with the animal. Nonetheless, it has been reported that animal-assisted therapy can reduce externalizing behaviour problems seen in CSA victims, including inattention, hyperactivity, oppositional disorder, and conduct disorder (Eggiman, 2006; Ewing et al, 2007; Shultz, 2005). Other studies utilizing equine-assisted psychotherapy have found improvements in a wide variety of areas including progress in psychological, social, and school functioning which have also included improvements in standardized assessments of functioning (Schultz et al., 2007). One of these studies reported that younger children, and children with a history of intra-family violence, showed the greatest improvement in scores (Schultz et al., 2007). Studies to date have suggested that animal-assisted therapy may improve feelings of anxiety, depression, fearfulness, and hopelessness, and also decrease the frequency of nightmares, the feelings of intrapersonal distress, and thoughts of self-harm (Eggiman, 2006; Ewing et al, 2007). In two publications equine-assisted therapy was found to improved cognitive abilities, peer acceptance and physical appearance in individuals who had CSA (Ewing et al., 2007; Eggiman, 2006). It should be noted that one of these was a case study describing how the therapist was able to address the victim’s lack of hygiene: the girl was taught how to groom the therapy horse and shown how to do the same with herself (Ewing et al, 2007). In the same way that Play Therapy has been proposed to help children disclose that CSA has occurred, another proposed advantage of animal-assisted therapy is that at times when a therapist is not able to express sympathy directly to a patient, an animal has no such reservations, and for example, a dog may put its head on the patient’s knee (Lefkowitz et al., 2005; Reichert et al., 1998). Interestingly, animal-assisted therapy can conceivably also have a wider role, since one study found that the presence of the animals impacted hospital staff, where an overall increase in self-awareness and staff morale occurred (Rossetti et al., 2008). Additionally, there have been suggestions that interactions with animals may have physiological effects that may be relevant to any psychological changes. Thus, it has been found that interactions with dogs significantly increases levels of oxytocin, a neuropeptide which is proposed to play an important role in pair bonding social affiliation and trust in many species (Cirulli et al., 2011). Other studies have shown that the presence, or even the observation, of animals can buffer physiological and psychological responses to stress and anxiety, lowering both blood pressure and heart rate. (Cirulli et al., 2011; Barker et al., 2003; Berget et al., 2011; Lefkowitz et al., 2005; Eggiman, 2006; Friedmann et al., 1983; Grandgeroge et al., 2011). Thus, there may be some physiological role for any psychological benefits. Despite these studies of animal-assisted therapy, several issues remain. It is clear that despite a long history of use, research supporting the efficacy of animal-assisted therapy remains rather limited. There is no clear standardization about the type or duration of interaction (Berget et al., 2011), and how this may best be potentially integrated with other therapies. Intriguingly, in this area there are a small number of reports suggesting that it may be most effective when it is combined with other accepted forms of therapy (Eggiman, 2006; Dietz et al., 2012). One final point that has been noted is the issue of publication bias, and questions have been specifically raised about the lack of publications reporting the absence of effects, or negative effects, of this approach. (Grandgeroge et al., 2011). Individual Therapy Versus Group Therapy One other area to consider in terms of the most appropriate forms of treatment (or combination of treatments) for CSA is the issues of individual therapy compared to group therapy. A potential theoretical advantage of group therapy is the interaction with other victims that have been through the same or similar problems. Baker (1985) tested the efficacy of both individual and group therapy in specific sexual abuse symptoms including self-concept, anxiety and depression. Although group therapy was found to be more effective in improving self-concept, both therapies showed similar results in decreasing anxiety and depressive symptoms. Others have also suggested that group approaches are best. Thus, it has been proposed that knowing that other participants of a group have been through similar experiences facilitates the building of trust amongst members helping, among other things, with disclosure and exploration of feelings (Knittle & Tuana, 1980). Others support the idea that a group is a safe and effective place for children and youth to develop and practice appropriate social skills (Knittle & Tuana, 1980; Boatman et al., 1981; Kruczek & Vitanza, 1999). This issue of safety has been further emphasized by others suggesting that children have the chance to learn from others about different types of abuse and how to protect themselves (Perez, 1987). Certainly, group therapy appears to be widely used (Kruczek & Vitanza, 1999), and has clear cut economic advantages (Kruczek & Vitanza, 1999; Tourigny & Hébert, 2007; Baker, 1985), but others have suggested using individual or group therapy according to the age of the individual and/or their specific response to trauma (Boatman et al., 1981). CONCLUSION Overall, the current review shows that both individual and group therapy can be helpful, but that multiple questions remain about what is the best form of therapy for an individual child or youth, and how this may vary depending upon their age, gender, and type of CSA. Other key issues also remain about the length of treatment and how this could be standardized (Baker, 1985; Tourigny & Hébert, 2007). It is interesting that while some of the therapies used in the treatment of CSA were proposed over 30 years ago, the research on the effectiveness for many of these is poor. This makes recommendations difficult. This review suggests that many types of treatment have been found to have some therapeutic benefits for child survivors of CSA. This is similar to the findings by Gillies et al., (2012) in their review of psychological therapies for PTSD. The authors concluded that there was not enough evidence to clearly say that one treatment is more effective compared to another. Our conclusion is similar. Nonetheless, of the various modalities, TF-CBT is the most researched treatment, while CBT, Play Therapy, EMDR and animal-assisted therapy all show some level of evidence for efficacy in reducing some of the symptoms associated with CSA. Much of the research on these various treatments specifically dealing with child CSA victims is in its infancy and further research is required to understand more about how different treatments may benefit youth who have been sexually abused. This review also suggests that symptom reduction is not very dependent on the type of treatment being received, since many of the different types of treatment appeared to improve a similar range of symptoms. Thus, there is a compelling need to further standardize therapies for this frequent condition, and in particular to actively explore the possibility of combinations of therapy. It is also extremely important to determine if briefer, more intensive forms of therapy (possibly carried out in a dedicated facility) is more or less effective than a longer-term, but less intensive, form of therapy. As noted repeatedly elsewhere, CSA is extremely common with millions of survivors across North America alone. 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