Counseling Sexually Abused Children: Lessons from Ghana and Zambia

The scourge of child sexual abuse has been on the increase world over, Ghana and Zambia inclusive with millions of children being sexually abused every year at a global prevalence rate of 34.4%. Using the qualitative narrative approach, the interview guide was used to gather data purposively from 112 participants made up of 40 Domestic Violence and Victims Support Unit officers, 32 parents and 40 victims aged 8–17 years who reported their abuse at 15 police stations across Central Region and Lusaka Province of Ghana and Zambia respectively. Data were thematically analyzed. The study found among others that children in both countries received safety nets and pieces of advice on legal and medical procedures. It also found that some victims expressed happiness at their abuses being reported and heard. However, lack of professional counseling training and power imbalances inhibit the police officers’ efforts. The study concludes that though officers use some skills and provide a kind of trauma counseling more is needed in the areas of individual and group therapy for comprehensive and effective counseling. Skills such as encourage-ment, assertiveness, and re-assurance can lead to disclosure, prevent future sexual abuse, reduce anxiety and fear, promote healing and empowerment. When children receive adequate counseling immediately after abuse they do immediate damage repair both of their psychological and social “self”. The study recommends training in counseling for the officers in both countries for effective counseling of abused individuals. Additionally, officers should be linked with professional counsellors at universities to refer abuse cases for treatment.


Introduction
The concept of counseling explains how individuals who feel less able to resolve their own problems resort to help in order to solve their challenges [1]. Associated with help seeking is the client's belief that he will receive assistance that will help him understand things that bother him such as complex and confusing emotions experienced during an event (e.g. abuse), receive alternatives, make informed decisions and move on generally in positive meaningful ways. Thus, the chance of successful counseling outcome may be higher, where needed support is provided and children's ability to overcome sexual abuse has been found to be dependent on timely psychological interventions [2].
This study adopts World Health Organisation's (WHO) definition of child sexual abuse as the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. The scourge of child sexual abuse (CSA) has been on the increase world over, Ghana and Zambia inclusive, with millions of children being sexually abused every year. In 2004 WHO reported that the global prevalence rate of child sexual abuse [3] was an estimated 150 million girls and 73 million boys under the age of 18 years who were victims of rape or other forms of sexual violence; that between 1 and 21 percent of women were victims of sexual abuse before the age of 15. By 2010, CSA was estimated at 34.4% of global violence cases [2].
Some of the earliest studies on child sexual abuse in Africa [4] reported on cases of child sexual abuse at a Cape Town Hospital with victims ranged from 2 to 12 years with the majority being females. In Malawi, [5] described 20 cases of child sexual abuse, which were presented at the Department of Obstetrics and Gynaecology, University of Malawi, between 1995 and 1997. Half of the victims were less than ten years old [5]. estimated that these cases were merely the tip of the iceberg, and were reported due to the serious injury caused in the rape of very young children.
Research on the occurrence of child sexual abuse by [6] reports that one in four girls and one in ten boys is a victim of CSA. In Zimbabwe, CSA studies show that, among unmarried sexually active youths, 52.2% had experienced forced sexual intercourse at least once and 37.4% of the first sexual intercourse was forced on them [7].
Child sexual abuse is recognised as a traumatic experience that can have a number of adverse effects on victims [8] citing [9,10] and that these children generally reveal significant problems in diverse areas of functioning including but not limited to affect, behaviour, cognition and interpersonal relationships [11,12].
Research has established a correlation between counseling and other forms of psychosocial support in promoting well-being of people. Although psychosocial supports have been used to investigate individuals' experiences in adverse circumstances, there is a gap in the literature regarding the use of counseling to overcome CSA experiences. While we are inspired by the possibilities offered by the vast literature on CSA, research suggests that psychosocial supports such as counseling services for victims of CSA are unsatisfactory [13,14] in a number of government institutions globally. A need, therefore, exists for effective treatment through counseling children who have experienced CSA [8]. The purpose of this study, therefore, is to explore how counseling as one if not the most crucial psychosocial support is used to assist victims of CSA in Victims Support Units (VSU) of the police services of Ghana and Zambia.

Theory
We connect our study to the works of [15] on the concept of trauma recovery of individuals to provide the theoretical basis for this work [15] developed a three stage model that has been used to treat trauma survivors during rehabilitation process. The model provides a useful set of goals for treatment providers regardless of theoretical orientation. Herman's model gives an in-depth description of the healing process of people who struggle with a number of problems relating to abusive or past traumatic experiences. The three stages of this process are (1) the establishment of safety, (2) remembrance and mourning, and (3) reconnection. This process is not typically linear; there are often advances, regressions, and impasses. It has, however, been suggested that many people do not complete all three stages during their recovery [16].
Establishing safety is the first step in the treatment of trauma because no intervention can succeed without the survivor feeling safe. Safety includes protection from violence and maltreatment by other people, basic needs being met such as medical care, financial security, safe living environments, adequate food and sleep, legal protection, and a supportive social network. Research established that torture and other forms of trauma can cloud an individual's sense of security and safety especially when trauma is experienced in childhood [16,17]. Re-establishing safety is important in the development of relationships that can be beneficial in the process of recovery for victims of child sexual abuse.
In the remembrance and mourning stage [15] the survivor constructs a narrative of his or her experiences in a therapeutic relationship. This inspires the need for CSA victims to receive counseling on report of abuse. The reconstructive disclosure of traumatic experience has been examined widely in theory and research. Cognitivebehavioural therapy that focuses on exposure to memories and emotions has been found to be a powerful method of treating PTSD with survivors of sexual assault [18].
In the reconnection stage, the focus is on building a future and empowerment. Once the past has been assimilated, the victim can focus on developing a more resilient and complete identity. The trauma victim strives to make a meaningful life through trust and hope that were developed during the first two stages of the recovery. The victim, now a survivor, may have a desire to help others who have been victimised similarly and to prevent future victimisation by raising public awareness through educational, legal, and political activism.
Trauma counseling is thus, geared towards assisting persons recover from overwhelming stress to functioning productively. This is where the traumatic individuals move from the ability to disclose and be believed to be provided help that empowers and strengthens. Drawing from these theories, the following questions guided the study: 1. What is the nature of the counseling services provided to children who report their sexual abuse experiences?
2. What are the challenges associated with counseling services offered to victims?

Methods
This research was qualitative in approach. Given the sensitivity of the topic, the denial of perpetrators, silence that mostly surrounds the knowledge of the canker, and the stigma often attached to the victims, qualitative methods were deemed appropriate. This study employed the qualitative Narrative Approach (NA) [19] to understand the nature, benefits and challenges of counseling services provided to victims of Child Sexual Abuse. Critical to the NA is active listening and its ability to externalise the problem beyond the person(s) and the world so as to liberate them from the control of the problem and develop power to address them. Thus, through the narrative discourse, individuals can gain the power to address their own trauma by positioning a 'named problem' (e.g. penetration, fondling). The narrative approach that employs disclosure with strong affinity with attending skills such as listening, questioning and probing, resonates well with Herman's stages of recovery from traumatic experiences.

Setting
The study was set in the Central Region of Ghana and the Lusaka province of Zambia. Ghana police service in the Central Region has seven divisions, Sexual Abuse -An Interdisciplinary Approach thirty-two districts and ninety-nine police stations/posts. The Region also has Police Command and Staff College for Senior Officers at Winneba [20,21]. The Regional Headquarters has 10 DOVVSU units/desks under its command [22]. Available statistics from DOVVSU suggest a downward trend in cases of child sexual abuse since 2002 (from 820 in 2002 to 670 by the end of 2005) though there is doubt about the reliability of these data [23]. The figures quoted by [23] however, were only on rape.
A year earlier, [24,25] reported that the evidence of sexual exploitation in Ghana is significant and that DOVVSU records indicate that every year quite a number of children and adolescents go through series of sexual abuse. They indicated that reported cases of defilement and rape of children and adolescents were: 1001-2002; 905-2003; 930-2004; 937-2005; 1772-2006. In addition to statistical records of reported cases of child sexual abuse, the Central Region was of interest due to recent public outcry of the rise in teenage pregnancy and social media circulations of sexual abuse against school girls (kitchen stool episode).
In the case of Zambia, according to [24], it is alleged that, majority of children who are sexually abused are females. Between 2011 and 2014, Zambia Police Victim Support Unit annual reports show a steady increase in cases of CSA from 1,939 cases in 2011 to 4,039 cases in 2014 (see Table 1 below: Zambia Police 2011 to 2014 Annual Reports).

Data collection procedures
Purposive and criterion-based sampling strategies were employed to contribute to the overall understanding of the topic [26]. In all, 112 participants were recruited from 15 police stations across the Central Region of Ghana and Lusaka Province in Zambia. The criteria for selection were that participants were children, aged between 8 to 18 years, had a history of sexual abuse, reported their abuse to the VSUs of the police and were predominantly English-speaking. In Ghana, the principal researcher and one research assistant collected data while the principal researcher and two assistants gathered data in Zambia. The cases were selected purposively from the police dockets between 2011 and 2016 and victims and their parents located per the address in the dockets. Many victims could not be traced as they have either left their addresses given at the time of the report of abuse or the given addresses could not be traced.
In Ghana, interviews were held with a total of 55 participants made up of 20 girls, 20 officers from seven DOVVSU desks as well as 15 parents. In Zambia, a total number of 57 participants were recruited into the study. This includes 20 VSU officers from 8 provinces, 20 victims and 17 parents of victims. In both countries, we started with engagement of police officers in charge of abuse cases then hooked in children identified and parents. There were initial challenges of recruitment as some identified parents were not willing to participate nor allowed their children to participate. With a lot of sensitization (one-on-one explanations on the challenges of CSA and the benefits of therapeutic methods) on the need to speak about the issue, some parents got involved and allowed their children to participate. Of the 15 parents from Ghana, 14 were females and only one male while parents from Zambia were all females. In all, parents from both countries comprise 25 mothers, one father, and six caregivers. From both Ghana and Zambia, there were no records of counseling services provided to victims though victims records were available.
The interview activities were conducted mostly under trees or nearby empty classrooms around victims' homes and schools. When a victim was identified, the researcher spent time to explain the rationale, and ethical issues of the study to them. In both countries, participants were informed of the purpose of the research and discussed the meaning of 'sexual abuse' to include fondling, touching, forced sex, defilement and sex without consent. Interview questions covered the: a) nature of the counseling services provided and received, b) operational challenges in receiving and providing counseling services, and c) views on benefits of counseling to victims. In all, each interview with victims and parents lasted approximately 50 minutes while that of VSU officers lasted for about 1 hour.
The data collection process took a total of four and six weeks to complete in Ghana and Zambia respectively. Responses of the interviews were manually recorded by the principal investigators. After data were manually written, they were typed and printed out. Data were then cleaned through proof reading and corrections. Manual coding was done to identify confirming and disconfirming themes within and across narratives. The data were coded with acronyms to promote confidentiality and anonymity. Data were thus coded GPO (Ghana) and ZPO (Zambia) for VSU officers and followed by the assigned number of the participant.
Ethical considerations and trustworthiness of the data and research process were achieved through triangulation of data with all three sets of categories of participants. Participants, especially victims and parents, had the opportunity to corroborate or otherwise the statements provided at the VSU offices. By these, data were cleaned and ready for thematic analysis.

Results and discussions
The results of the study were structured into five main sections: background characteristics, nature of counseling, approaches to counseling, challenges, benefits, and the way forward.

Profile of reported cases
The summary of sexual abuse cases made in the Ghana and Zambia (selected regions) police dockets and files recorded from 2011 to 2016 were 223 and 345 cases respectively. Of this total number of cases, 105 were initially identified regarding their age at the time of abuse, perpetrator characteristics, and their English-speaking ability. However, only 40 were found and included in this research. Of the 40 cases analysed, 36 (90%) involved victims less than 16 years of age. All victims were females. The mean age of victims was 12.1 years. The youngest victim was 9 year of age and the oldest was 17 years. Seven had experienced sexual abuse more than once and five had re-experienced sexual abuse after their initial abuse reported to the police. Twenty-two (55%) of the victims were school pupils at the time of the abuse. Of this 22, 18 victims became school drop outs as a result of sexual abuse related issues. Of the school drop outs, twelve sexual abuse incidents resulted in pregnancy in both countries.

Perpetrator characteristics
Most perpetrators were adults. In 36 (90.0%) cases, the perpetrators were less than 30 years of age. Most of the child sexual abuse cases were intra-familial. Of the 40 cases studied, eight victims were raped and or defiled by their fathers, twelve by uncles, six by cousins, four by brothers, four boyfriends, and six by unknown persons. This finding confirms other studies that most rape and defilement incidents are perpetrated by people known to victims and who are usually male family members [2].

Characteristics of reports and reporters
Narratives revealed two types of sexual abuse reports: direct and indirect. Direct reported cases are cases where victims and or their parents lodged complaint following an abuse and this could be following the abuse immediately or later. The indirect reported cases were cases which were not originally reported due to the sexual abuse. Rather, parents/caregivers often accompany victims to lodge complaints of neglect and or denial of pregnancy where interrogations revealed that the girls were impregnated through sexual abuse. About 60% of the cases were indirect reported cases while about 40% account for direct sexual abuse reports. This finding confirms [27] affirmation that, children rarely disclose sexual abuse immediately after the event. Out of the 40 victim participants, 27 (67.5%) pregnancies cases were recorded. Fifteen (37.5%) of the victims had been defiled more than once. Pregnancies were found mostly among 14 year olds and above who were defiled by intra-familial offenders.

Level of training of VSU officers in counseling
The level of education and or professional training of officers is presented in Table 2 below.  Data revealed that in both Ghana and Zambia, VSU officers were not adequately trained in counseling especially in the area of CSA. It must be mentioned, however that, some of the officers who indicated having a certificate did not necessarily undergo formal training in counseling, but were rather referring to certificate of attendance obtained from workshops.

Nature of counseling services offered
Under this theme we explored the general approaches, techniques and skills in counseling that VSU officers used in providing support to victims who reported their abuse. VSU officers disclosed that they lacked professional counseling skills. It was found that counseling was rarely offered in some VSU in both countries. VSU officers confirmed that: We rarely provide counseling services to children because of lack of proper counseling facilities and work over load. ZPO3 Similar narratives abound in the data. Narratives above imply that though officers were aware of the essence of counseling they lack the requisite training to practice. They therefore engage victims and their families in what they think best by resorting mostly to advice giving on medical and legal processes leaving out the psychological and emotional assistance that victims need.

Approaches to counseling
Results show that there were various services offered to victims of CSA to help reduce their trauma. These could be classified as: trauma counseling, individual counseling and group counseling.

Trauma counseling
VSU officers try their best to handle sexual abuse cases brought before them. Regarding cases reported, VSU officers first and foremost try to secure the victim's safety and then encourage disclosure of abuse. Under this approach, two stages of trauma counseling were identified. These are: establishing safety and security of victims, and encouraging disclosure (remembering and mourning).

Establishing safety and security
In addressing the issue of the nature of counseling services provided to victims, narratives reveal that officers usually try to provide safety nets as the first step to providing counseling.
We normally send them to shelters. Here, luckily for us there are two NGOs who work with us in providing shelter to these girls when they are brought to us. GPO17

We make all efforts to get perpetrators arrested and prosecuted ZPO11
Sexual Abuse -An Interdisciplinary Approach 8 We made prompt arrest and arraigned the offender before court. One very thing we did was to place the girl with the social welfare to secure her safety. GPO9

Some victims corroborated this:
When I reported my problem I was sent to the social welfare home. I spent one week there before my mother came for me. They [VSU Officers] told me that I should stay there so that the man who abused me will not harm me. GV6 This approach by VSU officers in providing safety and security for victims is entrenched in the first stage of trauma counseling [15]. Depending on the perpetrator characteristics, officers provide safety where some children were taken to shelters or social welfare homes for protection and to reduce revictimization. This resonates with [28] that sexually abused children generally need safety upon disclosure.

Encouraging disclosure
Disclosure of abuse was seen as one fundamental phenomenon in the healing process. When victims report their abuse they are requested to disclose. Data reveal that in most cases, the reports made by non-offending parents are quite incongruent with the disclosure of victims. One officer noted: When the mother came and reported that the daughter was abused through the anus and we asked the girl to tell us, she said the man penetrated through her vagina. GPO20 You see, some of the girls do not like to talk to us about their predicament initially. Sometimes we allow them to sit for about two hours or more before they begin to talk. And when they do they take so long to say something meaningful. ZPO 18 When I was taken there [VSU office] and I was asked to narrate my problem, I was scared. There were a lot of people around, moving here and there and then some of them were police men coming to the room. So I was not comfortable but I told them later. GV15 To overcome the stress of remembering and mourning, the victim needs to narrate his or her experiences in depth with great detail. The goal is to modify the traumatic memories so they become more meaningful in the person's life and less anxiety provoking. As the narrative develops, the memories become less disjointed, more depersonalised and more coherent. With this emotional reworking and cognitive restructuring, the memories become more manageable and the significance of the trauma changes from a story of victimisation to one of dignity and agency [16]. Once the victim is able to emotionally and cognitively process the traumatic experiences, he or she is then able to mourn the losses experienced during the abuse. Victims face the reality that they may never regain what they have lost. [15] argued that with the new story, the intrusive and hyper-arousal symptoms subside.
Associated with reporting and disclosure is the issue of power imbalance. The police stations do not seem to provide a safe environment that promotes disclosure. Ironically, while the officers were interested in providing safety from perpetrators, their own personalities and immediate environments smack of insecurity and impact on effective disclosure. In most cases, officers attempt to re-unite victims with their families especially with their non-offending parents or caregivers. This is as the result of lack of shelter and other logistics in handling the victims. Officers revealed: We have no place to keep them for long so what we do is to ask the parents to take them back and advised them strongly to take good care of them. ZPO5 You see we have the social welfare to take care of these children, but we do so in very severe cases where we suspect revictimization. GPO7 This reconnection is thus exigent on the prevailing circumstances in the VSU offices. One finds it difficult to assess whether reconnection to the families has positive outcome for the victims or not as VSU officers have no means of follow-up on cases. This study thus, revealed that the reconnection stage of Herman's model was woefully completed. Victims were not reconnected in the real sense of recovery geared towards healing and empowerment. At best their reconnections could be described as disposal.

Individual counseling
This is normally done with victims in the same office with their parents and other VSU officers. Narratives reveal that for lack of space and other logistics, VSU officers carry out their counseling activities right in the same office with other colleagues. One stated The term individual counseling is used interchangeably with taking victims' statements and asking probing questions for clarification. Through observation and narratives, it was revealed that the individual counseling provided was short of appropriateness. With individual counseling done in the same office with other officers and visitors coming in and out, then the counseling environment is not conducive enough to uphold the principles of confidentiality and to promote disclosure.

Group counseling
Data indicate that group counseling referred to in this context is when victims and their non-offending parents or caregivers are provided some advice on seeking medical treatment, legal procedures and general advice on how to prevent being re-victimised.
Normally we talk with the victims and their non-offending parents at the same place. We do not put victims together for counseling. You know, we deal with the victims on case-by-case level, individually GPO19.

Sexual Abuse -An Interdisciplinary Approach
Group dynamics such as purpose of group formation, theme, and other characteristics were not considered. Group counseling was offered in a form of family therapy usually with non-offending parent or family members.

Advice giving
Regarding the approach to counseling, it was found that the counseling that was provided (if at all) that could best be described as group counseling was used in all service (VSU) centers. The counseling provided here is more advice giving especially regarding victims' right to legal assistance, medical treatment, and how victims could ovoid revictimization, and parental protection and provision. Advice on legal procedures and investigations: victims and their parents were also provided needed information on legal opportunities available to them. An officer explained: It is our duty to explain all the procedures and investigation process to the family and what is expected of them especially during the investigations. ZPO11

Counseling skills and strategies
In addition to the approaches used, officers also employed some basic counseling skills such as encouragement, reassurance, and rapport. However, cognitive behavioural counseling techniques skills like assertiveness training, empathising, role-play, art therapy and belief of victims' stories were found missing. These were considered very important in reducing the grief and confusion that children abused normally go through thus, paving way for healing.

Operational challenges in delivering counseling to victims
On barriers associated with counseling service provision, the following subthemes emerged: lack of skilled personnel, lack of logistics, late reporting of cases, family interference, lack of safe and conducive environment coupled with presence of power relations, inadequate time and sessions among others.

Lack of training and structure
No, we have no guidelines to follow to do counseling. What we do is to take their statements when they come. This is the same way we take all statements at the station. I think we need more to handle these children GPO5

We don't have any format for doing counseling. I guess we all rely on what we think is counseling by asking the victims questions and telling them what they should do GPO7
We need further training to do counseling GPO8 Data reveal that VSU officers perceived themselves as inadequate in providing counseling services to victims. They, however, bemoan their lack of professional training and capacity. It was noted that in both countries, VSU officers have no psychological tests to administer to victims, they do not have any structured system or documents to use such as intake form upon report of an abuse.

Logistics and administrative challenges
Direct observation and in-depth interview report indicated that the VSU officers lacked capacity in terms of resources for their work. Apart from the units in the regional capitals of the study sites in both countries with one and two computers each in Ghana and Zambia respectively, the VSU desks in the study regions had no computers and therefore no database of cases before them. The police dockets were managed manually by using notebooks and files. Officers did not have filing cabinets. These challenges were acknowledged by the officers at the units. One officer indicated:

Late reporting of cases
Many victims did not report the offence until later when they fell ill or got pregnant and the men refuse responsibility.
A pregnant girl was brought here and a complaint was lodged against a man who refused responsibility. They [the girl and the mother] did not report of sexual abuse. It was during interrogation that the girl revealed that she was impregnated by her uncle and when we looked at her age, she was 15 years and we filled a case of defilement. GPO18 Late reporting or indirect reporting of Child Sexual Abuse cases makes it difficult for victims to receive any form of counseling (if any) from VSU officers. This finding resonates with other research that, sexually abused children rarely disclose sexual abuse immediately after the event [27].

Family interference
The constant appeals by family members to withdraw the cases from the courts do not only thwart the efforts of the courts to prosecute offenders, it also cuts short whatever counseling interventions that VSU officers could offer the victims since the withdrawals mark the end of victims' visit to the station for further assistance. One officer bemoaned: Hmm, it is difficult to provide the little help we can to these [abused] girls. You see there was this case where the girl came to report her abuse personally just after the incident. Everything was there to see. We made prompt arrest and arraigned the offender before court. One very thing we did was to place the girl with the social welfare to secure her safety. But do you know the trick the family played to get the case out of court? The family insisted that they want to have and keep the girl with themselves so we allowed them to take her away and to bring her back for hearing. That was all!!! They never showed up. The case was called several times and since the complainant was not present, the case was thrown out of court and the accused released. In this case what else can we do? GPO9 Families interfere too much in our efforts to deal with offenders. This also cuts short whatever little assistance we could offer them. ZPO11 These narratives point to the administrative challenges faced by VSU officers. In all, victims were provided first aid counseling. Police dockets revealed that most cases were discontinued. In most cases parents or caregivers request for withdrawal of cases to be settled at home. About 90% of reported cases were not followed up by parents and since the police have no means of following up, the cases die naturally and the courts closed dockets on them. Feedbacks on settlement were not provided by parents. The settlement of defilement cases outside court violates the very spirit and letter of the law on defilement [29] because rape under laws of both countries is a first degree felony [27].

Benefits of counseling victims and the way forward
Regarding benefits of counseling for victims, the following were some of the subthemes: need for professional training; assurance that will lead to disclosure, anxiety and fear reductioning, promoting healing, and empowering victims; nonbelief of victim's story and lack of privacy and confidentiality were seen as immediate issues that could be addressed to pave way for effective counseling of victims. The following narratives are revealing: Well, if we are asked to go for further studies, I think I would consider doing counseling because it will help me in my work when I return. That is if I'm posted back to this unit (referring to DOVVSU). GPO14 The service needs to support officers to do professional counseling and when they are done, such officers should be posted here to work. And you know, there are some officers who have their 1 st degree in counseling. I know some of my colleagues here who did counseling in your university (UEW) but they have not been posted to DOVVSU desks maybe they do not want to work here or the service refuses to post them here. But I think it is more about the bosses up there. GPO3 I don't know what to say. You know, my daughter was only talked to by the police woman and after that day nothing happened again. They did not ask us to come again. So that was it. All I observe is that from time to time, she seems lost to herself and sometimes too she wants to be alone. GP4 I thank God that I was able to talk to the police about my abuse and they helped me. They talked to me and assured me that the man would be arrested and they arrested him. GV10 I wish I was given the chance to talk to the woman alone. GV5