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Farr, Joanna and Edbrooke-Childs, J. and Town, R. and Pietkiewicz, D. and

Young, I. and Stapley, E. (2021) Counseling for young people and families
affected by child sexual exploitation and abuse: a qualitative investigation of
the perspective of young people, parents, and professionals. Journal of Child
Sexual Abuse 30 (1), pp. 102-123. ISSN 1547-0679.

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Running head: EXPERIENCES OF CSE COUNSELING 1

Counseling for Young People and Families Affected by Child Sexual Exploitation and

Abuse: A Qualitative Investigation of the Perspectives of Young People, Parents and

Professionals

Joanna Farr, Julian Edbrooke-Childs, and Rosa Town

Anna Freud National Centre for Children and Families and University College London

Deborah Pietkiewicz and Ian Young

Off the Record

Emily Stapley

Anna Freud National Centre for Children and Families and University College London

Author Note

Joanna Farr, Evidence Based Practice Unit, Anna Freud National Centre for Children

and Families and University College London, London, United Kingdom; Julian Edbrooke-

Childs, Evidence Based Practice Unit, Anna Freud National Centre for Children and Families

and University College London, London, United Kingdom; Rosa Town, Evidence Based

Practice Unit, Anna Freud National Centre for Children and Families and University College

London, London, United Kingdom; Deborah Pietkiewicz, Off the Record, Hyde, United

Kingdom; Ian Young, Off the Record, Hyde, United Kingdom; Emily Stapley, Evidence

Based Practice Unit, Anna Freud National Centre for Children and Families and University

College London, London, United Kingdom.

Joanna Farr is now at Birkbeck University of London, United Kingdom.

The evaluation was supported by a grant from the National Society for the Prevention

of Cruelty to Children (NSPCC). Emily Stapley (sixth author) and Rosa Town (third author)

are also partly supported by the National Institute for Health Research ARC North Thames.

The views expressed in this publication are those of the author(s) and not necessarily those of

the National Institute for Health Research or the Department of Health and Social Care.
EXPERIENCES OF CSE COUNSELING 2

Correspondence concerning this article should be addressed to Emily Stapley,

Evidence Based Practice Unit, Anna Freud National Centre for Children and Families, 4-8,

Rodney Street, London N1 9JH, United Kingdom. Phone: (0044) 20 7794 2313. Email:

[email protected]

Joanna Farr, BA, MSc, is a PhD. student at Birkbeck University of London, whose

research focuses on the qualitative evaluation of mental health services for children and

young people.

Julian Edbrooke-Childs, PhD., is an Associated Professor in Evidence Based Child and

Adolescent Mental Health at Clinical, Educational and Health Psychology, University

College London (UCL) and Deputy Director of the Evidence Based Practice Unit, UCL &

Anna Freud National Centre for Children and Families. His research focuses on empowering

young people to actively manage their mental health and mental health care, with a particular

focus on social inequalities.

Rosa Town, BA, MSc, is a PhD student at the Evidence Based Practice Unit and Clinical,

Educational and Health Psychology, University College London (UCL). Her research focuses

on self-management of mental health amongst LGBTQ+ young people.

Deborah Pietkiewicz, Edexcel level 5 diploma in therapeutic counselling (QCF),

specializes in working with families affected by domestic violence or sexual abuse.

Ian Young, B.Ed. Trip Hons. Geog, TP, Youth Work Dip, Lancaster University. Dip.SW,

MMU, is interested in developing and managing counseling provision for children and young

people within the voluntary sector.

Emily Stapley, PhD., is a senior research fellow in the Evidence Based Practice Unit,

whose research focuses on how young people and families manage their mental health and

wellbeing.
EXPERIENCES OF CSE COUNSELING 3

Abstract

Despite growing awareness of the negative impact of child sexual exploitation on young

people’s psychological, emotional and relational lives, little is known about how counseling

can support young people and their families. The aim of this study was to explore the

experience of counseling for young people and parents affected by child sexual exploitation

and abuse, with a view to examining what facilitates progress, from the perspective of young

people, parents and professionals. In-depth semi-structured interviews were conducted with

10 young people, 8 parents and 7 professionals and were analyzed using thematic analysis.

Findings suggest that through counseling, young people experienced affective and relational

improvements that were attributed to the process. Characteristics of the counseling

relationship that facilitated progress included being able to talk openly in a caring, non-

judgmental and unpressurized environment, as well as receiving advice, techniques or

solutions within a holistic approach. Facets of service delivery were also highlighted,

including the provision of confidentiality, flexibility and consistency, along with a multi-

agency approach that promoted engagement. Perceived obstacles to progress included

resistance at the outset and service location issues.

Keywords: Child sexual exploitation; CSE; counseling; child abuse; therapy

 EXPERIENCES OF CSE COUNSELING 4

1 Counseling for Young People and Families Affected by Child Sexual Exploitation and

2 Abuse: A Qualitative Investigation of the Perspectives of Young People, Parents and

3 Professionals

4 Child sexual exploitation (CSE) is a form of child sexual abuse (CSA) associated with

5 a range of psychological and behavioral consequences, including post-traumatic stress

6 disorder (PTSD), depression, anxiety, self-harm and attempted suicide (Berelowitz et al.,

7 2013; Edinburgh et al., 2015). The emotional distress experienced by young people can be

8 considerable, encompassing feelings of anger, pain and betrayal, as well as loneliness and

9 fear (Gilligan, 2016; Hallett, 2017). Relational tension and family breakdown can also occur,

10 due to emotional stressors and exploiters who isolate young people from their families

11 (Palmer & Jenkins, 2014).

12 While no globally agreed definition of CSE exists, in England it is defined as:

13 when an individual or group takes advantage of an imbalance of power to coerce,

14 manipulate or deceive a child or young person under the age of 18 into sexual

15 activity (a) in exchange for something the victim needs or wants, and/or (b) for the

16 financial advantage or increased status of the perpetrator or facilitator.

17 (Department for Education, 2017, p. 5)

18 In Europe, the prevalence of CSA is reported to be 13.5% for girls and 5.6% for boys

19 (Stoltenborgh et al., 2011), but no prevalence studies have been conducted on CSE

20 specifically. In England, it is estimated that 18,800 children are at risk of CSE annually

21 (Kelly & Karsna, 2018). Caution, however, is necessary due to definition and recording

22 difficulties and the recognition that prevalence figures for sexual violence are likely to be an

23 underestimation. Children in their teenage years living in England are most at risk

24 (Department for Education, 2017), as are those with vulnerabilities, including a prior history
 EXPERIENCES OF CSE COUNSELING 5

25 of sexual abuse (Lalor & McElvaney, 2010), having a disability or being in residential care

26 (Brown, 2016).

27 Literature on the efficacy of therapeutic approaches for sexually abused young people

28 is limited (Benuto & O’Donohue, 2015). Cognitive-behavioral therapy (CBT) has the

29 strongest evidence base and has been found to lead to reductions in depression, PTSD,

30 anxiety and behavior problems, as well as improvements in self-concept and self-protection

31 skills (Kim et al., 2016; Macdonald et al., 2012). The evaluation of interventions specifically

32 focused on CSE is also in its infancy (Moynihan et al., 2018). Recent studies suggest that

33 trauma-focused CBT group therapy can lead to reductions in PTSD, depression and anxiety

34 (O’Callaghan et al., 2013), and that a patient-centered approach to addressing trauma can lead

35 to reductions in emotional distress and suicide attempts, as well as improvements in family

36 connectedness and self-esteem (Bounds et al., 2019).

37 A small number of qualitative studies have explored the experiences of sexually

38 abused young people receiving therapy. These studies suggest the importance to young

39 people of establishing a trusting relationship with their therapist, with friendliness, empathy,

40 fun and confidentiality cited as facilitating this process (Allnock et al., 2013; Capella et al.,

41 2016; Dittmann & Jensen, 2014; Jensen et al., 2010; Jessiman et al., 2017). The value to

42 young people of talking about experiences is highlighted (Capella et al., 2016; Dittmann &

43 Jensen, 2014; Nelson-Gardell, 2001), as is the need for them to feel in control (Jensen et al.,

44 2010; Jessiman et al., 2017). The advantages of learning techniques during therapy to help

45 manage anger, anxiety and self-esteem have also been emphasized by young people

46 (Dittmann & Jensen, 2014; Foster & Hagedorn, 2014; Jessiman et al., 2017). During trauma-

47 focused CBT, however, some young people can struggle to talk through the trauma narrative

48 and avoid it (Dittmann & Jensen, 2014; Salloum et al., 2015). Indeed, fear and mistrust prior

49 to therapy are common, and a positive therapist relationship is needed to help young people
 EXPERIENCES OF CSE COUNSELING 6

50 remain in therapy (Capella et al., 2016; Dittmann & Jensen, 2014; Foster & Hagedorn, 2014;

51 Jensen et al., 2010).

52 No published qualitative studies have examined the experiences of children exposed

53 to CSE and receiving therapy, though important differences between CSE and other forms of

54 CSA highlight the need for further work in this area. What makes CSE distinct is the concept

55 of exchange between abuser and abused (Department for Education, 2017). The exchange

56 manifests in multiple ways and can only be understood within the context of the wider

57 challenges experienced by young people who are exploited (Appleton, 2014). Although CSE

58 is commonly framed by a grooming model, with predatory adults manipulating children, this

59 overlooks the complexities of sexual exchange that, for some young people, are a coping

60 response to emotional difficulties (Hallett, 2017). Young people describe the exchange as

61 being bound up in unmet needs, such as being uncared for, invisible or powerless,

62 experiences that increase their vulnerability to people who might exploit them.

63 Young people exposed to CSE may not recognize they are being exploited and may

64 not see themselves as needing help (Hickle & Hallett, 2016). Consequently, they can be

65 reluctant to engage with professional support or disclose experiences, a dynamic that is

66 compounded by a mistrust of adults and negative past experiences of support and care

67 services (Ahern et al., 2017; Gilligan, 2016). There is clearly a need for therapeutic services

68 that have an understanding of CSE and offer interventions to help young people resolve

69 underlying difficulties in a way that is acceptable to them.

70 A small group of qualitative studies have, however, explored how young people

71 exposed to CSE view wider statutory and voluntary support. Whereas young people are often

72 distrustful of statutory agencies or struggle with the inflexibility of children’s mental health

73 services, voluntary services can be seen more positively and as offering the conditions that

74 help meet young people’s needs, including time to establish longer-term relationships,
 EXPERIENCES OF CSE COUNSELING 7

75 flexibility, consistency and regularity of contact with support workers (Franklin & Smeaton,

76 2018; Gilligan, 2016).

77 Trauma-informed approaches to mental health services for people with experience of

78 CSA and CSE highlight the need to create relationships and environments according to the

79 needs of clients (Department of Health, 2018). Central prominence is given to the impact of

80 trauma on people’s ability to establish trusting relationships, with services structured to

81 engender safety, mutuality and empowerment (Sweeney et al., 2016). A key motivation,

82 underpinning this approach, is to prevent unanticipated retraumatization during support

83 provision.

84 While CSE does not only occur outside the family, emerging evidence suggests the

85 benefit of developing a family-based approach (Thomas & D’Arcy, 2017). Qualitative studies

86 conducted with parents of sexually abused children have shown that, after involvement with

87 an intervention, parents felt better equipped to talk to their child, promote their child’s growth

88 and manage their emotions and behaviors, while at the same time benefitting personally from

89 reduced self-blame and increased confidence (Jessiman et al., 2017; McCarthy et al., 2019;

90 Murray et al., 2014; Salloum et al., 2015).

91 To tackle the consequences of CSE, a multi-agency response is recommended (Herbert &

92 Bromfield, 2017) that includes the provision of counseling to facilitate young people’s

93 psychological, practical and social recovery (Department for Education, 2017), including

94 building resilience and processing trauma (Kaur & Christie, 2018). While estimates suggest

95 counseling is offered by 50% of support services in the UK for victims of CSE and CSA, no

96 published studies have examined the experience of counseling from the perspective of young

97 people exposed to CSE (Allnock et al., 2015). And yet CSE encompasses distinct difficulties,

98 highlighting a need to understand how counseling services should be tailored to support

99 sexually exploited young people. Furthermore, while the need to support parents is
 EXPERIENCES OF CSE COUNSELING 8

100 recognized (Thomas & D’Arcy, 2017), no study has focused on the experience of counseling

101 from their perspective. This study will, therefore, examine the experience of counseling for

102 young people affected by CSE and abuse, from the perspective of the young people (almost

103 all female), parents (almost all mothers), and professionals, with a view to examining what is

104 seen as helpful and unhelpful in facilitating progress.

105 Method

106 Setting

107 Time2Talk provides counseling targeted specifically at supporting young people aged

108 11 to 25 years who are exposed to CSE, child abuse and/or domestic violence. It is run by Off

109 the Record, a charitable organization, that specializes in counseling for children and young

110 people. It is estimated that over 80% of Time2Talk clients are victims of CSE. As part of a

111 multi-disciplinary team tackling CSE, Time2Talk works with representatives from social

112 care, the police, the probation service and health services.

113 The counseling offered is informed by the person-centered approach (also known as

114 client-centered) (Rogers, 1942, 1957). In person-centered theory, it is the therapeutic

115 relationship, founded on the core conditions of unconditional positive regard (acceptance),

116 empathy and congruence (genuineness), that facilitates a person’s own capacity for growth. A

117 key tenet of Time2Talk practice is that the therapeutic relationship is established prior to the

118 discussion of CSE. A holistic understanding of the client and their life outside CSE facilitates

119 this, as does building the client’s self-esteem. Disclosure of the exploitative event(s) is led by

120 the client, and therapeutic progress is not contingent on it. The client is, however, encouraged

121 to discuss associated difficulties, such as feelings of guilt, anger or loss after leaving the

122 exploitative relationship, as well as the meaning of relationships. CBT may be used for

123 specific difficulties, such as self-harm.

 EXPERIENCES OF CSE COUNSELING 9

124 In 2018, the Outcomes Research Consortium (CORC) and the Evidence Based Practice

125 Unit (EPBU; Anna Freud Centre and University College London; UCL) conducted an

126 independent evaluation of Time2Talk. This study presents the qualitative component, led by

127 the last author.

128 Participants

129 Interviews were conducted with 10 young people (nine females, one male), aged 12 to

130 25. Three were aged between 12 and 16. Four were former and current clients of Time2Talk

131 (i.e. they had been discharged and then re-entered treatment), five were current clients, and

132 one was a former client. Interviews were conducted with eight parents (seven mothers and

133 one father) whose children had received or were currently receiving sessions. Two young

134 people and two parents were from the same families.

135 Seven professionals involved with Time2Talk were interviewed. Three of these worked

136 within the counseling service (including the fourth and fifth authors) in service delivery or

137 management. Four of the professionals worked at local services (the police, social services,

138 probation services, and health services). Participants were recruited by the fourth author (the

139 lead counselor) who was asked to obtain variety in terms of the length of time that parents

140 and young people had been in contact with the service for and whether they were a current or

141 former client. The lead counselor was also asked to suggest professionals from local services

142 that the service worked with.

143 Ethical Considerations

144 Ethical approval for the evaluation was granted by the Research Ethics Committee of

145 both UCL (6087/010) and the National Society for the Prevention of Cruelty to Children

146 (NSPCC). All participants were asked to read a study information sheet and sign a consent

147 form prior to participating. Parental consent was also sought for young people under the age

148 of 16. It was made clear that participation was voluntary and that they could withdraw at any
 EXPERIENCES OF CSE COUNSELING 10

149 point, without giving a reason, which would not affect any services they were receiving from

150 Time2Talk or other organizations. While it was emphasized to participants that the interviews

151 were confidential, the limits to this confidentiality were discussed at the outset, in that if any

152 safeguarding issues arose, the evaluation team would discuss the issues with the Time2Talk

153 lead counselor. To maintain independence, the data, analysis and findings were not discussed

154 with Time2Talk until the evaluation was complete.

155 Data Collection

156 All interviews were conducted by the evaluation team (either the third or last author).

157 The majority took place in a private room at the service. One parent was interviewed over the

158 telephone, as were four professionals. The interviews were semi-structured in format. Young

159 people and parents were asked about their experiences of the counseling sessions or meetings

160 they had at Time2Talk, including their perceptions of the impact of the counseling, helpful

161 and unhelpful factors, and suggestions for improvement. Professionals from services working

162 with Time2Talk were asked about their experiences of working with the service, including

163 their perceptions of its added value for their organization. Finally, staff at Time2Talk were

164 asked about their perceptions of the mechanisms behind the impact of Time2Talk, the

165 barriers and facilitators to delivery and how the service could be improved.

166 All interviews were audio-recorded, transcribed verbatim and anonymized. The

167 interviews ranged from 11.51 to 62.23 minutes in length (M = 29.27 minutes. SD = 13.08).

168 The young people and parents received a £10 voucher as a thank you for taking part.

169 Data Analysis

170 All transcripts were imported into the NVivo (version 12) qualitative data analysis

171 software package and analyzed by the first and last authors using thematic analysis (Braun &

172 Clarke, 2006). Analysis was conducted from a critical realist perspective. This assumes that

173 although data can tell us about the real world, it is not a direct reflection of reality; it is
 EXPERIENCES OF CSE COUNSELING 11

174 participants’ interpretation of reality, which requires interpretation by the researcher to

175 further our understanding (Willig, 2012). An inductive approach was taken, with the aim of

176 staying close to participants’ words and meanings (Braun & Clarke, 2006). Recognition of

177 our position as mental health researchers ensured awareness of the influence of our

178 preconceptions and two aspects facilitated. First, a collaborative approach was taken to the

179 analysis, involving cross-checking researchers’ interpretations against the data. Second, the

180 literature review was completed after the analysis and prior to the discussion, thus enhancing

181 the inductive approach taken to thematic analysis (Braun & Clarke, 2006).

182 The analysis followed the method set out by Braun and Clark (2006). Following

183 familiarization with the data, preliminary codes were generated across the dataset which

184 described and labelled the content of transcript extracts relevant to participants’ experiences

185 of receiving support from or working with the counseling service. These preliminary codes

186 were then grouped into salient themes for each participant group (young people, parents,

187 professionals from other services and Time2Talk staff). The resulting themes were then

188 integrated into four superordinate themes that captured the similarities and differences

189 between group perspectives.

190 Results

191 Four superordinate themes, each with associated subthemes, were identified, as

192 summarized in Table 1 and described in-depth throughout this section.

Table 1.

Superordinate Themes and Subthemes

Superordinate theme 1: Characteristics of the service that facilitated progress

Subtheme 1: A safe and confidential place

Subtheme 2: Flexible and consistent delivery of care

Subtheme3: Cross-sector collaboration between services

 EXPERIENCES OF CSE COUNSELING 12

Superordinate theme 2: Characteristics of the counselor that facilitated progress

Subtheme 1: Being listened to, cared for and understood

Subtheme 2: Receiving advice, solutions and learning techniques

Superordinate theme 3: Factors that could hinder progress

Subtheme 1: Issues around service location

Subtheme 2: Anxiety and resistance at the outset

Superordinate theme 4: Perceptions of impact of counseling process

Subtheme 1: Affective improvements

Subtheme 2: Relational improvements

193

194 Superordinate Theme 1: Characteristics of the Service that Facilitated Progress

195 A safe and confidential space. The counseling sessions provided young people with

196 a confidential space where they could safely talk about private issues or experiences, which

197 they would not usually share with others. Young people spoke about being able to talk about

198 difficult topics with someone who was not going to judge them, tell others about what they

199 said, or get upset. One said:

200 When you have someone else to talk to that’s not a family member, that’s not going to

201 go back and say it to someone else, it just makes you feel a bit more happier and

202 relieved that it’s not just you that knows that’s how you feel.

203 The way that Time2Talk staff discussed and managed confidentiality was perceived

204 by professionals from other services as contributing to the service’s ability to engage young

205 people. One professional commented on the benefit of this approach:

206 If you come in [meet a young person] heavy-handed with a police officer, social

207 services, straight away the barrier comes down. Where [the counseling service] I
 EXPERIENCES OF CSE COUNSELING 13

208 believe offer[s] a unique service [is] where, if a child goes to speak to them and

209 [they] say: ‘It's off the record’.

210 Time2Talk staff also stressed the value of the sessions as a safe space for parents and

211 young people to discuss their experiences of CSE, supported by the counselor. This helped

212 them to resolve emotional issues and conflictual perspectives that, at times, had led to a

213 breakdown in the parent-child relationship. As one Time2Talk staff member explained:

214 “There's lots, lots of layers that go on, that need to be resolved and need to be talked about.

215 And being given that room and that space to be able to have them discussions safely is

216 mammoth.”

217 Flexible and consistent delivery of care.

218 Flexibility over contact with and ending of treatment. Participants from all groups

219 discussed their perceptions of the benefits of the flexibility of care that the counseling service

220 offered. Young people’s contact with the service ranged from a few weeks to several months

221 and years and they described the benefits of being able to pick up and leave, as and when

222 they needed to, as the service continued seeing them even if they had missed sessions. One

223 said:

224 I was there for about [18 months]. I could have, I could have phoned up and just

225 asked and I still can now if I really wanted to, if I needed any sessions, I’d phone up

226 and they’d, they’ll get me in sometime, to have a little chat.

227 Parents, likewise, spoke about flexible treatment endings and appointments, which

228 they found to be reassuring during difficult periods, with one commenting: “Knowing that

229 there’s always someone there is kind of a comfort because you know that you’re not on your

230 own.”

231 Professionals from other services viewed Time2Talk as having been tailored to meet

232 the needs of young people exposed to CSE and abuse. This included the acknowledgement
 EXPERIENCES OF CSE COUNSELING 14

233 that it takes time to build rapport with a young person and that long-term support may be

234 necessary, while also understanding that for some young people regular sessions may not

235 always be feasible.

236 Flexibility over setting, content and structure. Participants from all groups

237 highlighted the benefits of allowing young people to meet their counselor at a range of

238 community-based venues. Some young people felt more comfortable in an informal setting,

239 such as a café, and professionals from other services suggested that this significantly

240 improved the accessibility of counseling for this client group. One professional said: “[The

241 counselor] doesn't have to meet them [at the service], she’ll meet them anywhere, where that

242 child feels safe and comfortable to talk.”

243 Young people also appreciated the relaxed approach that was taken to their

244 discussions, where they were not forced to talk or follow a fixed agenda, as one explained:

245 It’s comfortable, it’s not something you have to, er, feel nervous to go to because

246 there’s nothing nervous about it. You don’t want to answer a question, you don’t have

247 to. You can just talk about what you want to talk about.

248 Another aspect commented on by young people was the flexibility of the service

249 regarding the involvement of parents in counseling sessions. Young people described how

250 their parents did not have to attend sessions, but that they were welcome to attend if this was

251 appropriate or if there was a need. Where the latter had happened, the counselor’s interaction

252 with parents was seen as helpful by both young people and parents.

253 Consistent delivery of care. The consistency of the service delivery was valued by

254 young people, who felt that seeing the same counselor for each session was helpful, as was

255 the regularity of their sessions. One said: “I like the way that they’ve been like, at the same,

256 at exactly the same time each week because it’s made it easier to fit into a schedule.”
 EXPERIENCES OF CSE COUNSELING 15

257 Parents also commented that this provided their children with a much-needed routine

258 and stability, as well as ongoing support for them as parents. Indeed, the availability of long-

259 term (and regular) support was stressed by Time2Talk staff and professionals from other

260 services, who saw it as providing a level of consistency that facilitated young people in

261 realizing and acknowledging their CSE experiences. One professional commented: “Seeing a

262 regular face on a regular basis, sometimes, [the counselor] can get a little bit more

263 information from these young people, you know, to look at the bigger picture and see what’s

264 happening for them.”

265 Cross-sector collaboration between services. The Time2Talk staff and professionals

266 from other services perceived a multi-perspective and joined-up approach to be a key

267 contributor to accessing, engaging and supporting young people exposed to CSE. Multi-

268 agency meetings enabled the sharing of important contextual information and insights into

269 cases, which both facilitated referrals to the counseling service and supported the prevention

270 of CSE activities in the area. Additionally, contact between agencies meant that young people

271 did not have to keep re-telling their story to every professional who may be involved in their

272 case. As one Time2Talk staff member explained:

273 Forming partnerships with the police and also other agencies like the probation

274 service allows us to work in a way that we would never normally work, which is to

275 work with an agency that is involved in the criminal justice system, that identifies

276 young people through the criminal justice system. And then, they look to us to

277 provide support for that young person.

278 Professionals from other services also commented on the level of engagement that the

279 counseling service could achieve with young people, which could in turn then encourage

280 young people to speak further with representatives from other services when necessary.

281
 EXPERIENCES OF CSE COUNSELING 16

282 Superordinate Theme 2: Characteristics of the Counselor that Facilitated Progress

283 Being listened to, cared for and understood. Young people spoke about how it was

284 helpful to have a counselor with whom they felt able to talk about anything and who would

285 listen to them. The patient, caring, understanding and non-judgmental nature of their

286 counselor, and the relaxed environment of the sessions, had helped to facilitate this and was

287 an incentive for young people to attend. One young person expressed the need to feel

288 accepted:

289 Just the way [the counselor] talks, you know, didn’t talk down, like a lot of, she didn’t

290 really judge, like a lot of people judge, you know, people’s lives or people’s pasts and

291 that. And I didn’t get that from [her].

292 Talking without interruption, pressure or fear of what the reaction might be was an

293 important part of this process, according to young people. The counselor’s impartiality and

294 ability to listen was also seen by parents as enabling her to build a trusting relationship within

295 which their children felt prepared to talk about their experiences. One parent said: “[The

296 counselor’s] definitely done her the world of good, just talking about it, over and over again,

297 without anyone saying, having an opinion, um. Just letting it all out I suppose.”

298 Receiving advice, solutions and learning techniques. Further helpful aspects

299 emphasized by young people were the advice and practical solutions that they had received

300 on how to cope with challenging situations, problems or relationships, and the techniques that

301 they had learnt to help manage their feelings. Young people talked about this as being both a

302 collaborative process, whereby they and their counselor worked together to try to manage or

303 solve their problems, and a more didactic process, whereby the counselor gave them her

304 opinion on, or interpretation of, situations and suggested solutions. As one young person

305 commented:
 EXPERIENCES OF CSE COUNSELING 17

306 She gives you her opinion, like, she doesn’t just act like a, like a normal, I’m not

307 saying all therapists are the same, but you have therapists don’t you that like, they’re

308 just not, they just sit there and like, ‘And how does this make you feel?’ That really

309 frustrates me, that.

310 Young people felt that this process had helped them to gain new perspectives on, and

311 insights into, the problems that they had talked about in their sessions, which enabled them to

312 deal with and better understand situations and feelings. One said: ”I’ll ask her like what does

313 she think is going on here and she’ll tell me and then I’ll listen to her and I’ll think ‘Okay’, it

314 just helps me to understand and it makes me feel better.”

315 Young people also alluded to the role of the counselor in providing advocacy, with

316 their agreement. This included liaising with other services and their parents and carers to

317 explain the issues that they were going through and to improve their care situation.

318 Finally, parents discussed the advantages of receiving parenting advice from the

319 counselor, which helped them build parenting skills and the confidence to renegotiate their

320 family relationships and de-escalate family tensions. One parent described a positive shift:

321 “[the counselor] She’s taught us to like walk away, it’s okay. She’s taught me not to be feared

322 of [my daughter] and or not to show my fear. Um, she’s taught me confidence.”

323 Superordinate Theme 3: Factors that Could Hinder Progress

324 Issues around service location. Although participants primarily spoke about the

325 factors that facilitated progress, they also discussed service-level barriers within and outside

326 the counseling service that could impede young people’s access to support. While some of

327 the issues that they discussed represented well-recognized challenges to services, such as

328 insufficient funding and long waiting times, participants also commented specifically on the

329 location of the service as being an obstacle to young people attending. This included the

330 reluctance of young people to travel independently, the distance of the counseling service
 EXPERIENCES OF CSE COUNSELING 18

331 from their homes, and encounters with others at one community venue, which had made

332 young people feel intimidated. The counselor’s flexibility in terms of the location of young

333 people’s sessions could help to mitigate this. One parent explained: “It’s [two] miles from

334 school to the center. So, I was having to walk to school to walk down to , back up. The kid

335 had done [four] miles before she started [school].”

336 Anxiety and resistance at the outset. A further impediment to engagement

337 highlighted by participants was the resistance of young people and family members at the

338 outset of counseling. Feelings of anxiety and mistrust were described by the young people

339 and were seen to fuel their initial reluctance to talk. Although they expressed relief that their

340 relationship with the counselor had helped them to overcome their fears, they nonetheless

341 described the power of these feelings at the start of contact with the service and their potential

342 to prevent them from receiving help. As one young person highlighted: “The first session I

343 came to; I did not want to come to therapy, I did not want to speak to anyone. [The

344 counselor] was my worst enemy at first.”

345 Time2Talk staff also described how family members could also be reluctant to engage

346 with the service, for example, when the counselor or the services offered were seen as a threat

347 from a community or family perspective.

348 Superordinate Theme 4: Perceptions of Impact of Counseling Process

349 Affective improvements. Young people discussed experiencing improvements in

350 anxiety, anger, low moods, self-harm and suicidality over the course of their sessions at the

351 counseling service. Talking to the counselor was seen to have a positive impact, as one young

352 person described:

353 I tell her how I'm feeling, what's wrong with me, and she'll give me some advice

354 back on what I should do about that. And, after that, I, I feel more better now.
 EXPERIENCES OF CSE COUNSELING 19

355 Like, once I've spoken to her about stuff that I'm upset about, er everything's fine

356 then. I'm more cheerful. I'm not as down as I normally would be.

357 Talking about difficult issues made them feel better, and the young people expressed

358 their relief in terms of ‘lifting a weight off their shoulders’ and ‘getting things off their chest’.

359 Young people also spoke about having a higher sense of self-worth and increased

360 confidence following their sessions, which included feeling more able to go out alone or with

361 their friends, standing up for themselves in difficult social situations, and feeling motivated to

362 reach goals like applying for college courses and jobs. One explained: “I just felt really

363 worthless and I, I didn’t have much of a voice. But then, coming to counseling has made me

364 realize that I'm worth more than I thought.”

365 Time2Talk staff also perceived gains in the confidence of their clients and believed

366 that this had helped young people to take control of their lives and sever links with CSE

367 perpetrators. One said:

368 Lots of young people who are the victims of sexual abuse often have very low

369 confidence and self-esteem and [the counselor] feels it's her role to try and nurture

370 that young person, so they can have more control over their lives.

371 Overall, however, the sense of progress described by the young people was not linear,

372 and there were periods when they still struggled with difficult moods and emotions, which

373 they found limited their potential to move forward. Although the young people worked on

374 some of these ongoing issues in their sessions, they experienced varying degrees of success,

375 for instance the techniques that they had learnt were not always successful in practice if, for

376 example, they did not remember to use them or recognized too late what was needed.

377 Relational improvements. Young people and parents talked about the improvements

378 that they had experienced in their relationships with each other, which had developed since

379 they had started attending the counseling service. This included having fewer arguments,
 EXPERIENCES OF CSE COUNSELING 20

380 having a better understanding of each other’s perspectives, being able to talk to each other

381 and an increased closeness. One young person described a positive change:

382 It was just always arguing before I started counseling and we was never really

383 considering each other’s feelings. But now we do and, if we th- know we’re going to

384 say something that will hurt the other person’s feelings, we’ll rather try to rephrase it

385 so it doesn’t hurt them.

386 Parents felt their children were more prepared to discuss difficult issues with them as

387 well as more able to manage their feelings, with one commenting:

388 [Since the counseling] she’s talking to me more. She seems more sensible in the way

389 she reasons about things. In the way she, she talks about things. Um, and just being

390 able to open up a bit more, I think, to me as well, yeah.

391 Improvements in communication were also seen by parents as contributing to

392 improved cohesion between family members and a sense of familial belonging. As one parent

393 explained: “She’s [counsellor] helped us become a family, rather than me and my daughter

394 and then my partner and my other daughter, she’s helped us become a family.”

395 For Time2Talk staff, improving family relationships was important in helping young

396 people to stabilize and avoid the risk of CSE. One aspect was the clarification of familial

397 roles, which encouraged parents to re-establish boundaries with their children.

398 Discussion

399 The young people in this study described a range of positive affective and relational

400 changes including improvements in anxiety, anger, mood, self-esteem and family

401 relationships that were attributed to the counseling process. Similar changes were observed

402 by parents who also described having more open conversations with their children and

403 improved relationships with them, as well as a greater confidence in themselves and their
 EXPERIENCES OF CSE COUNSELING 21

404 parenting. Overall, the counseling service was seen by participants as providing an important

405 source of support, and the findings illustrate three key aspects that facilitated progress.

406 Ability to Talk Freely During Counseling

407 The ability of young people to talk comfortably with the counselor about anything,

408 including experiences they had never previously disclosed, was seen by all participants as

409 supporting their progress. The benefit of talking was, however, reliant on them setting the

410 agenda and pace of conversations, feeling unpressurised and safe. In person-centered theory,

411 it is the qualities of the therapeutic relationship that facilitate a person’s own capacity for

412 growth (Rogers, 1957). Non-directivity and mutuality enable clients to discuss what they see

413 as important to recovery and at their own pace, thus promoting agency (Levitt, 2005).

414 Similarly, a trauma-informed approach to CSE and abuse emphasizes the need to

415 promote young people’s sense of choice, control and safety within both interpersonal

416 interactions and their environment in order to foster recovery and prevent retraumatization

417 (Department of Health, 2018; Herman, 2015). In the wider CSE literature, young people’s

418 experience of talking to professionals can either help or hinder depending on the way it is

419 approached (Gilligan, 2016; Hallett, 2017). When young people felt in control of when and

420 how they discuss their abuse experiences with support workers, they felt acknowledged and

421 safe; without it, any discussion left them feeling vulnerable (Hallett, 2017).

422 The interpersonal qualities of practitioners are commonly recognized to influence the

423 willingness of sexually abused young people and children to talk to practitioners during

424 therapy (Bruhns et al., 2018; Dittmann & Jensen, 2014; Jessiman et al., 2017). In the current

425 study, the benefit of talking to the counselor was attributed to their capacity to listen within a

426 non-judgmental and caring demeanor. In the person-centered approach, the counselor

427 qualities of acceptance, empathy and genuineness facilitate progress via the client’s

428 experience of being fully accepted and valued within the therapeutic relationship (Barrett-
 EXPERIENCES OF CSE COUNSELING 22

429 Lennard, 1998). Although these features are also highlighted in adolescents’ views of

430 professionals more generally (Freake et al., 2007), they may prove particularly important for

431 young people exposed to abuse who have experienced breaches of trust from adults, or been

432 subjected to negative judgements and conditional acceptance from abusers.

433 Young people’s perception of counseling as a safe space to talk was reinforced in the

434 current study by the confidentiality of the sessions, a finding that is consistent with other

435 CSA studies (Jessiman et al., 2017). In the current study, professionals believed that young

436 people trusted the confidentiality of the counseling service over and above other services.

437 This may have been due to the transparency around confidentiality: clients were assured that

438 should a safeguarding matter arise, every effort would be made to gain their consent prior to

439 disclosure. Young people were also informed of appropriate recourse, in the event they felt

440 their confidentiality had been unjustifiably breached. Clearly, balancing the limits of

441 confidentiality and safeguarding against young people’s need for safety and control is

442 delicate and current study findings point to the importance of transparency and consulting

443 with young people prior to disclosing information to others.

444 A Holistic Approach to the Provision of Support

445 Despite young people’s desire for mutuality, they also valued the provision of advice

446 and techniques, within a more didactic relationship, that helped them develop new

447 perspectives on themselves and their problems. In the person-centered approach, the

448 counselor’s non-directivity changes in response to the client’s capacity to operate from a

449 sense of their own value as a person. As a client has less need to seek advice or approval from

450 others, so the counselor can become more directive with guidance (Barrett-Lennard, 1998).

451 Overall, young people and parents valued the holistic nature of the support, in that it

452 addressed a range of logistical, psychological, emotional and relational issues. This is

453 consistent with emerging work that recognizes the need for adaptability from counselors to
 EXPERIENCES OF CSE COUNSELING 23

454 tackle the multi-faceted and changing priorities of young people (Bruhns et al., 2018).

455 Moreover, in the current study, the positives of a holistic approach extended to the views of

456 parents who perceived the combination of practical advice and expertise as helping them to

457 resolve emotional difficulties, build confidence in parenting and de-escalate family tensions.

458 Multi-agency working has been found to lead to positive outcomes for young people

459 exposed to abuse, including increased referral to and use of mental health services (Herbert &

460 Bromfield, 2017). A multi-agency response to CSE is recommended to meet the diverse

461 needs of young people and the voluntary sector is seen to have a unique role in engaging and

462 supporting them (Department for Education, 2017). Overall, current study findings offer

463 support for the inclusion of a voluntary sector counseling service in a multi-agency CSE

464 team, indicating that their flexibility and expertise can help engage and provide emotional

465 support, as well as facilitate information sharing and the disruption of CSE activity.

466 Flexibility, Consistency and Collaboration

467 In trauma-informed care, the structure and delivery of mental health services is

468 adapted to meet the needs and experiences of people exposed to trauma and to support their

469 engagement (Sweeney et al., 2016). In CSE service models in the UK, assertive outreach,

470 flexible access and consistent contact facilitate the engagement of young people, who may

471 struggle to seek help due to unstable lives, mistrust of adults or not recognizing their

472 exploitation (Barnardo’s, 2017). Findings in the present study, also, highlight the need for

473 flexibility and consistency over the duration of contact to help meet young people’s needs

474 and promote their engagement and progress. Prolonged and consistent contact with

475 professionals has been recognized to facilitate trust building and accommodate the disclosure

476 patterns associated with CSE, which often involve a process of multiple disclosures and trust

477 testing over time (Ahern et al., 2017). Equally, persistence in maintaining contact was seen
 EXPERIENCES OF CSE COUNSELING 24

478 by staff in the present study and also by professionals in the literature, to facilitate young

479 people’s safety during periods of disengagement from services (Hickle, 2017).

480 The need for flexibility of access identified in the literature (Ahern et al., 2017;

481 Barnardo’s, 2017), which includes meeting young people at their preferred venues, is

482 supported by findings in the current study. However, the finding that some young people

483 viewed one community-based venue as intimidating reflects a need to balance the advantages

484 of flexible access against the priority that young people who have been exposed to trauma

485 feel emotionally and physically safe (Sweeney et al., 2018).

486 While facets of service structure in the current study facilitated engagement,

487 flexibility over the number of sessions also had implications for the provision of the person-

488 centered approach. Participants highlighted the importance of having sufficient time, not only

489 to establish young people’s trust, but also to experience the quality of relationship that could

490 help resolve issues and facilitate progress. As Hallett (2017) attests, in order to support young

491 people exposed to CSE and prevent further exploitation, trust alone is not enough; what is

492 also needed are relationships that are experienced as meaningful, interdependent and mutual.

493 Strengths and limitations

494 The primary strength of this study is that it is the first published account of users’

495 experiences and perceptions of a counseling service that offers support for young people

496 exposed to CSE and sexual abuse and their families. A further strength is that the interviews

497 were in-depth and conducted by an independent evaluation team outside of the service.

498 However, study findings also need to be considered within the following limitations.

499 First, participants were recruited by the lead counselor which may have provided a bias

500 towards a more positive view of the service. When recruiting from within services power

501 dynamics are likely, particularly when conducting research with survivors of trauma.

502 Therefore, the transferability of findings to those not invited or who declined to participate is
 EXPERIENCES OF CSE COUNSELING 25

503 unknown. Given that only one of the young people who participated was male, this study is

504 essentially an account of the female view. Although boys constitute a minority of sexual

505 abuse victims (Stoltenborgh et al., 2011), it is estimated that one third of CSE service users in

506 the UK are male (Cockbain et al., 2015). Reports suggest gender-specific support needs for

507 male victims, requiring understanding of communication barriers and criminality as a

508 response to trauma (McNaughton, 2014). Thus, the degree of transferability of the findings to

509 the male perspective should be treated with caution, as male views are under-represented. To

510 develop effective interventions, future studies will need to focus on the experiences and

511 support needs of males exposed to CSE.

512 Conclusions

513 The findings suggest that young people affected by CSE and their parents perceived

514 person-centered counseling to be an important source of support and that it contributed to

515 young people feeling happier, more confident, better able to manage difficult feelings, and to

516 improvements in family relations and parental well-being. Specific qualities of the counseling

517 relationship, along with facets of service delivery, were identified as facilitating the process.

518 The ability of young people to talk freely was paramount, yet this was contingent on them

519 feeling safe, unpressurised, and in control of the agenda and pace of interactions, as well as

520 the non-judgmental and caring qualities of the counselor. The findings also highlighted the

521 value of sometimes taking a more didactic approach to the provision of advice and expertise

522 and the need for holistic practice in addressing the range of issues faced by young people and

523 parents. The value of a joined-up approach between organizations that facilitated referrals

524 and information sharing was also discussed. Flexibility, accessibility and consistency in

525 service delivery for young people, including a choice of meeting venues and non-time-limited

526 contact, were seen to promote engagement and support. Study findings point to the potential

527 advantages of the person-centered approach in supporting young people exposed to CSE and
 EXPERIENCES OF CSE COUNSELING 26

528 their families, in that its primary focus is the creation of a therapeutic relational environment.

529 Flexibility of service delivery is also identified as contributing to this process, as well as

530 facilitating the engagement of young people and the acceptability of care.

531
532 Disclosure of Interest Deborah Pietkiewicz (fourth author) and Ian Young (fifth author) lead

533 on the implementation of Time2Talk, were interviewed as part of the qualitative evaluation of

534 Time2Talk and contributed to the description of the service for this paper. They were not

535 involved in the data collection nor data analysis for this manuscript.

536

537 Ethical Standards and Informed Consent All procedures followed were in accordance with

538 the ethical standards of the responsible committee on human experimentation [institutional

539 and national] and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent

540 was obtained from all patients for being included in the study.

541

542 Acknowledgments The evaluation team would like to extend their utmost gratitude to the

543 young people, parents and staff who generously shared their experiences of Time2Talk.

544 Thanks also goes to the wider evaluation team, Sally Marriott, Kate Dalzell, and Luís Costa

545 da Silva, as well as to three anonymous reviewers who provided helpful comments on an

546 earlier draft of this manuscript.

547
548

549

550

551

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