Dr. Frances (Fran) Leili is the director of psychological services at EMQ Children & Family Services, a leading provider of mental health and social services for troubled children and their families in California. Their protocol follows the Giarretto Treatment Program, internationally recognized for its work with sexual abuse offenders.

The Giarretto approach is based on the tenet that the entire family of an abuse victim has to be treated in order for healing to take place.

Lora: Can you tell us a little bit about EMQ's services?

Fran: Our emphasis is on reuniting families that have been torn apart by sexual abuse.

We used to work with adult offenders, but because of limited resources we don't do that any more. Our facilities are fully dedicated to working with victims of sexual abuse, their families, and juvenile offenders.

Lora: Who do you see come through your programs?

Fran: The victims we see are usually children ages three to eighteen. Our juvenile offender program is, with rare exceptions, populated by young men between the ages of twelve and eighteen.

We consider sexual acts committed by children younger than twelve to be reactive to abuse, and do not place these children in the offenders program. We treat them as victims who are acting out abuse they've experienced, either indirectly — through pornography or through viewing adult sexual behavior — or directly, by being victimized themselves.

Lora: Isn't it true of all juvenile sexual offenders that they are actually victims?

Fran: That is sometimes true and sometimes not. Once an individual enters puberty, sexual drive and hormones play a part in the acting out of sexual abuse.

Lora: What do you think are the primary factors that allow sexual abuse to occur?

Fran: That's a big question. It's really so individual. Sexual abuse cuts across class, race, and gender. There doesn't seem to be any group that's free of sexual abuse.

Also, we don't think it's true that sexual abuse is more prevalent today than in the past. There is a greater awareness of this issue today. It's openly discussed now. But there is no evidence to support the idea that there is more sexual abuse in the family today than there was 100 years ago. It's just that until recently it was not part of our social consciousness.

That said, we do live in a society that is highly sexualized in its values. The media bombards us with sexualized images. And yet there are strict prohibitions against sexual expression. In this atmosphere, and with little if any guidance, young children cannot always discriminate in their behavior. They can be very confused.

Lora: Can you tell me how sexual abuse is perceived from the offender's perspective? Is sexual abuse a distortion of love?

Fran: Sexual abuse may be a grossly distorted way of seeking love or expressing it. I do see that. Still, we need to underscore that it is abuse.

And all the research that I've read that has tried to break offenders down into a typology has fallen short. There really doesn't seem to be any single category into which we can place juvenile or even adult sexual offenders.

There are many different reasons that sexual abuse occurs — anger, fear, sexual discomfort, feelings of superiority, feelings of inferiority, narcissistic disorders, sociopathy. . . There seem to be so many factors at work that we can't pinpoint one or two that would lead someone to become a sexual offender. Each case we work with here seems to have its own issues.

Some factors are internal to the person, having to do with the ability to emotionally or cognitively process experience. Sometimes it's mainly a question of impulse control.

Lora: I'm really struck by what you are saying. Coming into this interview, I thought there would be basic clues about the personality type that would carry sexual abuse as a part of their presentation in the world. And what I hear you saying is that that's absolutely not true; that under any circumstance, with virtually any type of individual, this type of distortion could exist in a person's character.

Fran: This goes back to your earlier observation. It's true that there is a distortion, a perversion, in the way that the offender is seeking love.

But research has shown that every attempt to place individuals who commit sexual abuse in "boxes" — to try to understand what makes people behave this way — has failed. Individuals have biological, chemical, environmental, and social bases for what they choose to do or not do, consciously and unconsciously. It's very, very difficult to squeeze people into a box and type-cast them.

What we have developed are tools that help us understand the level of risk an offender has of re-offending. That's really about the best we can do at this point. And still, these tools fall far short of being able to predict absolutely that this or that person is or is not not a risk to society.

Lora: Are we talking about mainly incest? Does most child sexual abuse occur within the family?

Fran: If when we say "family" we mean the extended family — grandparents, boyfriends, stepparents — then yes, most sexual abuse probably does come from within the family. But on the other hand I wouldn't say it's a vast majority. A lot comes from other sources.

Lora: Can you describe an example of what you see in your program and how the treatment process works?

Fran: Yes. A common scenario might involve an older brother who has been referred to our program for molesting his younger sister. This may have happened only once, or it could have gone undetected for quite a while.

We start with the victim and her parents. They will all immediately begin both individual and peer-group counseling.

The girl's group will be age appropriate, and will allow her to realize that she's not alone in this. And because the victim often feels responsible for the abuse we will assist the child to understand that it is her abuser, not herself, who is really responsible.

We'll teach her about boundaries — good touch and bad touch — and help her learn skills for protecting herself in the future. Then, together with the child, we will develop a plan for her to use if something happens in the future. She'll have someone she can tell, and a strategy for getting help.

She'll work in this group for about four months.

Concurrently, one or both parents will attend a therapeutic group, also for about four months, with other parents who are in the same predicament. In that group, the parents will be learning the very same things that the abused child is learning. We build on their strengths, and also help them with the skills to identify normal versus abnormal sexual behavior of children at various ages. They will learn how to be protective.

Working with other parents enables the mother and father to talk openly about what has happened in their own home. This helps reduce the levels of guilt and shame, and enables them to explore factors in their family life that might have contributed to the abuse.

There may be alcoholism or marital tension. Or perhaps there's no one in the home to supervise the children due to the parents' work demands. We help them to look at these factors and learn ways of supporting their child. They learn that it is important to encourage the abused child to communicate with them, and that they need to affirm to her that she was not responsible for her abuse.

At the same time, the parents will each receive individual therapy, and the family itself will be in therapeutic programs as a group, except for the juvenile offender.

Lora: And what happens to the offender?

Fran: The therapy program for the abuser is designed similarly to that of the victim child and the parents. There are both group and individual therapy sessions.

Most often, a juvenile offender — in this case, the older boy — will be removed from the home. If he has been arrested, he may be placed at first in juvenile hall or one of the ranch programs, which are detention-based programs where we provide services. We may or may not be involved in the offender's therapy. After that, he would live with an aunt or grandparent or in a foster home or group home. During all of this time he would be receiving intensive inpatient and then outpatient therapy.

When the offending child enters the outpatient program, it's usually not until after the victim and parents have completed the four-month group program. At this point, the parents will join a new group, with other parents of young offenders. They also will work on what happened in their home — how it came about, and what can be done to create a "safety plan" for the victimized family member.

At weekly meetings, the parents will receive psycho-educational materials on safety, sexuality, communication, and parenting skills, while working with a family therapist and with their daughter.

Over time — and only when the victim is ready, this is really what decides the timing — the courts will look at the possibility of reunifying the family. At this point, we work with the entire family together in therapy, with the goal of hopefully allowing the offending child to return.

In allowing this, we must feel that the parents are able to keep all members of the family and the community safe. We must have observed that the offender has taken responsibility for his actions, has demonstrated empathy for his victim, and has developed the skills to control his behavior.

Lora: How successful are you at getting families back together?

Fran: Reunifying families that have been split by sexual abuse is something that happens regularly here. In most cases, the adolescent does come back home and the family is reunited. The court has the final say in reunification.

Sometimes — and this is a rare exception — an offender is even left in the home. This happens only when the parents can clearly show the social worker or probation officer that the victim is not at risk. It would have to be clearly demonstrated that the offender will not continue his or her behavior.

Lora: Is there an effort to reunify the family when adults are the offenders?

Fran: There is. And there have been successful reunifications. But in this case, there are many variables. The offender must be able to demonstrate that he is no longer a threat to the family or other children.

Generally speaking, it is the nonoffending parent — usually the wife — and not just the victim who needs to be ready and willing for the offender to return to the family. And it often happens that although an offender may be ready to return, the wife will refuse to reunify the family.

Lora: How successful is your juvenile offender program. How do you measure its success?

Fran: We measure success by the offenders' capacity to have empathy and to take responsibility for their actions. They must understand what drove their abusive behaviors, and what the "red flags" are for them — the chain of events that leads to their difficulties. They must have developed a relapse prevention plan.

We work with the whole family, because often the family has a major part to play in helping the young offender to make better choices. The family can support him in making those choices, and the community can assist by helping the young man to have healthier outlets for meeting his needs.

We have the most significant amount of success when families are involved and support their son through this program. In the process, families learn a lot about themselves.

Lora: You said earlier that sometimes abuse is caught the first time it happens, and that in other cases it may go undetected for quite some time. Yet I think every parent would like to believe that if something like this happened to their child, they would catch it immediately.

Can you help with this? What are the warning signs that one's child has been abused?

Fran: For younger children, it's often precocious sexual interest — such as when a young child masturbates frequently, especially in public.

Another sign is a radical change in the child's behavior, especially if the child goes quickly from being outgoing to being shy and fearful. It will appear as if something is wrong in the child's world. They're withdrawn and don't interact as much with others.

Another thing to watch out for is exposure to pornography — either deliberately or through unsupervised access. It's important, for example, to know what kids are doing on the Internet — what sites your children are visiting, what their interests are.

Of course, during adolescence there will always be an interest in normal sexuality. But if there is an interest in pedophiliac material or other types of distorted sexual material, this is a clue that something may be wrong.

Any problems at all with genitalia — a young girl with vaginal pain, or a boy who has a medical problem with his penis — may indicate that something is going on.

Also, kids often ask questions that will lead an alert adult to wondering where that question came from. If we really know our children and pay attention to what interests them, we will recognize the signs of preoccupation with sexual issues. Then we can ask our own questions and find out what's going on.

These are just some of the more obvious signs.

Prevention comes from really knowing and being connected to our children and what they are doing. We need to know their friends, their interests, how they spend their time. Open communication with our children is essential. This level of parental awareness can certainly help prevent abuse.

Lora: Can a juvenile offender, a young person who has made a mistake like this, heal and go forward in life?

Fran: Absolutely. We see a very low percentage rate of repeat offenders from our juvenile treatment program.

Lora: That really is wonderful. And are there very many of these types of programs available?

Fran: There seems to be a scarcity of treatment programs for adult offenders. But for juvenile offenders, there are many local chapters of Parent's United, all using this model I've described. And there are quite a number of other programs that operate similarly to ours.

In addition, many practioners trained through our educational programs offer individual and family counseling for further support.

Lora: Do you have a closing message for our readers?

Fran: What is often not said is that although sexual abuse in childhood can create emotional damage that lasts for a lifetime, it doesn't have to be that way. When a child who has experienced molestation is believed and supported by the parents, that child can come through the experience without lasting scars.

It doesn't have to be the end of the world.

Dr. Frances Leili has more than twenty-five years of experience as an individual, couples, and group therapist, specializings in sexual abuse treatment. She is senior supervising psychologist at EMQ Children & Family Services, formerly the internationally-recognized Giarretto Sexual Abuse Treatment Program. A licensed psychologist, Dr. Leili holds a Ph.D. in clinical psychology from Fordham University in New York. She can be reached by phone at 408-437-8343, or by email at . Dr. Hank Giarretto established an ongoing and internationally-attended series of training programs for professionals working with sexual abuse victims and offenders, addressing the need for systematic family treatment rather than just individual treatment. Giarretto's website, which contains a great deal of information about obtaining help, is at Giarretto.org. EMQ acquired the Giarretto institute in 1999. They are members of Parents United, a world-wide, guided self-help program offering services to sexually abused children, their families, adult victims, offenders, and all support persons.