CHILD

Celano et
MALTREATMENT
al. / ATTRIBUTION
/ FEBRUARY
RETRAINING
2002

Attribution Retraining With Sexually

Abused Children: Review of Techniques

Marianne Celano
Ann Hazzard
Emory University School of Medicine
Susan K. Campbell
Georgia Center for Children
Claudia B. Lang
Emory University School of Medicine

Clinicians increasingly use empirically based cognitive- be-
havioral techniques in their treatment of child victims of sexual
abuse. Attribution retraining is often a primary component of
this work, and it involves various techniques aimed at decreas-
ing abuse-related self-blame and encouraging the child to at-
tribute responsibility for the abuse to the perpetrator. This
article reviews literature that highlights the complexity of self
and other blame for sexually abused children in terms of devel-
opmental status, the multifaceted nature and interrelationships
of abuse-specific attributions, and the psychological effects of
self-blame and perpetrator blame. A review of written attribu-
tion retraining techniques developed by diverse authors for use
with sexually abused children and their nonoffending parents is
provided, including written and verbal techniques and tech-
niques using games and the arts. The relative utility of different
approaches with children of various stages of development is
discussed, along with the need for empirical research regarding
the effectiveness of these techniques.
sion and anxiety (e.g., Kendall & Treadwell, 1996;
Lewinsohn, Clarke, Rohde, Hops, & Seeley, 1996). Attri-
bution retraining has recently been adapted for use with
sexually abused children, given the increasing acceptance
of models that include victims’ cognitive appraisals
among those variables that influence the effects of abuse
on mental health (e.g., Finkelhor & Browne, 1985;
Newberger & De Vos, 1988; Spaccarelli & Kim, 1995).
Although early anecdotal literature suggested that self-
blame1 was common among all sexually abused children,
recent empirical findings suggest gender and age-based
variability in children’s attributions. For example,
Hunter, Goodwin, and Wilson (1992) found gender dif-
ferences in interrelationships between different types of
attributions (e.g., family blame and perpetrator blame,
self-blame and perpetrator blame). In addition, Hunter et
al. (1992) found self-blame for sexual abuse to be more
prevalent among adolescents and adults than among child
victims in a nonpsychiatric sample. Using a clinical sam-

I n recent years, increasing attention has been given to at-

tribution retraining techniques (also called cognitive re-
structuring) in which the therapist encourages the client
to modify maladaptive beliefs, often by using logical anal-
ysis to demonstrate how the beliefs are irrational (Finch,
Nelson, & Ott, 1993). These techniques are commonly
implemented in empirically supported cognitive-behav-
ioral treatments for children and adolescents with depres-
Authors’ Note: Reprint requests may be sent to Marianne Celano,
Ph.D., Department of Psychiatry & Behavioral Sciences, Emory Univer-
CHILD MALTREATMENT, Vol. 7, No. 1, February 2002 64-75 C sity School of Medicine, Box 26064, Grady Health System, Atlanta,
© 2002 Sage Publications H GA, 30335. E-mail: mcelano@emory.edu

64

ple and a different methodology for assessing attributions,
Hazzard, Celano, Gould, Lawry, and Webb (1995) found
that younger children blamed themselves more for the
abuse than older children among a sample of 8- to 13-year-
old girls.
Developmental theory and empirical literature in
social cognition suggest developmental variation in social
cognitive processes related to attributions. For example,
preschoolers’ attributions are influenced by their ten-
dency to overattribute intentionality, underattribute
behavior to stable personality traits, and evaluate people
and actions according to their outcomes (Miller & Aloise,
1989). However, it is not well understood how these
developmental factors affect young children’s attributions
of responsibility for sexual abuse. Development also
affects the extent to which children can understand and
reliably report self-blame. The interchangeable use of the
terms blame and responsibility in the treatment literature
(Dalenberg & Jacobs, 1994) may obscure young children’s
self-attributions. That is, younger children may be reluc-
tant to admit blame, as this term carries negative connota-
tions, whereas older children may more readily perceive
that blame refers to the broader concept of causal respon-
sibility (Dalenberg & Jacobs, 1994).
One assumption embodied by the anecdotal literature
on child sexual abuse is that self-blame and perpetrator
blame are two extremes on a single continuum. However,
some empirical findings challenge the assumption of an
inverse relationship between self-blame and perpetrator
blame. For example, Hunter and colleagues (1992) did
not find an inverse relationship between self-blame and
perpetrator blame for male victims. In addition, Chaffin,
Wherry, and Dykman (1997) did not find internalized
coping style (blaming and isolating self, remaining quiet
and passive about the problem) and angry coping style
(blaming others and expression of anger) to be negatively
correlated in a sample of sexually abused children.
The empirical literature is supportive of the early clini-
cal assumption that victims’ self-blame has negative
effects. Studies assessing child victims’ attributions of
responsibility for their abuse have found internal attribu-
tions to be related to low self-esteem (Morrow, 1991),
higher levels of depression (Morrow, 1991; Spaccarelli
& Fuchs, 1997), and post-traumatic stress disorder
(PTSD) symptoms (Wolfe, Sas, & Wekerle, 1994).
Chaffin and colleagues (1997) found an internalized cop-
ing style to be significantly related to child-reported
PTSD hyperarousal and guilt symptoms. Mannarino and
colleagues (Mannarino & Cohen, 1996; Mannarino,
Cohen, & Berman, 1994) found that negative abuse-
related attributions and perceptions were strongly related
to symptom formation in sexually abused children at dis-
closure and follow-up. In a longitudinal study of the rela-
tionship between attributions for abuse and adjustment
CHILD MALTREATMENT / FEBRUARY 2002
Celano et al. / ATTRIBUTION RETRAINING 65
among sexually abused children (Feiring, Taska, & Chen,
2002, this issue), abuse-specific self-blame attributions
were found to be related to self-reported depressive symp-
toms, PTSD symptoms, and poor self-esteem at study
entry and 1 year later, even after controlling for age, gen-
der, and number of abuse events.
Despite the empirical support for the negative effects of
self-attributions, some authors have suggested that spe-
cific, behavioral self-blame may be adaptive in some cir-
cumstances (e.g., Lamb, 1986; Shapiro, 1995). For exam-
ple, the child may have made errors in judgment that
increased the likelihood of abuse, suggesting that some
internal attributions of responsibility may be appropriate.
Thus, it is important to distinguish between those self-
attributions that stem from cognitive distortions and
those that are the natural result of children’s failure to
meet adults’ legitimate expectations (Celano, 1992). A
related dilemma is the presumed positive relationship
between perpetrator blame and feelings of powerlessness,
often called “the attributional dilemma” (Shapiro, 1989).
Thus, attempts to discourage victims’ self-blame may have
the unintended effect of increasing children’s perceived
helplessness and concomitant anxiety.
A related assumption in the clinical literature is that
perpetrator blame has positive effects for the child victim.
However, Chaffin et al. (1997) found that a coping style
characterized by blaming others and expression of anger
was associated with the greatest number of behavioral
problems. This finding raises questions about how clini-
cians should encourage appropriate attributions of blame
to the perpetrator without promoting expressions of rage
that may exacerbate acting-out behavior. In addition,
encouragement of perpetrator blame is a delicate matter
in cases in which the perpetrator is important to the child.
Several authors have pointed out that anger toward an
offender who is a cherished parent figure can be very pain-
ful, and some children may cling to positive internal
images of a perpetrator-caregiver (Friedrich, 1990;
Shapiro, 1995).
The empirical and clinical literature have emphasized
self-blame and perpetrator blame more than blame of fam-
ily members (e.g., nonoffending caregivers). Among a
sample of women survivors, McMillen and Zuravin
(1997) found both self-blame and nonperpetrator family
blame to be independently associated with adverse out-
comes, suggesting that clinicians should broaden their
assessments of child victims’ attributions to include
nonperpetrator family blame. In their factor analysis of
abuse-specific attribution items, Feiring et al. (2002)
identified a factor (External-Mom) that was positively
related to the factor measuring internal-global abuse-spe-
cific attributions. The impact of parent blame is not well
understood but probably depends at least in part on the
child’s developmental status (i.e., dependence on the par-
66 Celano et al. / ATTRIBUTION RETRAINING
ent), the circumstances of the abuse, and the relationship
between the parent and the perpetrator.
Even internal attributions of responsibility can benefit
from further differentiation. Celano (1992) offered a
typology of child victims’ internal attributions including
responsibility for failing to recognize abuse, for participa-
tion in the abuse, for failing to seek help, for failing to
avoid or control the abuse, for pleasure gained, for failure
to protect siblings, for failure to protect oneself, and for
the family reaction to disclosure. Children may make dif-
ferent attributions for various aspects of the abuse; for
example, a girl may blame the offender for the abusive act
but blame herself for failing to disclose the abuse. In gen-
eral, the empirical findings on attributions of responsibil-
ity for sexual abuse suggest that child victims’ attributions
are more complicated and differentiated than was once
thought and may require more sophisticated and differen-
tiated treatment responses.
Advances in theoretical development have informed
the treatment of sexually abused children’s attributions.
Abuse-specific treatment has been guided by cognitive-
behavioral theory (Deblinger & Heflin, 1996), the four-
factor traumagenic dynamics model (Finkelhor &
Browne, 1985), and life-span developmental theory
(Newberger & De Vos, 1988). These theories are more
alike than they are different in their emphasis on the role
of victims’ attributions in influencing the effects of abuse
on the child’s functioning. The life-span developmental
theory is unique in its emphasis on the time dimension
over which the child’s recovery (including attributions)
evolves and on the reciprocal interaction of child behav-
ior, cognitive processes, and environmental response.
In addition, general theoretical models linking attribu-
tions for negative events to consequences have been
applied to sexually abused children’s attributions.
According to the learned helplessness model (Abramson,
Seligman, & Teasdale, 1978; Seligman et al., 1984), nega-
tive outcomes, such as depression, accrue when children’s
attributions for negative events are internal, stable, and
global. According to the compensatory model (Brickman
et al., 1982), positive outcomes are most likely when the
individual does not take responsibility for the origin of the
problem but takes full responsibility for problem solution
(i.e., coping with effects of the problem and avoiding
recurrence).
Treatments designed for sexually abused children usu-
ally include techniques designed to reduce self-blame and
help child victims attribute responsibility for the abuse to
the offender. These techniques vary in the degree to
which they address the complexities and controversies
inherent in attributional training. The purpose of this
article is to review attribution retraining techniques
developed for use by clinicians treating sexually abused
children (see Table 1). To locate written attribution
retraining techniques, we searched psychological and
medical databases for material on attributions of sexually
abused children. Articles, workbooks, or texts including a
detailed description of an attribution retraining tech-
nique were included.
ATTRIBUTION RETRAINING TECHNIQUES
Verbal and Written Techniques
Many techniques primarily involve verbal discussion
of thoughts and feelings or written materials that are used
to stimulate discussion or record thoughts. The tech-
niques summarized in this section use primarily verbal/
written formats although some may include visual illustra-
tions as secondary aspects to the material.
Cognitive-behavioral challenges of negative thoughts.
Deblinger and colleagues (Deblinger & Heflin, 1996;
Deblinger, McLeer, & Henry, 1990) pioneered the appli-
cation of cognitive-behavioral principles to the treatment
of sexually abused children, using a PTSD conceptualiza-
tion of abuse effects. They present the cognitive coping
triangle model to clients, to illustrate that thoughts, feel-
ings, and behaviors are interrelated. Negative thoughts
may lead to a variety of negative affects about the abuse
situation (e.g., anger, anxiety, guilt). The authors provide
several detailed examples of how a therapist might elicit
specific thoughts contributing to guilty feelings (e.g.,
What are the thoughts going through your head when you
are feeling guilty?) and then use the Socratic method to
dispute these thoughts. For example, for a girl who blames
herself because she wore short, baby doll pajamas, the
therapist normalizes the child’s behavior by asking if other
children her age wear that type of pajama and whether
they were abused. The therapist encourages an alternative
attribution that wearing the pajamas did not really cause
the abuse but was an excuse used by the perpetrator.
With preschoolers, Cohen and Mannarino (1993) rec-
ommend first presenting the child with brief descriptions
of positive and negative situations unrelated to sexual
abuse (e.g., you leave your bike in the driveway and your
father hits it with his car) and then describing a sexually
abusive situation. For each situation, the child tells who
he or she thinks is responsible for making the event occur.
If the child makes an inappropriate attribution, the thera-
pist is encouraged to (a) ask what the person he or she
named did to make the event happen, (b) ask if anyone
else did anything to contribute to it, and (c) offer alterna-
tive explanations for why the event occurred. Finally, the
therapist follows this procedure related to the child’s own
abuse. Because of young children’s egocentric view of cau-
sality and limited logical reasoning skills, Cohen and
Mannarino (1993) note that the therapist may need to
make more direct statements such as “I don’t think it was
CHILD MALTREATMENT / FEBRUARY 2002
 Celano et al. / ATTRIBUTION RETRAINING 67

TABLE 1: Attribution Retraining Techniques for Sexually Abused Children

Name of Activity Authors Target Age Modality

Verbal techniques
Cognitive coping triangle Deblinger et al., 1990 Latency Individual
Challenging negative thoughts Cohen & Mannarino, 1993 Preschool Individual
“Why List” Celano et al., 1991 Latency Individual
“Guilt-Free Kids” Crisci et al., 1997 Latency Individual/group
List of blaming beliefs Munson & Riskin, 1995 Teens Individual
Story metaphors
“Kit’s Story” Crisci et al., 1997 Preschool Individual/group
“Sugar for Diabetics” role-play James, 1989 Latency Individual
“Jay’s Story” Karp & Butler, 1996a Latency Individual/group
“Why Me?” Celano et al., 1991 Latency Individual
Affirmation techniques
Children’s books Sweet, 1981 4 to 12 Individual/group
Workbook sheets Spinal-Robinson & Wickham, 1992 Latency, teens Individual/group
Boulden & Boulden, 1994 Latency Individual/group
Stowell & Dietzel, 1982 Latency Individual/group
Expressive affirmations James, 1989 All ages Individual
Games and the arts
“Why Pie” Celano et al., 1991 Latency Individual
“Responsibility Ruler” Mannarino, personal communication Latency, teens Individual
“Innocence of Childhood” Crisci et al., 1997 Latency, teens Individual/group
Draw self and perpetrator Wieland, 1997 Latency Individual
“Red Riding Hood” role-play Crisci et al., 1997 Preschool Individual/group
“Best Friends Role-Play” Deblinger & Heflin, 1996 Latency Individual
Gestalt chair technique Wieland, 1997 Latency, teens Individual
“Time of Confusion” song Celano et al., 1991 Latency Individual
“Hat Game” Hansen et al., 1998 Latency Group
“Guilt Trip Game” Crisci et al., 1997 Latency Group
Offender-oriented techniques
Explanation of offender blame Berliner & Wheeler, 1987
Letter to the offender Celano et al., 1991 Latency Individual
Mandell & Damon, 1989 Latency Group
Spinal-Robinson & Wickham, 1992 All ages Individual
Lindon & Nourse, 1994 Teens Individual
“Hero Declaration” Allen, 1995 All ages Group
“Truth and Lies” Allen, 1995 4 to 12 Group
“Talk Back” cartoon bubbles Crisci et al., 1997 Teens Individual/group
Courtroom role-play Pearce & Pezzot-Pearce, 1997 Latency, teens Individual

that child’s fault” or “I think the grown-up should have
known better.”
Lists of attributions and suggested challenges. Several au-
thors have compiled more comprehensive lists of possible
reasons that children may blame themselves for the occur-
rence of abuse, for delayed disclosure, and/or for family
disruption following the abuse. These authors generally
advise clinicians to spend ample time eliciting specific at-
tributions and gradually discussing alternative view-
points, cautioning that premature reassurance that abuse
is never the child’s fault may interfere with disclosure and
reframing of negative attributions.
Celano, Hazzard, and colleagues developed an eight-
session curriculum based on Finkelhor and Browne’s
(1985) traumagenic dynamics conceptualization of abuse
sequelae. The curriculum includes two sessions of activi-
ties related to self-blame, including the “Why List,” which
lists 17 possible self-blaming attributions from which the
child is asked to choose any thoughts he or she may have
(Celano, Hazzard, Simmons, & Webb, 1991; Hazzard,
1995). Among the possibilities are: because the person
picked me to abuse, because I liked getting affection,
because I accepted gifts, because I didn’t obey a parental
rule, and because some of the ways the person touched me

CHILD MALTREATMENT / FEBRUARY 2002

68 Celano et al. / ATTRIBUTION RETRAINING
felt good to my body. Therapists are provided with sug-
gested approaches to counter each of the self-blaming
attributions on the list. For example, the therapist might
encourage a child to question whether the offender really
picked the child because of personal characteristics or
because of convenience. Children who made an error in
judgment that may have increased their risk are encour-
aged to acknowledge their mistake (e.g., make a situa-
tional attribution) but are discouraged from assigning
global internal blame: “Even if you make a mistake, no
one has the right to abuse you.” For self-blaming attribu-
tions related to the victim’s sexual arousal, the child can
be informed that sexual arousal is an automatic response
of the body, similar to automatic laughing or twitching in
response to tickling.
Crisci, Lay, and Lowenstein (1997) use similar tech-
niques in their “Guilt-Free Kids” activity, one of a number
of creative therapeutic activities for sexually abused chil-
dren included in their book. In this activity, children are
introduced to a comic book with cartoon characters that
have been sexually abused. Each character is depicted
making a guilty statement, such as “I feel to blame because
my parents split up after I told” or “I feel guilty because I
really miss the abuser.” Following a discussion of the many
ways guilt feelings occur, children are asked to help the
cartoon characters “tell it like it is” by writing a guilt-free
response to each one of the character’s guilty statements.
Activities with older children generally involve
encouraging child survivors to develop their own list of
things they should or should not have done, which they
(or others) believe may have contributed to the abuse.
Munson and Riskin’s (1995) workbook normalizes guilty
feelings in introductory paragraphs by offering self-blam-
ing comments the authors have heard from other chil-
dren. Teens are then given the opportunity to write their
own blaming beliefs and statements made by the perpetra-
tor or others that have contributed to self-blaming attri-
butions. The authors then offer a checklist of ambivalent
feelings that adolescents may experience (e.g., liking the
gifts or money, loving the abuser) to which they respond
with educational reframes.
Story metaphors. A number of authors have used story
metaphors to elicit and challenge self-blaming attribu-
tions. For example, Crisci et al. (1997) describe a story-
telling activity called “Kit’s Story”, particularly
appropriate for younger children. In the story, a cat named
Kit is sexually abused by Tom Cat, the big barn cat next
door. Kit shares her feelings of responsibility and guilt
with her friend, the Wise Old Owl, who helps her sort out
her confusing feelings. After reading the story, the thera-
pist engages children in dialogue by asking questions such
as, “how do you think Kit felt when Tom Cat told her to
keep what happened a secret?”
James (1989) combines the story metaphor technique
with role-playing. After acting out a story involving a girl
with diabetes whose parents are told never to give her
sugar (“Sugar for Diabetics” role-play), the children
answer questions about responsibility when the father
gives the child a candy bar that makes her very sick.
Children are asked, “Who did the wrong thing? What if
the little girl didn’t make the father stop? What if she
enjoyed the candy?” The story illustrates that no matter
what the child did or felt, the adult made the mistake by
doing something he knew was wrong for the child.
Karp and Butler (1996a) developed a workbook with
an accompanying clinician’s guide (Karp & Butler,
1996b). The workbook includes “Jay’s Story” about a
child abused by his older brother. After reading the story,
children are asked why Jay thought the abuse was his fault
and what the brother did to make Jay think that the
touching was OK; this activity is followed by eliciting and
disputing the child’s own self-blaming attributions.
“Why Me?” is a fill-in-the-blank story in which a girl is
abused and wonders why this happened to her (Celano et
al., 1991). This third-person format allows elicitation of
the child’s probable attributions for his or her own abuse
in a less threatening format. There are four versions of the
story: stranger rape and stepfather molestation versions
for both boys and girls.
Affirmation techniques. Most of the techniques dis-
cussed involve eliciting specific reasons for self-blaming
attributions and offering alternative perspectives to chil-
dren. Other authors simply affirm to the child that abuse is
never the child’s fault (e.g., Corder, Haizlip, & DeBoer,
1990), often using books (e.g., Something Happened to Me
by Sweet, 1981) or workbook sheets such as Cartwheels
(Spinal-Robinson & Wickham, 1992), Secrets That Hurt
(Boulden & Boulden, 1994), and My Very Own Book
About Me (Stowell & Dietzel, 1982; Stowell, Dietzel, &
Gleason, 2000). James (1989) asserts that therapists
should quickly and clearly tell children that the abuse was
not their fault. She acknowledges to them that it may take
a while to believe this statement, however, and she ex-
plores any self-blaming thoughts the children express.
James has developed several expressive affirmation activi-
ties that encourage bold declarations of “It’s not my fault!”
(INMF). For example, she encourages children to yell the
phrase out of the therapist’s office window, has children or
families make INMF banners for display in the home, wear
INMF badges, and create INMF dances and prayers. James
(1989) theorizes that imprinting the message in this way
creates a circumstance in which “the child first tells the
universe, then learns to tell himself” (p. 70).
CHILD MALTREATMENT / FEBRUARY 2002

Techniques Using Games and the Arts
A number of techniques have been developed that use
visual stimuli, music, drama, or games to address chil-
dren’s attributions. Although these techniques generally
involve verbal explanation as well, they may be more
appealing and developmentally appropriate for children.
Visual techniques. The “Why Pie” is a drawing of a pie
that the child is instructed to divide into various-sized
pieces, with each different-colored piece representing
how much he or she blames a given person (Celano et al.,
1991). This technique allows one to assess the relative
amount of blame to self and other individuals (including
but not limited to the offender). Mannarino and col-
leagues (personal communication, May 2000) use a simi-
lar technique called the “Responsibility Ruler,” in which
children measure out the relative responsibility of differ-
ent individuals for their abuse.
In the “Innocence of Childhood” activity (Crisci at al.,
1997), therapists ask children to bring pictures of them-
selves taken at the age when they were abused. Looking at
the pictures, therapists elicit discussions geared toward
identifying how vulnerable and trusting the children
were. This is followed by discussions aimed at increasing
their understanding of how the offender misused their
trust and exploited their vulnerability.
In her description of techniques based on a psycho-
dynamic trauma-internalization model, Wieland (1997)
recommends having the child draw a picture of himself or
herself at the age of abuse and a proportionally sized pic-
ture of the perpetrator. This activity emphasizes the size
and power differential between victim and perpetrator
and helps the child recognize the realistic limitations of
his or her ability to “fight back.”
Drama/role-plays. In an activity for younger children
called “Little Red Riding Hood,” therapists introduce the
concept of “being tricked” by performing a magic trick,
followed by a discussion on why we like tricks and how
they work (Crisci et al., 1997). They then read the story of
Little Red Riding Hood, which is followed by a discussion
on what trick confused Red Riding Hood and what trick
frightened her. Therapists relate the concept of tricks to
sexual abuse, explaining the difference between the fun
tricks in a magic show and the scary or confusing tricks in
secret touching. Using a puppet show to dramatize the
story of Red Riding Hood may make this technique even
more appealing to young children.
Deblinger and Helfin (1996) use a “Best Friends Role-
Play” as a mechanism to help children counter
maladaptive cognitions. The therapist plays the role of a
child who is having negative abuse-related thoughts. The
child client is encouraged to pretend that the therapist is
CHILD MALTREATMENT / FEBRUARY 2002
Celano et al. / ATTRIBUTION RETRAINING 69
his or her “best friend” and to try to convince the best
friend/therapist that his or her negative thoughts are not
true.
Wieland (1997) suggests using the Gestalt chair tech-
nique for a role-play between two conflicting internal
parts of a child. For example, a child’s “now-self” may be
angry and blaming of the abused self for not telling sooner.
The child moves between two chairs during a role-played
conversation between these two aspects of himself or her-
self. The therapist assists the abused self in expressing
what made it hard to tell or the nonverbal ways he or she
had tried to tell but no one had paid attention.
Musical techniques. Celano et al. (1991) developed a
rap song, “Time of Confusion.” The song is available on
tape with their curriculum and may be especially appeal-
ing to African American clients. The song’s lyrics address
issues such as (a) bad things sometimes happen to good
people; (b) wanting to be liked is normal, and sometimes
others take advantage of that feeling to trick you, (c) say-
ing yes to one activity doesn’t mean you said yes to every-
thing, such as sex.
Games. Project SAFE is a 12-session treatment proto-
col for latency-aged children and nonoffending parents
that uses a parallel group format (Hansen, Hecht, & Futa,
1998). The “Hat Game” is used to elicit and address self-
blame and stigmatization issues. A hat is filled with ques-
tions such as “Has your body changed since the abuse?”
“Have you felt like you could have stopped it?” and “Do
you think it was your fault?” The hat is passed from one
person to the next, with each child reading and respond-
ing to a question.
The “Guilt Trip Game” (Crisci et al., 1997) is a board
game particularly effective in engaging resistant latency
and preteen children. In this game, group members sit in a
circle with the “Guilt Trip Game” board placed in the
middle. First, a toy car is placed on the “start” square.
Then, the leader distributes “guilt eraser” cards among the
players. The first player moves the toy car along to the first
square of the board and reads the situation aloud to the
group (e.g., A kid kept the abuse a secret for a long time).
The leader then asks the player, “What thoughts would a
child have to make him feel guilty about having kept the
abuse a secret?” Once the player responds, the leader asks,
“Who has a guilt eraser card that will challenge this child’s
feelings of guilt?” An example of an appropriate guilt
eraser card could be “Abusers trick kids into keeping the
abuse a secret.” The player with this card is asked to read it
aloud and explain why he or she thinks it challenges the
guilt. Through a fun, interactive, and familiar modality,
therapists can assess the children’s perception of responsi-
bility, challenge cognitive distortions related to feelings of
70 Celano et al. / ATTRIBUTION RETRAINING
guilt, and reinforce the concept that children are not to
blame for sexual abuse.
Offender-Oriented Techniques
A number of authors focus on discussion or explana-
tion of offenders’ motivations as a means of clarifying
responsibility. Although self-blame and offender blame
may not necessarily be inversely related, most authors
assume that increasing appropriate offender blame is
facilitative of positive child outcomes. For example, Ber-
liner and Wheeler (1987) suggest directly explaining that
“the offender has a problem. He wants to be sexual with
children, something which most grown-ups don’t want.
And he tells himself it’s OK even though he knows it’s
wrong.”
One of the most common techniques, recommended
by many authors, is a “Letter to the Offender,” generally
not to be mailed (e.g., Celano et al., 1991; Mandell &
Damon, 1989; Spinal-Robinson & Wickham, 1992). Fill-
in-the-blank formats are often used with younger clients
whereas an unstructured format may be more appropriate
with adolescents (Lindon & Nourse, 1994). The purpose
of this activity is to facilitate expression of feelings about
the perpetrator as well as elicit the child’s abuse-related
attributions.
One session of “Heroes Great and Small,” a 12-week
support group for children (Allen, 1995), is devoted to an
evening of art and role-play involving thoughts about the
perpetrator. Each child is assigned an adult volunteer,
with whom he or she draws a picture of a perpetrator (not
necessarily the person who abused them) and then write
down things they would like to say to the perpetrator. In
front of the group, the child then says to his or her partner
those things the child would like to say to the person who
abused them. The session ends with a “Hero Declaration,”
in which children place fault with the perpetrator and
acknowledge their bravery and hopefulness about
healing.
Allen (1995) uses dramatic techniques in an addi-
tional group exercise entitled “Truth and Lies.” Children
are again paired with an adult partner, with whom they
generate a list of things they were told by the perpetrator,
and a list of the truths of their experience. Adult partners
are provided with sample lists of lies to facilitate the pro-
cess (e.g., you made me do it, you wanted it, you deserved
it). When the exercise is complete, group leaders bring the
children to a section of the room where a large poster with
the word danger hangs, alongside one poster with the word
truth and one with the word Lies and a collection of card-
board boxes. Children are told that by knowing the truth,
they can build a safety wall between themselves and per-
petrators. Each child comes to the front with his or her
adult partner, reads a lie, and posts it on the Lie poster.
The group boos and yells, “lies.” The child then reads and
posts the truth, to the cheers of the group, and places a
cardboard block between the truth and lie posters to
chants of “build a wall!” When the brick is in place, the
group applauds and in unison pronounces the child a hero.
Crisci et al. (1997) describe a similar activity designed
for young teens (“Talk Back” cartoon bubbles). The
leader explains that the guilty feelings children have are
often generated by an abuser’s statements, which are
designed to absolve his own feelings of responsibility.
Therapists hold up a cartoon with an example of what an
abuser might say to a child. Children are then encouraged
to deconstruct the statement by examining why the
abuser might make the statement, how the victim might
feel, and what the actual truth is. Children are then given
a set of cartoon bubble sheets with offender statements.
They choose the ones that apply to them and then gener-
ate “talk back” statements for the victim bubbles.
Pearce and Pezzot-Pearce (1997) suggest using a court-
room role-play to elicit and challenge the child’s attribu-
tions. The therapist initially portrays the judge, and the
child is asked to be the defense attorney for the perpetra-
tor. The judge asks the child-attorney to explain the per-
petrator’s behavior. If the child blames the abuse inappro-
priately on himself or herself, the judge can challenge the
attribution. Reversing roles for a subsequent role-play is
recommended to help empower the child and solidify
appropriate attributions of responsibility to the offender.
Techniques With Parents
Many structured treatment programs for sexually
abused youth include parallel treatment protocols for
their parents because parental attributions, emotional
reactions, and support have been found to be strongly
related to child outcome (e.g., Cohen & Mannarino,
1998; Everson, Hunter, Runyon, Edelsohn, & Coulter,
1989; Hazzard et al., 1995). The therapist is typically
urged to address both inappropriate parental self-blame
and potential child blame.
Self-blame. Inappropriate parental self-blame can lead
to immobilizing guilt and inappropriate models of self-
blame for the child. To address parent self-blame, most au-
thors rely primarily on verbal cognitive-behavioral tech-
niques. Deblinger and Heflin (1996) encourage therapists
to elicit self-blaming attributions such as “Why didn’t I
recognize this was happening?” or “I must be a bad
mother.” They encourage the therapist to provide educa-
tional information to facilitate alternative cognitions. For
example, the therapist can let parents know that even ex-
perts cannot identify perpetrators based on everyday be-
havior and that abuse is very difficult to detect because of
the secrecy and pressure on the child not to tell. Some au-
thors use techniques that parallel those used with chil-
dren; for example, Deblinger and Heflin (1996) also use
CHILD MALTREATMENT / FEBRUARY 2002

their “Best Friends Role-Play” technique with parents,
and Hansen et al. (1998) uses a parallel “Hat Game” with
parents.
Cohen and Mannarino (1993) and Celano et al.
(1991) note that in some cases, parents may have contrib-
uted to circumstances that made the child’s abuse more
likely, and acceptance of some responsibility may be
appropriate. In some cases, parents may consider ways of
making restitution to the child. Wieland (1997) notes
that it may be appropriate for parents to apologize for
problems in the parent-child relationship that made it
hard for the child to disclose immediately, for not creating
a safe enough family situation, or for not recognizing the
child’s nonverbal ways of telling. In other cases, it may be
helpful to assist parents in distinguishing differences
between feelings of regret (e.g., for an unforeseeable bad
choice of babysitter) from feelings of responsibility
(Mannarino, personal communication, May 2000).
Child blame. To address potential child blame,
Deblinger and Heflin (1996) recommend asking parents
to identify ways that the perpetrator engaged their child in
abuse. They offer a list of ways that perpetrators engage
children to facilitate psychoeducation and discussion
(e.g., encouraging the child to think that the activity was
a game or an appropriate expression of affection, taking
advantage of the child’s eagerness to please or respect for
authority). Many parents are most frustrated by the child’s
delayed disclosure; Deblinger and Heflin encourage par-
ents to consider from the child’s point of view the many
reasons not to tell. Again, a list of reasons children may
not tell is provided to assist with reframing (e.g., they
don’t have appropriate language skills, they don’t recog-
nize the activity as inappropriate, they are embarrassed,
they fear getting in trouble or getting the perpetrator in
trouble, they don’t want to disrupt family relationships,
they are afraid of perpetrator threats).
DISCUSSION
A diverse array of attribution retraining techniques
have been developed or adapted for use in treatment of
sexually abused children. Clinical efforts to discourage or
reframe children’s self-attributions of responsibility for
the abuse have become more sophisticated since the early
days of sex abuse treatment, when clinicians tended sim-
ply to affirm that the abuse was not the child’s fault. Cur-
rent attribution retraining techniques explore differenti-
ated self-attributions of responsibility, offer several
vehicles for discouraging self-blame (e.g., story meta-
phors, games, direct discussion), and employ creative
nonverbal components (e.g., visual illustrations or music)
to make them more appealing to children. Despite the
proliferation of attribution retraining techniques, most
CHILD MALTREATMENT / FEBRUARY 2002
Celano et al. / ATTRIBUTION RETRAINING 71
are designed for use with latency-aged girls. There are
fewer attribution techniques developed or adapted for use
with boys, preschoolers, adolescents, or children from
racial and ethnic minority groups. In addition, more tech-
niques are needed for nonoffending parents, especially
given the strong influence of parent support on child out-
comes (Cohen & Mannarino, 1996a, 1998) as well as the
value of parents’ involvement in abuse-specific treatment
(Saywitz, Mannarino, Berliner, & Cohen, 2000).
There is also scant attention to the role of broader cul-
tural factors in the development, reinforcement, and
treatment of children’s self-attributions of responsibility
for sexual abuse, despite evidence that variables related to
ethnicity influence the psychological functioning of sexu-
ally abused girls (Sanders-Phillips, Moisan, Wadlington,
Morgan, & English, 1995). Furthermore, children’s attri-
butions about themselves and others often are embedded
within a social context of race, gender, or socioeconomic
status discrimination. Wyatt (1990) described how multi-
ple dimensions of victimization, including institutional
racism, parallel or amplify the sequelae of sexual abuse for
ethnic minority children. For example, a child may inter-
nalize subtle forms of racism, leading to low self-worth.
Thus, attempts to discourage self-blame among ethnic
minority children should be integrated with efforts to
build or reinforce a strong positive ethnic identity. Given
the cultural variability in family structure as well as indi-
viduals’ appraisals of and responses to specific traumatic
events, attribution training should be tailored to the
child’s and family’s cultural group(s).
Although this review has selectively considered attri-
bution techniques in isolation, virtually all authors
describe these techniques within the context of a multi-
faceted treatment program in which attribution training
is an important but probably not sufficient component.
For example, several programs explicitly target affective
symptoms (i.e., those associated with anxiety and depres-
sion) in addition to attribution retraining. In this vein,
further clinical and empirical examination of the recipro-
cal relationship between mood and attributions would be
helpful. Research is needed to determine the relative
impact of attribution retraining versus pharmacological
treatment on depression in sexually abused children.
All of the attribution techniques reviewed aim to dis-
courage self-blame and promote attributions of responsi-
bility toward the perpetrator; however, the techniques
vary along a number of dimensions, raising issues for the
clinician to consider in selecting an appropriate tech-
nique for a given child. First, the reviewed techniques dif-
fer regarding the degree of cueing used to elicit children’s
attributions. At one end of the continuum are techniques
that provide written or verbal self-attributions for the
child to consider (e.g., “Why List,” “Guilt-Free Kids”); at
the other end are techniques that use only open-ended
72 Celano et al. / ATTRIBUTION RETRAINING
questions or tasks to elicit attributions (e.g., cognitive
coping triangle, “Why Pie”). Story metaphors (e.g., “Why
Me?” “Jay’s Story”) provide some cueing in the story nar-
rative, but the clinician may not always ask children to
share their attributions about their own abuse. The heter-
ogeneity in the extent of cueing offers clinicians many
choices in selecting a technique appropriate for a given
child. Story metaphors may be a less threatening way of
exploring the child’s attributions than direct questions.
However, clinicians should use caution in implementing
story metaphors with young children before they have had
a forensic interview, as the child may confuse details of his
or her abuse with those described in the story narrative.
Techniques with considerable cueing may be helpful
for children with high levels of defensiveness, poor ver-
bal expression skills, and differentiated self-attributions of
responsibility (i.e., in incest cases). A potential drawback
of techniques employing cueing is the possibility that such
techniques could increase guilt in suggestible or concrete-
thinking children.
The techniques also vary with respect to the specificity
of self-attribution retraining. Some (e.g., affirmation
techniques) vest clinicians with the responsibility for
making a global statement such as “what happened to you
is not your own fault,” whereas others require the commu-
nication of specific reframing messages tailored to specific
self-attributions (e.g., cognitive coping triangle, “Why
List,” “Guilt Trip Game”). Direct communication that
the abuse is not the child’s fault may be most appropriate
for younger children, given their tendency to make attri-
butions of responsibility based on whether the behavior is
viewed as good or bad and to rely on authority figures for
moral guidance. In addition, young children may not have
the cognitive reasoning skills to engage in the logical
analysis of their attributions required by specific attribu-
tion retraining techniques (Friedrich, 1996). On the
other hand, a global reassurance of blamelessness may be
perceived by the child as a prohibition against sharing
self-attributions (Celano, 1992).
Older children and adolescents may benefit more from
techniques that use specific attribution retraining tech-
niques. In some cases, children who blame themselves for
the abuse are encouraged to make unstable and specific
self-attributions, consistent with the reformulated
learned helplessness model (Abramson et al., 1978;
Seligman et al., 1984). For example, a girl who blames
herself because she mistakenly let the perpetrator (a
neighborhood acquaintance) into the house while her
mother was gone can be reminded that her mistake is only
a small and impermanent aspect of herself. The therapist
might say, “You let him in because you didn’t know any
better; lots of kids would have made the same mistake.
Now that you are older and know more, you won’t make
that mistake again.” The primary advantages of specificity
in attribution retraining are (a) consistency with attribu-
tion theories, (b) the potentially increased efficacy
associated with the encouragement of alternative attribu-
tions tailored to a specific child and abuse situation, and
(c) minimization of helplessness by encouraging the child
to attribute responsibility to specific controllable factors
(Shapiro, 1995).
Most of the offender-oriented attribution techniques
reviewed encourage fairly specific abuse-related attribu-
tions, assuming that these attributions promote positive
outcomes for the child victim. However, most authors
have not explicitly cautioned clinicians about potential
dangers of encouraging global negative attributions or
expressions of rage toward the perpetrator. As noted pre-
viously, global negative attributions about an offender
may be contraindicated when the offender is emotionally
important to the child victim, especially if family reunifi-
cation is a goal of treatment. Instead, children should be
encouraged to attribute abuse to specific, unstable, and
controllable factors within the perpetrator (Shapiro,
1995) and should be helped to accept ambivalent feelings
toward him or her (Cohen & Mannarino, 1993;
Deblinger & Heflin, 1996). However, processing and
accepting ambivalent feelings may be particularly difficult
for preschoolers, who tend to perceive others in global
terms such as “all good” or “all bad” (Saltz & Medow,
1971).
Another disadvantage of global attributions of blame
toward the perpetrator is the role such attributions may
play in the potential process from victim to victimizer
(Ryan, 1989). In encouraging children to globally blame
the perpetrator, therapists might inadvertently reinforce
the child’s feelings of persecution, which may provide per-
ceived justification for retaliatory aggression (Celano,
1992) or identification with the aggressor (Ryan, 1989).
Thus, clinicians should not encourage expression of rage
toward the perpetrator, especially for children with poor
impulse control, feelings of persecution, or parents who
have difficulty teaching the children to take responsibility
for their actions. Therapists should also discourage rumi-
native anger and generalization of anger to others. For
example, an adolescent can be told that becoming “stuck”
in anger affirms the offender’s power, while getting
“unstuck” reduces the offender’s control over his or her
life.
Despite the increasing focus on therapeutic techniques
to challenge sexually abused children’s attributions, there
have been few published treatment studies using attribu-
tions as an outcome or a predictor variable. Several studies
have found that cognitive-behavioral treatments (CBT)
for sexually abused children result in better outcomes
than nondirective supportive therapy (e.g., Cohen &
Mannarino, 1996b, 1998; Deblinger, Lippmann, & Steer,
1996), which may be due to the emphasis in CBT on
CHILD MALTREATMENT / FEBRUARY 2002

addressing and correcting distorted attributions about the
sexual abuse. Celano, Hazzard, Webb, and McCall (1996)
used self-blame as an outcome measure in a study examin-
ing the efficacy of a structured treatment program based
on Finkelhor and Browne’s (1985) traumagenic dynamics
model as compared to an unstructured control interven-
tion. Both treatments decreased self-blame among low-
income, African American girls; the parallel structured
intervention for nonoffending parents was more effective
than the comparison intervention in decreasing parent
self-blame. Recently, Cohen and Mannarino (1996a,
1998, 2000) have assessed the extent to which abuse-
related attributions and parent support predict differential
response to treatment. In their analysis of factors predict-
ing treatment outcome for sexually abused preschool chil-
dren, they found that parental emotional distress was the
strongest familial predictor of child outcomes at
posttreatment (Cohen & Mannarino, 1996a), but paren-
tal support (operationally defined as high support and low
blame of the child) became a stronger predictor of out-
come at the 6- and 12-month follow-up assessments
(Cohen & Mannarino, 1998). In their treatment out-
come study of 7- to 14-year-old sexually abused children,
Cohen and Mannarino (2000) found that negative abuse-
related attributions and excessive family flexibility signifi-
cantly predicted posttreatment trauma symptoms. Unfor-
tunately, these studies have not employed the statistical
strategies recommended for testing mediated or moder-
ated effects (Holmbeck, 1997). Thus, assertions that chil-
dren’s attributions about the abuse mediate or moderate
treatment outcome await empirical validation.
Thus, there is little empirical information about the
overall effectiveness of attribution retraining techniques
with sexually abused children and their parents to guide
clinicians in their interventions. There is much need for
additional treatment research that assesses sexually
abused children’s attributions as a mediating, moderating,
or outcome variable. Further research could also address
differential treatment effectiveness according to chil-
dren’s developmental stage, treatment format, or treat-
ment modality. For example, studies could address the fol-
lowing questions: Are direct affirmations that “It’s not
your fault” more effective than specific cognitive restruc-
turing techniques with children age 7 and younger? Are
attribution retraining exercises presented in group for-
mats more effective than those presented individually?
Are techniques using arts or game modalities more effec-
tive or well accepted than verbal/written techniques?
Continued research on the relationship between parental
and child attributions is also needed. Finally, single-sub-
ject and qualitative research designs may be helpful in
investigating some of the more subtle issues in this area,
such as the impact of wording (e.g., blame versus responsi-
bility), the relationship between self-blame, family-blame,
CHILD MALTREATMENT / FEBRUARY 2002
Celano et al. / ATTRIBUTION RETRAINING 73
and perpetrator-blame, and whether situationally specific
self-attributions are adaptive in some circumstances.
NOTE
1. The terms self-blame and internal attribution of responsibility
are used interchangeably in this manuscript. Similarly, perpetra-
tor blame and attributions of responsibility toward the perpetrator are
considered synonymous.
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tifying dimensions of victimization. Professional Psychology: Research
and Practice, 21, 338-343.
Marianne Celano, Ph.D., is a licensed clinical psychologist on the
faculty in the Department Of Psychiatry and Behavioral Sciences at
Emory University School of Medicine. She has participated in an
empirical outcome study of a structured treatment program for sexu-
ally abused girls and their nonoffending mothers. She has also con-
ducted regional and national training workshops on treating sexually
abused children and their families. She has published several articles on
child sexual abuse, cultural issues in professional practice, and pediat-
ric asthma.
Ann Hazzard, Ph.D., is a licensed clinical psychologist on the fac-
ulty in pediatrics at Emory University School of Medicine. She has
directed a federally funded clinical research project on a sexual abuse
prevention curriculum and a state-funded program evaluation of a
structured treatment program for sexually abused girls and
CHILD MALTREATMENT / FEBRUARY 2002

nonoffending mothers. She has published numerous articles related to
abuse in professional journals and provides training and supervision
about sexual abuse sequelae and treatment, play therapy with chil-
dren, and cognitive-behavioral treatment approaches with families.
Susan K. Campbell is a licensed psychologist who has studied and
worked in child sexual advocacy center settings and is currently clini-
cal director of the Georgia Center for Children, which serves sexually
abused children and child homicide witnesses in Atlanta. She oversees
the clinical, forensic, and training components of this program. She is
involved in research efforts with local universities and provides agency
consultation, training, and expert testimony on a statewide level.
CHILD MALTREATMENT / FEBRUARY 2002
Celano et al. / ATTRIBUTION RETRAINING 75
Claudia B. Lang is a licensed clinical psychologist in private prac-
tice and at the Marcus Institute for Development and Learning at
Emory University. From 1995 to 1997, she was the clinical director
of the Sexual Abuse Trauma Clinic at the University of Miami School
of Medicine. Currently, she performs evaluations and therapy for
children with developmental disabilities, learning disabilities, attach-
ment disorders, and sexual abuse. She has published in the areas of
maternal depression, attachment theory, autism, and sexual abuse.