Enduring Trauma Through the Life Cycle

Eileen McGinley, Arturo Varchevker, Eileen McGinley, Arturo Varchevker

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429913266
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This is a multi-authored book on the complex subject of psychic trauma as encountered at different stages of the life-cycle, and describes some of the clinical challenges, technical issues and differing theoretical approaches that arise when working with the traumatized individual.The concept of psychic trauma is a complex subject, but one which has more recently gained prominence. This book contains a collection of papers which grew out of a series of talks given by the Psychoanalytic Forum of the British Psychoanalytical Society entitled Trauma Through the Life Cycle. The authors, all highly respected authorities in their fields, give insights into what we mean by psychic trauma, what constitutes a traumatic event, and the psychopathological sequelae to trauma at different stages of life. Judith Trowell and Nick Midgley look at the effects of infantile and childhood traumas. Catalina Bronstein and Sara Flanders, from differing psychoanalytic perspectives consider how childhood traumas can become reactivated in adolescence and colour subsequent developmental situations.

Part I
Childhood

CHAPTER ONE
The emotional impact of abusive experiences in childhood, particularly sexual abuse

Judith Trowell

In the late 1970s and early 1980s, the occurrence of childhood sexual abuse began to be widely recognised. The Cleveland Inquiry report was published in the United Kingdom in 1988, and in this Lord Elizabeth Butler-Sloss confirmed that sexual abuse did indeed occur and existed. Until then, many in society did not believe this to be so. What is important is to ask whether it matters that sexual abuse actually happens to children. We know about the Oedipal conflict and the enormous power of the associated phantasies. But the actual physical enactment of the act of adult-child sexuality—masturbation, oral, anal, or vaginal intercourse, and then all the various other sexual acts some children experience—is a very different psychological trauma from the effect of phantasy. Violation of the actual body, and the accompanying threats to ensure silence and secrecy, are damaging in a way that differs from phantasies. The fear of violence and the actual violence that so frequently accompanies the abuse are also very different from the phantasy of destruction of murderous rage.

We have become much clearer about the problems and behaviour associated with childhood sexual abuse. Beitchman and colleagues have undertaken two extensive reviews. The first (Beitchman, Zucker, Hood, Dacosta & Akman, 1991) looked at forty-two different studies to draw out the short-term effects; the second (Beitchman, Zucker, Hood, Dacosta & Akman, 1992) reviewed the long-term effects. These effects have been summarised by Cotgrove and Kolvin (1996) as four main long-term associations with child sexual abuse:

1. Psychological symptoms consisting of depression, anxiety low self-esteem, guilt, sleep disturbance, and dissociative phenomena,
2. Problem behaviours including self-harm, drug use, prostitution, and running away
3. Relationships and sexual problems—social withdrawal, sexual promiscuity, and re-victimisation.
4. Psychiatric disorders, particularly eating disorders, sexualisation, post-traumatic stress disorder, and borderline personality disorder.

We have also become increasingly aware, as the children and adults abused as children have been able to speak about their experiences and seek help, that the therapeutic work needed is very complex and difficult. In order to understand and think about the emotional impact of this abuse and how to work therapeutically, we have learned that it is vital to draw on the understanding of child development and of sexuality and aggression that is central in object relations psychoanalytic theory. Psychoanalytic theory has a significant contribution to make to the work—in particular, the understanding of transference, countertransference, and early mechanisms for trying to manage intense feelings such as splitting, denial, projection, and projective identification—because they are used so extensively by these individuals and their families.

Child sexual abuse

Sexual abuse is defined in the United Kingdom by the Department of Health (Schechter & Roberge, 1976) as "the involvement of dependent developmentally immature children in sexual activities that they do not truly comprehend and to which they are unable to give informed consent, and that violate the social taboos of family roles".

In this chapter, what is being considered is contact sexual abuse, which means that the child or the adult as a child has touched or been touched by the abuser. The acts have been kept secret and may involve bribery, threats, or violence, and some children may have been involved in multiple sexual abuse with groups of children and adults. The abuse may have occurred once or lasted over a period of years with variable frequency.

It is important to always remember that sexual abuse is riot a psychiatric disorder, it is a psychosocial event, and the mental health sequelae vary from individual to individual. What to us seems horrendous abuse may not profoundly impact on the survivor; lesser abuse may leave the victim very damaged.

Assessment

When we started work in this area, we mainly saw adolescent girls and women abused as children. Over the years, we have seen more and more younger children, down to 6/12, and more boys and men abused as children or adolescents.

The only definite diagnosis is made when semen or seminal fluid is found. So most abuse is diagnosed on the balance of probabilities. The child bleeding from the anus or vagina, or bruising in the area, are pretty clear signs. Colposcopy can be used and this may show signs invisible to the naked eye. However, most cases are diagnosed on the basis of the history and the interviews with the individual.

Adults can recall abuse, and often siblings or friends can corroborate events. A man in his fifties recently talked to me of abuse lasting several years by his older brother's best friend. The friend used to offer to read a bedtime story and abused him. But back then, he felt special, "the chosen one". Only later did he realise. Of course, there are no physical signs in these retrospective accounts, but often others can confirm.

One needs to be careful, given the "false memory syndrome", regarding an individual who has become convinced they were abused. Such individuals often have no corroborating details, and this arouses my suspicion. Survivors talk of gazing at the ceiling and describe the lights or the wall covering, the situations where it occurred, floating out of their bodies arid looking down. There are usually some details that imply an authentic account.

Adolescents can be very vocal about what has happened but suddenly embarrassed to give precise details. They can sometimes draw or tell it in the third person—as a story. We have learned over the years that most assessments only reveal a small amount of what really happened; a fuller account emerges later in treatment.

Children and adolescents need to know that the therapist can bear to hear it. Often, we say, "other boys and girls have told us that bad things happened to them, they were touched in private places, or made to do things they didn't want, has this ever happened to you?"

I have assessed many individuals, but also had to assist in Ireland in an extensive way in a case in which many children were involved. I also went to Orkney where there were fifteen children potentially abused, and have been leading teams working with boys from a church choir and two boys' special church residential schools.

Many of these young people have been terrified to talk, and most only allow glimpses of what has occurred. Later, they report it takes six months to a year before they really dare trust anyone.

However, one has to make some judgements, and generally we give up to four sessions and the individual can in that time convey enough. Often, when seen in a group, they can talk more. But if one is aware there may be court proceedings, group interviews are not permitted. Small children often need a "safe", trusted person with them or just outside the door, to speak. We have reasonable accounts from three-year-olds.

But one must always bear not knowing and that, for many, uncertainty remains. More and more assessment interviews must not be allowed. I use dolls (pipe cleaner), play dough, cellotape, felt tips and paper, small animals and string, whether with children or adults. They need to be doing something and cannot just sit and talk.

This whole internal ferment is going on for the child around each significant relationship. The child, not surprisingly, becomes very confused. They have to make sense of real experiences of loss and separation, and at the same time be trying to adjust to their present set of relationship standards, expectations, and do all the mental work of appraising their internal representations, real or fantasy. Not surprisingly, many of them do not have the mental or emotional energy to do this.

Identity is based on these internal representations. Older children, despite being relieved to be away from the external reality of their home, carry it with them in their minds. All of them may have to settle for either siding with and idealising the internal representations of mother or father, or rejecting them and living in fear of retaliation, retribution, and intense feelings of disloyalty.

Interventions

We concluded from our work that the individuals, children or adults, need a menu of treatments. Debriefing does not seem to be helpful—the belief that it must be talked about. Some individuals need to talk—some flood one with it and have to be helped to slow down and reflect. Others do not want or cannot talk; to force them is wrong. Some need help to manage themselves and their behaviour, some need medication initially for depression or post-traumatic stress disorder. Art or music therapy may be helpful.

What is so important is, when they are ready, to offer help for the deep emotional pain, confusion, and distress. Psychoanalytic work is vital to help them recover, because the emotional impact of the abuse is like an intra-psychic abscess that poisons all aspects of the individual's internal life. We cannot cure them, they will be left scarred, but the wound can heal; it does not need to be a raw, suppurating wound.

Many such patients start once weekly terrified of being in a room one to one. Gradually, frequency can be increased. Some manage a group, and from every group of six, then two or three need individual work. The families or partners of patients need help also, as there are consequences for them, and there may also be issues raised from their own pasts.

Psychological sequelae of sexual abuse

There is a persistent and frequently unresolved question: has abuse occurred, is it real—reality—or is it imagination, or is it some form of phantasy, conscious or unconscious? Is it possible to understand this? Trying to understand childhood trauma and its impact on thinking and memory, we have to consider post-traumatic stress disorder (PTSD), some features of which are applicable to child sexual abuse. In PTSD, there can be flashbacks, the person is awake, conscious, and is suddenly dramatically and vividly back, in the mind, in the very stressful situation, re-experiencing the events. Also they can have flashback dreams, in which they dream the re-experiencing, and if they awake during this "action-replay" dream, their confusion and distress is even greater than with the awake re-experiencing. Experiencing a flashback, being able to distinguish phantasy from reality when the phantasy had, in fact, been a real experience, is very distressing.

But there are other features of PTSD that also need to be considered and can be helpful in understanding why children, or the child inside the adult, function in the way they do after traumatic experiences. Part of PTSD is what is known as psychogenic amnesia—the memories are pushed out of consciousness. This may be done so successfully that individuals are aware there are things that they cannot remember, but they do not know what those things are. Alongside this goes an inability to concentrate, a lack of emotional involvement, a loss of liveliness sometimes described as feeling of numbness. It is not surprising, therefore, that individuals appear to be confused and uncertain about what has happened to them. It is also not surprising that their emotional reactions may be rather flat, that they do not show the level of distress or anger that might be expected.

It is easy to understand how rather flat accounts that do not have great detail in them lead to questions about whether the abuse occurred or not. Why it is so difficult to confirm or refute abuse in the absence of physical signs begins to make sense; the difficulty of staying with the uncertainty as far as the legal system is concerned is a large part of the problem. Post-traumatic stress disorder also involves avoidance and dissociation. The abuse victim appears to be somewhat vacant or blanks out, will pause and then change the subject completely during an interview. This is partly conscious avoidance but also seems to be a process occurring in the preconscious or the upper levels of the unconscious. Memories and experiences that are too painful and distressing are blanked out, and the individual becomes very adept at doing this so that the interviewer may hardly notice the pauses and the switches in themes or diversions.

But PTSD does not explain why sexually abusive experiences cause so many difficulties. Psychoanalytic theory is needed to try to understand the persistent and long-term problems.

Childhood sexual abuse can be seen as the abusing adult's "madness" being forced into the mind of the child, and it penetrates deep into the unconscious: the child's mind is "raped". The mental mechanisms used to deal with the overwhelming trauma are splitting, denial, projection, projective identification, introjection (introjective identification), and manic flight. Experiences, thoughts, feelings are split off; they may then be projected or they may be denied. Understanding these processes and the phantasies that accompany them is crucial in the understanding of childhood sexual abuse.

One of the things that seems to happen in sexual abuse is that the split-off denied experience forms a bubble, which can become encapsulated, It may be a very small bubble if it was an experience that did very little damage, or it may be a very large bubble if there was major emotional/psychic trauma. This bubble may then sink—a denied split-off fragment that, like an abscess, can give off undetected poison—and the person may be impaired in a number of ways: their learning capacities, their capacity to make relationships, or their complete hold on reality. Alternatively, the split-off experience, the encapsulated bubble, may be quite large and encompass quite an area of mental life and functioning and cause considerable impairment. The impairment may be significant in the area of learning, in developing relationships, or on the individual's hold on reality, but for all of them there is impairment, a block on their normal development.

If the individual has had good-enough early experiences and their development had been proceeding satisfactorily, then the abuse and its resulting split-off and denied aspects can be dealt with using displacement, disavowal, or dissociation; in a way, the child gets on with their life, and it is as if the abuse never happened. But the protective processes may fail at some point, and then awareness re-emerges: for example, when trying to make intimate relationships, when pregnant or giving birth, when their child is the age they were when the abuse took place, or during the course of seeking help for something altogether different.

Where the abusive experience was extensive and early childhood experiences were not good enough, then the split-off, denied abusive experiences seem almost to take over the whole person, leaving very little mental or emotional energy available for current life. Unconscious phantasies dominate and spill out in bizarre and disconcerting ways, for the individual and for those around them. It appears that the individual is using projection and projective identification as a means of struggling to return to some psychic equilibrium. The individual can go on to become a borderline personality or to be overtly psychotic; the ability to establish relationships and the capacity to function can be very limited.

Some clinical examples to illustrate the therapeutic intensity of the work with an abused child

“Phillipa”

Phillipa, an early adolescent aged fourteen years, was referred by an outside psychiatrist for treatment; she was doing extremely well at school, spending hours there, and was reluctant to leave to go home. She was very small arid uncared for but was very friendly with teachers; child sexual abuse was discovered when she talked to the deputy head, saying her father came to her room at night.

She was the eldest of three children, with a younger brother and then a sister. Since her sister's birth, when Phillipa was five years old, mother and father had been having problems. Mother adored her younger brother and sister. Phillipa had to help in the house, run errands, and give father his meals as her mother was busy with the other two children. Phillipa was very fond of her father; her father began to cuddle Phillipa a lot, then to visit her bedroom for cuddles, then to get into her bed. They had intercourse; at the start, this was anal and was then vaginal for about the last three years.

The therapy

Phillipa was fostered by a teacher at school. She was very angry: "Why do I need to come? I only come because I'm made to. What do you know? What could you do—nothing. You haven't been abused—have you." I was totally useless, there was no point in her coming. In spite of ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ABOUT THE EDITORS AND CONTRIBUTORS
• INTRODUCTION
• PART I: CHILDHOOD
• PART II: ADOLESCENCE
• PART III: ADULTHOOD
• PART IV: OLDER AGE
• PART V: TRAUMA AND THE COUPLE
• PART IV: TRAUMA AND SOCIETY
• INDEX