Adult Analysis and Childhood Sexual Abuse

Howard B Levine

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780881630831
• eBook ISBN: 9781317714552
• Edition: 1
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Following a case study approach organized around the psychoanalytic process, this book addresses clinical issues that arise in analytic work with adults who were sexually abused as children. Special emphasis is given to the way in which childhood sexual trauma affects the treatment process and influences the contents and quality of transference. Contributors also focus on the formation of the therapeutic alliance, countertransference issues, and disturbances in ego functions.

Clinical Considerations and Psychoanalytic Process

4	Technical Issues of the Opening Phase David L. Raphling

The initial phase of psychoanalysis with an adult patient whose background includes a childhood or adolescent history of incest assumes, as in all analyses, a distinctive pattern derived from the unique combination of analyst and patient at work. The psychoanalytic situation, though utilizing a standard and fundamental method and procedure, is ultimately influenced by the patient’s personality and psychopathology, as well as by the analyst’s own psychology and his theoretical and technical biases. The product of these factors in any given analytic dyad will determine how and when the analytic process will be initiated. The effect of incest trauma on personality and psychopathology can range from minor disturbances in function to severe psychic disorganization. Some incest victims with perilously weakened mental structure bring to the opening phase much less potential for engaging the analytic situation than do others whose psychic structure and function may have been less disturbed.

Sexually abused patients often enter analysis with more trepidation than do other patients because their traumatic life experiences have alerted them to danger and sensitized them in the sphere of intimate relationships. The regression necessary for free association within the analytic situation requires suspension of censorship and relaxation of certain ego controls and defensive postures. This relaxation can be accomplished by the patient only in an atmosphere of trust, where uncertainty and ambiguity can be experienced and tolerated with a prevailing sense of security. The strain on their ability to partially abrogate their habitual protective stance and defensive strategies for the purpose of psychoanalytic inquiry is particularly great for patients whose bodily integrity, autonomy, and sense of self have been violated in incestuous relationships.

Patients with a background of incest enter analysis for a variety of reasons. At one extreme, certain patients begin analysis without any memory of past incestuous experience, whereas others’ sole conscious impetus for analysis stems from having endured sexual abuse. Patients for whom the incest barrier has been transgressed view the often desperately needed treatment as a possibly devastating repetition of the trauma; they believe that in any situation incestuous fantasy may again become reality. The motivation for treatment may be impaired in those for whom childhood incestuous experience was registered and elaborated as a traumatic psychic reality. These patients are reluctant to engage in a procedure that threatens to revive events whose intrapsychic meaning may have had a powerful, and often profoundly damaging, effect on their psychic integrity. Resistance is especially noticeable when features inherent in the analytic situation or those created through fantasy enactment by the patient seem to mirror closely any aspect of the original traumatic experience. For these patients, the decision to embark on analytic treatment carries with it a certain sense of danger that looms as the background of the opening phase and beyond.

CASE EXAMPLES

AV, a 40-year-old single woman, sought analysis for severe depression and began work with a female analyst. She had been severely traumatized during her prepubertal years when her father touched her breasts and repeatedly urged her to fondle and suck his penis. The patient began analysis feeling helpless and anxious. She actively sought protection and support from the analyst, whom she idealized as a nurturing figure. The patient’s dependence on this idealized image of the analyst reflected her wish and need for an unambivalent relationship with an available maternal figure unlike her own alcoholic, depressed mother. Her mother was an unreliable caretaking figure, who may have encouraged her husband’s incestuous activity with the patient. AV had looked in vain to her mother for protection from her father’s seductive and abusive behavior. She encountered, instead, unpredictable maternal behavior: emotional unavailability and an irrationally critical attitude. It soon became clear, however, that the most crucial aspect of her need for the analyst to protect her from images of her abusive parents was a deep mistrust of her own part in the incestuous behavior. She indicated this mistrust by looking to her analyst for approval of her choices of men to date and permission to become sexually involved with them.

Hatred of both parents and an enormous fear of punishment as a consequence of incestuous involvement appeared as frightening to her as her forbidden sexual wishes. The danger of her destructive impulses prompted her defensively to idealize the analyst and to use splitting to maintain an “all good” image of the analyst early in the analysis.

It was not long before the analyst became the focus of the patient’s erotic sensitivity as subtle but unambiguously sexualized derivatives of the idealizing transference emerged in the form of an intense curiosity about the analyst and intrusive attempts to befriend her outside the confines of the analytic setting. Defensive regression to preoedipal wishes emphasizing nurture and support then became more evident as these incestuous strivings produced anxiety and depressive affect.

The patient’s seductiveness was apparent in the opening phase as she attempted to go beyond the limits described by the analytic situation. She was able to stimulate the analyst’s interest in the graphic details of her incestuous experiences enough so that the analyst’s aroused curiosity triumphed over evenly hovering listening, and temporary lapses of neutrality occurred. She found the analyst’s probing sexually stimulating, and she was excited by the analyst’s occasionally sharp reactions to teasing and intrusiveness. Her wish for sexual gratification from the analyst, however, conflicted with her need to make certain that she was safe with an analyst who, unlike her parents, could resist her seductive pressures.

Another woman, BD began analysis with me soon after a long and largely satisfactory period of analysis with a female analyst ended when the patient moved from another city to take advantage of a professional opportunity. BD had been fondled and masturbated by her mother until age 14 “for as long as I could remember.” She had been in casts for her first year and a half or two years for a minor congenital deformity of her lower extremities. The caretaking requirements of this situation became an early focus of her mother’s preoccupation with her body, a focus that later became frankly sexual. The mother’s intrusive concern with the patient’s bowel habits and general hygiene showed itself through enemas and manual manipulation of anal and genital orifices in the name of cleanliness. This manipulation, and the later masturbation, caused BD to feel as if her mother “possessed” her body, which she could not “own” herself. She felt that her mother had invaded her mind as well as her body. Mother’s sexual interest in her, however, alternated with utter rejection, which often caused her to feel that she did not even exist apart from being an object of her mother’s sexual exploitation. Although she had been passive in relation to the repeated sexual stimulation, and enraged and deeply resentful of her mother for it, she had discovered in her previous analysis that she had also sought out and enjoyed the incestuous sexual contact.

Having difficulty working out the logistics of scheduling and fees, BD began her analysis with a great deal of resistance. She very much wanted to begin the analysis, but this venture stirred up her anxiety and, with it, reactivated her dependency on her first analyst, whom she again consulted. At first she could attribute her anxiety only to being “uncomfortable” with me “for some reason.” Each session made her stomach rumble audibly, which embarrassed her and had never occurred in the previous analysis. She was not sure she could trust me even though I did not actually appear to give her cause for concern.

From the first, BD acted almost inappropriately friendly and always greeted me with an innocent but enigmatic smile that seemed simultaneously to express and to belie her apprehension. She realized that she had been thrown off balance by me because, unlike her first analyst, I was a relatively young-appearing man toward whom she could be physically attracted. Though this realization threatened her, she was also conscious of how attractive she might be to me and appeared freshly made up and perfumed for her sessions. Her smile began to lose its innocence and became seductive. On entering and taking leave, she stared at me intently and several times asked why I had such a “strange” look. Inquiry revealed that strange meant sexual, which was exactly what her own staring and smile had seemed to me. I raised the possibility that she was unwittingly reading into her perception of me something of her own expression. She acknowledged having had a sexual interest in me from our initial meeting and was quite possibly looking at me in a seductive way, but she could not shake the idea that there was “something” about the way I looked at her. As a consequence of this interchange I became more conscious of how I looked at her and realized that I had been drawn into looking at her more closely than is usual for me. She feared she had been sexually provocative without realizing it when I acknowledged that indeed I must have been staring at her. She said that she had been having conscious sexual fantasies about me, something she had never encountered with her female analyst. BD had felt safe from sexual interest in her first analyst, though she did not know why, considering that her incestuous involvement had been with a woman.

She briefly developed a stiff neck, which she attributed to restraining herself from looking at me, though this symptom had other, deeper meanings related to her feeling of having been used as a phallus for her mother’s pleasure. She later connected the stiff neck with memories of her legs in braces when her mother began to molest her. She had a fantasy of me undressing her, medically examining her neck, and touching her in ways that would be sexually arousing. BD believed she must explore these fantasies and feelings to complete the analytic work begun with her first analyst. I realized that she also imagined this sexual material would intrigue me. But she feared the associative process would lead to a loss of control and said, “Whenever I let my sexual feelings be known to mom, she took me up on them.” I interpreted to her that the conscious memory of her mother’s seduction was less threatening at the moment than what she now wished to avoid—the possibility of seducing me.

From the beginning of the analysis, BD frequently interrupted me when I intervened with interpretations. It now became clear that my interventions, like her mother’s sexual advances, seemed exciting, but “scary,” because they were not under her control. She was not aware of feeling angry even when she experienced my interventions as intrusions that diminished her seductive power over me.

As the analysis progressed we learned that BD’s almost immediate, somewhat exaggerated sexual interest was also a reaction against having hostile impulses toward me that were instead displaced to her current boyfriend.

Projective mechanisms and ambiguity concerning the internal versus external origin of transference wishes and superego criticism in the opening phase were even more pronounced in another patient, CW, whose difficulty differentiating aspects of self from object directly reflected her suspicion of having been sexually abused by her father during childhood. Though she was convinced of this, she had no conscious memory of any incestuous experiences. The patient did not mention the possibility of paternal incest until treatment was well underway. She was ashamed of having such an idea, especially if it were untrue. She would then really have to view herself as “perverse.” On the surface she minimized the notion that incest could have actually occurred, and she began exploring unconscious conflicts activated by her recent marriage. She had initially sought psychotherapy some months prior to her wedding because of trepidation about marriage. After a brief period of dynamic psychotherapy, we agreed that psychoanalysis would be the best treatment for her. She had been in therapy with a female analyst since late adolescence, when she was in turmoil, became pregnant, and was experimenting with drugs. She stated that she had successfully avoided discussing sexual matters with her analyst and, as far as she could remember, did not mention the possibility of having had incestuous experiences.

This topic came up when in the course of our work CW began to feel “intimidated” by me to a degree that she realized was exaggerated: she had a persistent feeling that I would find her attractive and want to take advantage of her. She felt that I, and other men in her life in positions of authority, had sexual designs on her; and though she realized this could not possibly be true, she still felt anxious around me and other men. She was aware of feeling attracted to me and acknowledged fantasies of allowing me to seduce her. Meanwhile she struggled with ambivalent feelings toward her husband, who she feared was “a wimp” and perhaps homosexual, definitely neurotic, and self-centered. CW felt that her husband’s treatment of her was erratic: he could be close and warm with her one minute and cold, critical, and rejecting the next. In sexual relations, she often felt he was using her for his own gratification without regard to her feelings.

CW would come for most of the hours in a state of agitation and tears. She was feeling like a helpless victim, at the mercy of her husband, others at work, and her family, who she believed were directly critical of her or made disparaging remarks about and references to her. She wanted to look within herself for the source of her marital problems (if for no other reason than to please me), but she was convinced that her husband was largely to blame. She complained that I, like everyone else, doubted that her father had abused her. I interpreted that now she could feel similarly abused and denied by me if she thought I did not believe her. While privately considering how her insistence on a traumatic event could prove to be a resistance to analyzing intrapsychic motives, I maintained an inquiring attitude, believing everything and believing nothing regarding the possibility that paternal incest had actually occurred.

CW’s father had been a victim of incest himself. He had been sexually molested by his paternal grandfather at the age of 12 and was then sent away by the family to boarding school. He was severely depressed and a chronic alcoholic during CW’s childhood. He had been devastated by the birth of a congenitally deformed son born six years after CW and had divorced her mother two years later. The father died of alcoholic cirrhosis when CW graduated college.

As she spoke of her father on several occasions during hours, CW’s eyes began to tear, but in the absence of emotion. This occurred once when she was recalling a dream of the previous night “of a man who gets into the house and is under the bed. He has broken in, but also he had the keys and that was how he got in. He was scuzzy—but then he seemed very nice. When he leaves I get new locks for the doors.” This dream reminded her of another dream, of a man breaking into their house through the window. The house in the dream was her father’s, where she visited him after his divorce from her mother when the patient was eight. “The man seemed cuckoo brained. What an odd, juvenile expression, but that’s what came to mind.” “Cuckoo brained” meant that “he acted unpredictably: nice one minute and disgusting the next. It makes me sick to my stomach: like throwing up. Somehow we were at a table eating. I don’t understand. Mother was in the background.” She said her father was unpredictable, out of control when drunk, usually passing out. She recalled having driven across an icy bridge in winter fearing that she would lose control and surprising herself by crying aloud, “I won’t tell.” She now wondered if this referred to something illicit with her father. She felt that her husband used her for sex. Sex smothered her. She felt repulsed and disgusted as she did in the dream. In the next hour she had an image of a threatening man standing behind her with an erect penis. This led to feelings of being trapped, of grossness, and a flash thought of performing oral sex on me. This and other material certainly made consideration of actual paternal incest plausible, though she has not yet uncovered any memory of incest.

DISCUSSION

The opening phase of analysis is literally an introduction. It is a joining of two strangers in a shared experience of growing intimacy in which they are bound at the end to become more intimate strangers. From the beginning, they want to know everything about one another. Though the patient looks to psychoanalysis as a way to achieve profound self-knowledge, she also strives to know more of her analyst. This need to make out the analyst behind his screen of anonymity, a powerful motive for all patients, is absolutely compelling for a patient whose parents directly or indirectly violated an intimate relationship by permitting incestuous fantasies to become realities.

For abused patients there is a blurring of distinctions between important aspects of self and other (Kramer, 1983), between instinctual wishes and seductive external pressures, and between guilt and innocence (Shengold, 1980). Patients bring to their analyses the atmosphere of ambiguity, denial, and distortion in which incest was consummated. They confront these dangers in the opening phase with anxiety, mistrust, hypervigilence, and even hostility toward the analyst, though they hope for the protection and support of a benign analyst whose image will contrast with those of both the abusing parent and the parent who failed to shield them from abuse (Steele, 1986). In the introductory phase, patients need to assure themselves of the analyst’s respect for their psychic and bodily integrity. As in all analyses, the basic conditions for this assurance and protection are the analyst’s nonintrusive empathic inquiry and his cogent, well-timed, appropriate interpretations. On occasion, however, these conditions alone are not sufficient for patients otherwise deemed suitable for analysis to overcome their apprehension concerning the dangers aroused by beginning analysis. They may require some modification of the analyst’s technique in order to establish an analytic process.

Patient BD’s previous analyst had established her analytic sessions on a thrice-weekly schedule, which the patient has been unwilling to change in her analysis with me. This resistance reflects the many conflicts stimulated by havi...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• Contributors
• Introduction and Overview
• Clinical Considerations and Psychoanalytic Process
• Issues of Technique
• Author Index
• Subject Index