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Ethical Boundaries: Treating Childhood Sexual Trauma
Childhood Sexual Trauma continuing education addiction counselor CEUs

Section 20
Boundaries & Recovered Memories of Abuse

CEU Question 20 | CEU Test | Table of Contents | Child Abuse
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

Before presenting some clinical material from an adult patient, it may be useful to bring together some thoughts and observations about the effect of child abuse on children, from the Cassel setting, in order to provide a backdrop to the more traditional psychoanalytic work. There is now considerable evidence from clinical and research findings (see, for example, Bentovim et a!., 1988) to show that the effect of sexual abuse, usually involving genital and/or anal penetration, has lasting effects on the child's developing mind and personality, including the production of wide-ranging behavioural, emotional and learning difficulties. Psychosomatic symptoms, over-preoccupation with sexual matters, inappropriate sexual behaviour and aggressive behaviour can occur in those severely and persistently abused. In adolescence, sexual abuse can be associated with anorexia, attempted suicide, self-harm, prostitution and long-term depression. Increasing evidence of previously undisclosed sexual abuse is being discovered in the population of psychiatric patients. I have seen several women who seemed normal until the birth of their first child, when memories of their own child abuse has suddenly flooded them once they were faced with the reality of their own vulnerable child. It can be quite difficult to define what is specific to the effect of abuse on the child and subsequent adult in these situations; but what seems to stand out is that the victims of abuse vary greatly in the way that they handle the trauma, depending on the severity of the abuse, the nature of the family relationships at the time, the temperaments of the children, and their capacity for resilience. The abuse can be dealt with reasonably effectively, or it can be encapsulated or compartmentalized within the person's mind, with varying subsequent effects, or it can have a massively damaging effect on many aspects of the personality. The latter situation tends to be seen in the population admitted to the Cassel Hospital, with less global damage in those seen in psychoanalytic practice. However, what is common, though perhaps obvious, to all these abusing situations, is that not only has the child's body been used and abused as a mere object by another (usually an adult, but sometimes another child), but that the child's mind is also affected, and may have great difficulty in being able to function effectively. Quite how it is affected may well vary greatly, and we still know little about what happens. Learning problems, with impairment in the capacity for symbolic thought, are common. Formal research at the Cassel on the abusing parents who have abused their children has so far shown that often on admission they reveal great difficulties in their capacity to reflect on their past and present experiences. Those parents who improve during treatment show a changed capacity for self-reflection and this seems matched by their improved relationships with their children. Clearly, then, the abuse has major effects on the capacity of the mind to remember the past and to make emotional sense of experiences.

It would seem that what can be damaging is the merging of the damaged adult's mind with the vulnerable and immature child's mind, where there has been an active intrusion into the child's bodily and mental boundaries. Laplanche (1987) has emphasized that there is always a seduction by the adult of the child, as the child is relatively helpless and immature at first and has to confront the adult's mind. His notion of a primary seduction has, however, nothing to do with a sexual assault. Primary seduction describes a situation 'in which an adult proffers to a child verbal, non-verbal and even behavioural signifiers which are pregnant with unconscious sexual signification' (p. 126).

Though the child is, of course, immature, nonetheless the kind of evidence now coming from child development research (see, for example, Stern, 1985) shows that infants are in many ways exquisitely adapted to their situation, that of actively and even creatively eliciting care from the parent. Babies are very active, aware of their surroundings, and constantly making sophisticated discriminations about their caretakers. They even seem to learn through their emotions and through their relationships. Learning takes place through shared affect in the context of a relationship, one in which the baby is not some passive and helpless partner. For example, experiments closely observing mother-baby interactions show that the baby's reactions are imitated by the mother, as much as the baby imitates her. That is, the baby conveys meanings to the mother as much as the mother conveys meanings to the baby.

However, Laplanche emphasizes how the adult unconsciously conveys sexual meanings, which the baby cannot yet adequately comprehend and, in this sense, there is seduction. Presumably, if there is then an actual seduction of the growing child, then there is damage to the quality of the child's subsequent relating, and an impairment in the capacity to deal with the signifying environment.

The children at the Cassel Hospital often seem haunted by their abuse and unable to free themselves from its consequences without considerable help. As others have repeatedly observed, such children often show a number of pathological features. For example, they may be unable to concentrate on a task for long; appear over-stimulated with poor impulse control; have a haunted and driven quality in their relating and a tendency to be aggressive and testing of boundaries; they sometimes show inappropriate sexual behaviour; they may go in and out of confusional states when they become very anxious, particularly about being abandoned; they have difficulty in trusting adults; and, in more ordinary terms, they can be very intrusive and irritating in their behaviour. The parent-child relationships are usually pathological, with varying degrees of disorganized attachment patterns. There is often role reversal, in which the children try to control the parent and are over-solicitous, while the parents have problems in maintaining ordinary child-adult boundaries. The children may have a build-up of emotional tension with which the parent cannot deal, which then leads to an outburst of frustration and despair. These episodes may be accompanied by the projection of primitive fantasies between child and adult, in which there is a mix-up of child and adult elements. The children may be confused about their own identity and also trying to expel the 'malignant' projections coming from the adult. This kind of repetition may be evidence of an earlier failure to help the children build up integrating experiences.

A frequent simple finding in the parents is that they consistently show great difficulty in being emotionally attached to their children, with inhibition of the capacity to play. They are often inconsistent, at times cut off and self-absorbed. Suicidal feelings in them may be triggered off by the threat of experiencing vulnerability. Acting rather than understanding is a common means of communicating for both parents and children, which often makes the treatment of both very demanding and at times exhausting. This is particularly the case when the staff may have to be the ones who feel the child's pain and vulnerability for the parent. There often seems to be a need for the children to make a particular kind of powerful emotional impact on their parents and other caretakers, especially when the parents are impervious to the child's emotional needs. The children may be trying desperately to get the parents to acknowledge their needs, while also attacking them for having failed them. Many of these children have had to suffer in solitude, and have had to bear, on their own, horrific experiences.

It may be unlikely that a severely abused child will end up in later life in psychoanalysis, as desirable as it may be for them to have such help. The abused adults one tends to see in analysis have somehow managed to wall off their traumatic experiences to a greater or lesser extent, though these experiences usually remain essentially unresolved. This is not to underplay the horrors of their own experience; but they have tended either to be particularly resilient personalities, and/or to have had some reasonably good early caretaking. One may wonder, what is the effect on the mind to have to keep such experiences walled off or hermetically sealed? One consequence may well be that certain 'imaginative' elements of mental life, such as dreams and fantasy life, may also have a sealed off and unavailable quality to them. These elements may be felt as persecuting or as almost inanimate objects, split off from the rest of the mind.

Research at the Cassel Hospital has, so far, indicated that adults who have had abusing experiences in childhood and who respond to these experiences by an inhibition of reflective self-function are less likely to resolve their abuse, and are also more likely to manifest borderline pathology (Fonagy et al., 1996). Their diminished capacity for self-reflection seems to make them unlikely to seek the kind of self-reflective help offered by psychoanalysis; instead, they will look for environmental solutions to their difficulties. From the effect of our treatment programme, the indications are that if the abused child or adult has access to a relationship which can help them deal with the emotional impact of their abuse, they can to some degree resolve the experience; they may then be protected from severe borderline pathology.

In a sense, the treatment experience provides a setting for the possibility of just such a resolution of past abuse. Indeed, the treatment of the abused child is perhaps less concerned with the issue of recovered memories of the past as such than in confronting the emotional impact of the abuse, and the effect of the abuse on the mind's emotional functioning. Not infrequently, this issue arrives in an analysis when the patient makes a particular kind of emotional impact on the analyst. It would be too simplistic to describe the situation as being one in which the analyst becomes the abuser in the transference, though not untrue, it seems too gross a description of what may take place. Rather, the analyst almost inevitably proves to be a failure, there is a breakdown in usual functioning; a failure of nerve or some lapse in concentration. The reasonably empathic atmosphere may suddenly deteriorate, with the ready creation of misunderstandings, which may leave the analyst feeling that he or she has somehow mistreated the patient. Rather as in the treatment of abused children outlined above, the abused adult will re-create the emotionally absent parent, the parent who could not bear the child's pain and vulnerability and who has left the child with a sense that the environment has fundamentally failed him or her, and that there is a kind of breach, or unbridgeable gap, in the parenting experience. An unbridgeable gulf may suddenly appear between patient and analyst, which either party may be tempted to deal with by some kind of precipitous action, such as termination. Bearing the unbearable is an issue in any analysis, but with the abused adult it somehow becomes acutely relevant. Other themes may include the familiar one of testing of the analytic boundaries and overemphasizing the role of the abuse, by, for example, tapping into the analyst's wish to find answers rather than accept uncertainty. Finally, the pre-abused child's body may become idealized, while the postabused body may become a source of persecution. The patient's body, which obviously experienced real intrusion and damage, may feel unintegrated.
- Kennedy, Roger, Child Abuse, Psychotherapy, and the Law, Free Association Books: New York, 1997.

Personal Reflection Exercise #6
The preceding section contained information about recovered memories of abuse in children and adults. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Ensink, K., Borelli, J. L., Normandin, L., Target, M., & Fonagy, P. (2020). Childhood sexual abuse and attachment insecurity: Associations with child psychological difficulties. American Journal of Orthopsychiatry, 90(1), 115–124.

Jones, T. M., Bottoms, B. L., & Stevenson, M. C. (2020). Child victim empathy mediates the influence of jurors’ sexual abuse experiences on child sexual abuse case judgments: Meta-analyses. Psychology, Public Policy, and Law. Advance online publication.

Karlsson, M. E., Zielinski, M. J., & Bridges, A. J. (2020). Replicating outcomes of Survivors Healing from Abuse: Recovery through Exposure (SHARE): A brief exposure-based group treatment for incarcerated survivors of sexual violence. Psychological Trauma: Theory, Research, Practice, and Policy, 12(3), 300–305.

Online Continuing Education QUESTION 20
What characteristics do the parent of an abused child exhibit? Record the letter of the correct answer the CEU Test.

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