Sunday, December 6, 2009

Working with Patients who have Survived Childhood Sexual Abuse

Today, in Winter Park, FL, I had the pleasure of discussing with the Florida Organization for Relational Studies (FORS), an affiliate of The American Psychological Association’s Psychoanalytic Division (Division 39) the Davies and Frawley (1994) text Treating Adult Survivors of Childhood Sexual Abuse. After laying the biological groundwork for dissociation:
Hormones triggered by stress impair hippocampal functioning, while neurotransmitter (NE) stimulates the amygdala. Generally speaking, the amygdala is responsible for procedural (behavior you can do without thinking, like riding a bike) memory, perceptional-sensory/body memories (like when the hair on the back of your neck stands up when you sense danger, even before you have a conscious recognition of danger), and emotional memory. The hippocampus is responsible for episodic (event) memory, for explicit, semantic (symbolically encoding, giving words to) memories, and for contextualizing events with their emotional significance.

When implicit, perceptual, affective memory is enhanced, but not linked to the event (such as childhood abuse), we have fragmented affective states without a link to their causes. And we have episodic memory of a moment (e.g. a flash of the abuser’s face) without link to its emotional significance or meaning. That these memories are not linguistically encoded has a huge impact on therapy which has traditionally relied on words and narrative. As a result, trauma in childhood impairs organization of memories.

Abuse is also an attack on subjectivity. Consequently, Intersubjectivity as a developmental achievement (the capacity to recognize the subjectivity of the other as well as the self) [subjectivity defined as the sense of self as a subject with an independent agency and desire] is impaired. Because therapy is an invitation to consider meaning from one’s own point of view, inviting a patient to hold forth her own reality can produce anxiety and panic. When the abuse was denied or invalidated by caretakers, the child’s sense of reality (reality testing) is also impaired.
To survive, a child must preserve the needed ties to caregivers and so takes upon herself (introjects) the sense of badness of the abuser, leading to decreased Self esteem and sense of self. The child maintains an illusion of control (‘if I caused it, then if I change it; if I can change the situation, then I am not helpless).
Without sound reality testing and the ability to trust her perceptions, adult survivors cannot adequately obtain gratification nor avoid danger. They tend to subjugate their reality to that of an Other, including complying with therapists’ interpretations. Not being recognized, comforted and protected, the isolation is profound. The world is seen as unsafe, and others, as betrayers.
There is also an impaired capacity to self regulate, such that any arousal is experience as hyperarousal. Therapy, inviting feeling, and intimacy, can lead to hyperarousal. To self soothe a survivor may engage in dangerous or self-abusive behavior to feel the subsequent calm (facilitated by the release of endogenous opioids) and to feel in control (turning passive into active), as well as attacking the abuser-introject, serving, at the same time, to attack the treatment and the therapist’s ability to contain and help.
The therapist can imagine out loud (symbolize in words) what the behaviors might be telling us.

“Behaviors have meaning. They tell us things that have yet to be put in words. When you miss sessions or come late or come high I think about how this unpredictability and instability is what you experienced when your parents could lash out for no reason or when they could not get up to get you to school. Since I am left confused, disappointed, and resentful about the interruption of our work here together, I can only imagine that you too might likely have felt these things (and more) at the hands of your parents. Maybe your lateness and missing sessions is your hope to help me see what it was like for you as a child.” [Note: in this way you highlight the behaviors without blaming. In fact, part of you is grateful to be getting the message. You also let the pt know that one can have negative feelings and still be invested in the relationship and the work. This kind of disclosure does not reveal personal content like where you went over the weekend or how many children you have. It reveals personal feeling states and thoughts about what is going on between the two of you, revelations that model the naming of feelings, their connection to events, and that having feelings does not self or other or the relationship.]

Or the therapist can make empathy-filled interpretations:

“It makes sense that, with the unpredictability of childhood events, you want to be the one who says when the pain starts or stops.”

Before traumatic experiences can be remembered, they must be reenacted. Through projective identification various roles in relational paradigms will be reenacted in complementary, simultaneous, ever-shifting, and overlapping fashion, like hot potatoes passing freely between patient and therapist. Davies and Frawley explicate many permutations of the Neglecting Adult -Neglected child; Abusing Adult -Abused child; idealized and omnipotent Rescuer-Entitled/needy child; and the Seducing Adult-Seduced child, all eight roles, representations of the patient’s child and adult selves, and of her object representations.
Sometimes the pt, unconsciously identified with the uninvolved parent, is the cold, rejecting, unavailable one, silent and withholding, disdainful, preoccupied, bored, hostile. The therapist, as the complementary neglected child, may feel compelled to try harder to reach the patient. When the therapist is reenacting the indifferent adult, her neutral ‘blank screen” may parallel the indifference and denial of the non-protecting parent.
When the patient is reenacting identification with her abuser, she may attack the therapist, the therapeutic frame, or engage in self-abuse. Privileging the love (attachment to the abuser), pain and terror around which the abusive behavior is organized may be easier for pt to engage.

“We all prefer to feel in control, even powerful, rather than feel so painfully vulnerable and helpless. Because I sometimes feel helpless to meet your demands, I wonder if these demands aren’t the additional communication to me that you really want me to know what it felt like to have your father make such controlling, angry demands on you. Also, all children wish to be loved by their parents, even abusing, out of control parents. Maybe if you can be like him sometimes, that allows you to feel a connection to him, and then it is not so sad to feel you never were close to your father.”

Or about the self abuse:

“I understand that this way you feel you are the one in control of the pain-- when it starts, when it stops-- just as your father had been when you were a child.”

As therapists, we are already drawn to the role of rescuer. The pressure to heroically save the abused plaintive child must be made explicit. To attempt re-parenting can interfere with mourning the lost childhood and the loss of the idealized parent. Instead the pt’s adult-self must be allowed to mourn. The therapist must accept that there will be constant tension between symbolic gratifications, frustrations, and interpretations.

“It may seem to you that the only way I can be with you is to be in the same geographic place, that it is not enough that I hold you in my mind or that you hold me in your mind. As much as we both might want to have dinner… together, to do so would have me feeling like your intrusive and inappropriate (father) and then you would begin to doubt the safety we are beginning to forge here.“

Thx needs to recognize pt as sexual subject, without the threat of action.

“Sometimes children learn that the only way anyone seems to pay attention to them is when something flirtatious or teasing is going on.”

“It is only natural that describing sexual activities is, however unwelcome, arousing. I am concerned on the one hand that you may feel rejected if I do not respond in kind to your overtures, but, on the other, am concerned that you may feel responsible for my arousal, the way you did about your father’s, and that would cause you to worry even more that you are dangerously seductive.”

Davies and Frawley use a Treatment Model of: Containment (of hyperarousal); Recovery, Disclosure, Elaboration (of trauma experiences); Symbolization and Encoding (putting into words, making explicxit); Integration (Contextualization); and Internalizing New Object Relationships. Taking for granted first co-creating a safe place, I like mnemonic devices, so I call it the four I’s: Identification (Recovery); Interpretation (putting into words); Integration; and healing as Internalization (of new relational paradigms).
In creating a safe space, the therapist must be comfortable with protracted chaotic reenactments and must maintain the frame, including the stopping and starting on time, and the patient respecting the therapist’s privacy, sleep, vacation. To foster safety, effects on both the therapist and pt of the daunting and protracted reenactments, must be discussed along with how to better negotiate tenacity for the therapeutic work and relationship. This includes inviting the patient to tell the therapist what the therapist does, or does not do, which leads to the therapist or the therapy being [inadvertently] experienced as re-traumatizing. Reality testing can be strengthened by asking what aspects of therapist’s behavior led pt to arrive at her conclusion. Treatment must be a MUTUAL process. The working alliance includes awareness of therapist’s contributions to the relationship. Two-person psychology means the therapist’s behavior is under scrutiny. If not part of the negotiation, then the one-sidedness parallels the abuser’s abrogation of responsibility. It is in negotiation, about the difference in how therapist and patient experience their relationship and each other, that the absence in childhood of toleration of difference is highlighted.
The therapist must ask herself: Can I tolerate the demands, survive the psychological assaults, complaints and invectives, participate in reenactments, work with the dissociated child-selves? Do I get angry when pt brings up… ? Am I reluctant to fully experience myself as a bad object? Am I un-comfortable with my own aggression and helplessness?

Discrepancies in therapist’s and patient’s experience create the potential for managing contradiction and the opportunity for strengthening the pt’s reality testing. To explore these discrepancies requires collaborative inquiry. It is the process, including validating (considering patient’s reality as something to be considered), not the content that is useful. The experience to agree, or disagree, without concomitant loss of integrity on either’s part, leads to mutual recognition, and to an increased subjectivity. It’s a paradox: one needs subjectivity to negotiate well, and negotiation develops/enhances subjectivity.
Empathic immersion and affective attunement foster capacity for self regulation; and diminish self doubt, and affective instability. Containment paves the way for recovery, disclosure and elaboration. As reality testing is strengthened and confidence in her memory increases, memories will emerge.
When you contain, listen and accept (believe), you change the original traumatic experience of isolation and despair and bring about a new object relations configuration, a change in internal structure. These MUST be repeatedly enacted.
Being curious about the meaning of the behavior helps the patient be curious about its meaning.

“This behavior is trying to tell us something, give us clues to something. You are telling us so emphatically through action, over and over again, it is as if you’ve had the experience of no one hearing or believing you.”

“You must have been very distressed, fearing being abandoned by me if you let us both know how angry you were at me. The cutting, by stimulating release of your body’s natural painkillers (opioids), temporarily relieves your fear and helps you feel in control.” [This type of empathic comment makes explicit the meaning of the behavior without passing judgment.]

In Tx: Ask questions and make interpretations to help make CS the roles being enacted.

“I have a theory about this recent cutting behavior, would you like to hear it? When I would not accommodate a change in appointment time I was the abuser who did not care about you, but cared only about herself. This understandably would make anyone angry. We have already discussed that you are uncomfortable with being angry at anyone, and prefer to be angry at yourself, take anger out on yourself. Could that be what was happening here, when after our last session you cut yourself? “

But the dangerous concreteness of self abuse can lead to the therapist’s dilemma which needs to be actively stated:

“I am concerned that should I under react and not step in to hospitalize you, then you could seriously, even fatally endanger yourself, but, on the other hand, I am concerned that if I over react and arrange to Baker act you, I become like your mother who never heard the meaning behind your crying and who got angrier at you and sent you away when you needed her help the most. So you and I together have to figure out what kind of danger you are in right now and what needs to be done about it.”

Replacing a the sadomasochistic struggle with collaborative effort may take years of active interpretation and repetition, containment and self soothing.

All the self states need to participate in treatment. “Neutrality” now comes to stand for the therapist’s capacity to keep fluid these ever changing re-enactments. Here neutrality means equidistance from all the multiple selves that are patient and therapist. Working through, for patients with dissociation, means integrating episodic memories with their dissociated emotional and cognitive significance, as well as integrating dissociated self and object representations.
It is from mis-attunement and correction, rupture and repair, from failing but surviving, that recognition and mutual respect arise. The child-self, previously existing only in the context of the abusive internalized object relationship, now can be integrated into the whole personality and child-like creativity and spontaneity are there to be expressed without fear of fragmentation of the self or without fear that disappointment will devastate. Integration of self and object representations is an aspect of healing, and it is heralded by mourning. Both the child and adult selves have struggled to come to terms with the horrific, deadening realities: That the abuse occurred; that childhood was destroyed and is never to be reclaimed. The pateint has come to terms with the finality and irreversibility of loss.
Treatment is a negotiation between two people each of whom requires a mutual recognition of difference, and allowing for each person to impact and influence the other. New object relationships accept both loving and hating identifications. Acceptance changes intrapsychic and interpersonal reality. Patient has seen that her own hate does not destroy the other and that the therapist’s anger is not accompanied by the attempt to destroy the pt. The experience in treatment to agree, or disagree, without loss of integrity on either’s part, leads to mutual recognition, and an increased subjectivity.
Healthy, mature self-organization is an amalgam of widely varying self- and object representations, each unique in its affect and ideational content, some even contradictory but no longer mutually exclusive. Internalization of new object relationships now allow for different self-states to have mutual understanding, respect, and affection (adult/child) for each other. There is increased tolerance and empathy. Now the child-self confers on the adult survivor increased vitality, passion-without-shame, play, fantasy, creativity, imagination, and ambition. The increased capacity to tolerate contradiction, love and anger, in self and others, and intersubjective experience, leads to an increased capacity for intimacy (exploring interiority of another and allowing an Other in) (both sexual and non-sexual).
Healing, like treatment, is an ongoing process, an ongoing dialogue between self states. It is not a finished product. Because treatment is co-created, no two therapists will have traveled the same path with a given patient. The acceptance of defeat without dissolution, failure, but survival, exists. Now there is a philosophical expansion of a profound appreciation for life, and for connection with an Other.

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