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Abstract
In
the present study the research focus is on the consequences of
childhood sexual abuse in conjugal life and the effectiveness of
psychodynamic psychotherapy in the case of a female survivor of
childhood sexual abuse who experienced marital problems. The client
engaged in three years of psychodynamic psychotherapy with the request
of improving her relationship with her husband. Central to the
problems she was facing in her marriage was the sexual abuse she
endured as a teenager by her father, which is a main theme processed
throughout the therapeutic process, as it has shaped her attachment
style and has been an inhibitory factor in her relationships with men.
In order to assess the impact of psychodynamic psychotherapy in the
present case three tests were used in the beginning and the end of the
therapy. To begin with, she completed the Dyadic Adjustment Scale (DAS),
the Experiences in Close Relationships-Revised (ECR-R) Questionnaire,
and the Thematic Apperception Test (TAT), which allowed us to
understand in depth her attachment patterns, evaluate her marital
situation and explore her inner and intra-personal world, as well as
interpersonal couple and family functioning. The therapeutic approach
employed in this case is discussed.
Introduction
Child
sexual abuse Sexual abuse in childhood affects a large number of
children across different countries and cultures. A common
misconception about child sexual abuse (CSA) is that it is a rare
event perpetrated against girls by male strangers in poor, inner-city
areas. To the contrary, child sexual abuse affects children of sexes
and all ages, races, ethnicities, cultures, and economic backgrounds.
According to the US Centers for Disease Control and Prevention (CDC),
child sexual abuse is “any completed or attempted (noncompleted)
sexual act, sexual contact with, or exploitation (i.e, noncontact
sexual interaction) of a child by a caregiver.”1 The CDC
distinguishes sexual acts as those involving penetration, abusive
sexual contact as intentional touching with no penetration, and
noncontact sexual abuse such as exposing a child to sexual activity,
taking sexual photographs or videos of a child, sexual harassment,
prostitution, or trafficking.1 Epidemiology The WHO 2002 World Report
on Violence and Health suggests that cases reported to authorities may
reflect a more physically violent subset with injuries requiring
treatment, as these cases are less easily hidden. It likens the
magnitude of CSA or sexual violence to an iceberg, in which only the
smallest portion is reported to authorities, a larger yet still
incomplete portion is reported on surveys, and an unquantifiable
amount remains unreported because of shame, fear, or other factors.2
The 2006 World Report on Violence against Children3,4 provided
estimates that in 2002 approximately 150 million girls and 73 million
boys were subject to contact CSA worldwide, including 1.2 million
trafficked children and 1.8 million exploited through prostitution or
pornography. Consequences of childhood and adolescent sexual abuse in
adulthood Before talking about the consequences in adulthood, it is
important to refer very briefly to the short-term consequences
children experience after facing CSA. Short-term consequences
Consequences of sexual abuse experienced in childhood or adolescence
are often manifested as psychological disorders (e.g., anxiety,
depression, and somatization), outsourced disorders (e.g., aggression,
opposition, problematic sexual behaviors) or mixed.5,6 The clinical
picture of survivors of sexual trauma remains heterogeneous and
variations are associated with the socio-demographic or psychosocial
characteristics of the victims (e.g., victim’s age and sex, coping
strategies), the severity or chronicity of assaults, the parental
responses observed following disclosure, other forms of victimization
experienced, and the quality of psychosocial services received by the
child.7,8 These data are based on the conclusive results of a series
of cross-sectional and longitudinal studies and currently form the
basis of a broad consensus within the international scientific
community.6−10
Long-term
consequences
In
the long run, these effects seem to persist in adulthood and manifest
themselves through a complex symptomatology that is strongly expressed
in romantic relationships.11,12 This preponderance of interpersonal
effects is explained by the need, in adulthood, to reconcile the
developmental tasks related to intimacy and sexuality in a context
where the efforts of emotional regulation to deploy are sometimes
complex. Sexual assault experienced at an early age causes an
imbalance in the neurobiological systems that amplify sensitivity to
the situations of treason, shame and helplessness that inevitably
occur at different stages of the couple’s life.6 In addition, sexual
intercourse is based on transgressing the physical boundaries of the
other, which requires an adequate metabolism of desire and
aggression.13 These characteristics of adult sex exchanges are likely
to provoke reactivation or intensification of the residues of past
sexual assaults. They also lead to confusion between feelings of
sexual desire and fears of exploitation.14 The after-effects of sexual
assault can therefore play a key role in the process of forming a
conjugal union and weakening it. Sexual abuse survivors present
difficulties in trusting others, in having confidence in oneself and
in their feelings and show an insecure attachment.15 In fact, the
current scientific literature identifies higher rates of break-ups,
unfaithful behavior, domestic violence, and marital or sexual
dissatisfaction among these victims.16−20 More recently, Miller
et al.21 have shown that these marital difficulties persist even by
controlling the effect of post-traumatic stress symptoms and
additional traumas experienced in adulthood.
A
body disconnected
Research
in the field has shown that women who have experienced sexual abuse as
children face difficulties in perceiving their bodies as sexual
objects.22 The experience of sexuality is largely based on the
experience of the body, which is greatly affected by the violence
imposed on it. Indeed, abuse affects not only body image but also the
way one connects to their body; the way they respond to bodily
functions and responses such as sexual desire and stimulation. As a
consequence, abuse victims fail to connect to their body sexually and
thus experience an increased difficulty in connecting to others
sexually as well.
Depression
In
a recent study involving 732 Boston women who received therapy for
depression, Wise et al.23 found that 50% of them had experienced
sexual abuse in childhood. “The earlier the incest takes place, the
greater the risk of irreversible identity damage”.22 The victim of
sexual abuse is blocked in their identity construction at the age of
the trauma. Most clinical observations highlight this aspect. Weiss et
al.24 conducted a review on the role of childhood sexual abuse in
relation to the risk of later developing depression (7 community
studies, 5 high school studies, and 9 clinical studies). It turns out
that sexual abuse in childhood is a risk factor for both male and
female victims.
Personality
disorders
Various
personality disorders are mentioned in the literature as the distant
aftermath of sexual abuse during childhood. Most common among victims
is borderline personality and antisocial personality disorder.26,26
Luntz et al.27 showed that in a group of 416 child victims of abuse /
neglect, compared to 283 witnesses, child abuse and child sexual abuse
were predictors of symptoms of antisocial personality or antisocial
personality diagnosis. Similarly, Fox et al.28 showed that child
sexual abuse victims develop more empathy compared to adults who have
not experienced abuse. The personality disorders caused by childhood
abuse seem to depend on the nature of abuse. Thus, Jonhson et al.29
have shown that, while child maltreatment generally increases the risk
of a personality disorder in early adulthood, physical abuse is mostly
associated with a risk of antisocial personality disorder and sexual
abuse with borderline personality disorder.
Intra-familial
and repeated sexual assaults related to marital difficulties
In
general, in comparison to other forms of sexual abuse, intrafamilial
sexual assault is associated with higher rates of marital distress,
especially when such abuse is accompanied by anal or vaginal
penetration. 29,30,16,19,20,31. Watson & Halford,19 after
recruiting a large sample of women, report that while all types of
childhood sexual abuse are associated with marital problems in
adulthood, abuse perpetrated by family members is specifically
associated with a higher risk of future marital separation and marital
dissatisfaction. In addition, Vaillancourt-Morel et al.32 through
their study have shown that the abuse associated with penetration or
perpetrated by a family member will be associated with higher rates of
marital distress, psychological distress and insecure attachment among
victims who have marital or relationship difficulties. Regarding
relational proximity to the abuser, the results of Vaillancourt-Morel
et al.32 reveal that victims who have been sexually abused by a
parental figure present higher rates of psychological distress and
anxiety than non-abused participants. This subgroup of victims is also
more psychologically distressed than victims who have been sexually
abused by a stranger and show more privacy avoidance than victims who
have been sexually abused by strangers or acquaintances. From a
clinical point of view, sexual acts by a person whose status involves
affection, protection and care may elicit more conflicting or
ambivalent emotions (eg, pleasure, love, shame, guilt, betrayal,
anger). They also create great difficulties in reconciling the image
of an abusive parent with the representation of a protective and
loving parent. Thus to cope adequately with sexual abuse, the child
faces great ambiguities. For example, they may be undecided about
unveiling or experiencing conflicting feelings of pentup anger and
love for the abusive parent. This type of reaction among adult victims
of childhood sexual abuse refers to the process of failure to
mentalize a traumatic experience. This concept is well illustrated in
the qualitative study by Berthelot et al.33 reporting speeches by
adult victims of child abuse who have difficulty mentalizing
adequately the abusive experience. In addition, abuse by a parental
figure often involves neglect or lack of protection of the non-abusive
parent, which may increase feelings of betrayal and negative
representations of oneself and others. Thus, the child may have to
deal with the loss of a feeling of security in his family environment,
a feeling that is necessary for the general development of the child,
the specific development of a secure attachment and possible training
of a loving union. In this sense, a recent article by Godbout34
highlights the role played by attachment figures following trauma.
They reveal that when the child or adolescent announce an abuse, the
nature and strength of parental support impacts the subsequent
psychosocial adjustment. Finally, with regard to the frequency of
sexual abuse, the results of Vaillancourt-Morel et al.32 show that
victims of chronic sexual abuse have a higher degree of psychological
distress than non-abused participants and that other victims of sexual
abuse during childhood (ie: single episode, a few times). In terms of
the type of sexual abuse suffered, their results indicate that victims
who have experienced abuse with anal or vaginal penetration present
more psychological and conjugal distress as well as more insecure
representations of attachment compared to non-abused participants and
other victims of sexual abuse. Indeed, this type of intrusive sexual
abuse seems to have a significant effect on the impact noted in
adulthood. These victims have greater marital distress and privacy
avoidance than all other participants (non-abused and other victims).
All of these results converge with those of previous studies
interested in the characteristics of abuse that suggest that a victim
of sexual abuse perpetrated by a parental figure,19,35 with
penetration36 or chronic37 will experience more severe intra- and
interpersonal repercussions in adulthood than the others. In this same
line of thought, Whisman20 (2006) emphasized, based on a large
probability sample of 5877 American, that penetrative sexual abuse is
the only childhood trauma associated with separation and marital
satisfaction, regardless of the relationship with the abuser and the
number of abuses suffered. Fleming et al.30 report that in a sample of
710 women representative of the Australian female population, sexual
abuse involving anal or vaginal penetration, in comparison to other
forms of abuse, is associated with higher risks of later relational
difficulties. Finally, Liang et al.16 looked into the case of 136
American women who experienced sexual abuse during childhood. Their
findings reveal that in cases of sexual abuse, penetration is
associated with higher rates of marital dissatisfaction than other
types of sexual assault. An overview of these studies also shows that
until now, in adulthood, the association between the frequency of
sexual abuse during childhood and marital consequences in adulthood
has not been studied enough.
Case
study
Patient’s
history
Mary
visited our practice requesting support as the status of her marriage
was deteriorating and she felt she was unable to deal with it on her
own. In her own words, ‘I don’t know what to do..Umm.. it’s like
we’re drifting apart, and umm, there is this distance between us, I
don’t really know why, I’ve tried everything and I’m feeling a
bit lost, so I thought, cause the last time I tried therapy it was
very helpful..’. Mary informed us from the first session she had
received therapy in the past, and when asked about it she introduced
us to her history of abuse. She grew up in the suburbs of Athens in a
flat with her mother and father, who both worked full time, and had
her grandmother help with her upbringing. According to Mary, her
parents had a very stable relationship, with no fighting and friction,
but with no intimacy either; ‘there was never any yelling at home…but
it felt there was no real conversation going on either.. I remember
them sitting at the kitchen table for dinner and talking about the
weather, or mum’s work, or the neighbors’. She described herself
as a very active kid, with many friends and many extracurricular
activities she was thriving at, such as tennis, gymnastics, painting
and learning foreign languages. ‘It was my mum who first wanted me
to join the tennis club when I was in primary school, and I did really
well there, so umm, as years went by I kept requesting to join more
clubs, cause that meant I had to spend less and less time at home’.
Mary mentioned she had really warm memories of her grandmother, who
died when she was 5 years old, leaving her to spend a lot of time on
her own at home when her parents were off at work. Before speaking of
the abuse, Mary’s body language changes; she breaks eye contact, she
locks her arms in a defensive position around her core, and she lowers
her voice. ‘I still remember the first time he came into my room…
I must have been 11 years old.
It’s
weird because I don’t remember much of this year of my life… It
started happening on a weekly basis, he would come into my room late
at night when mum was asleep and then leave without saying anything,
or looking me in the eyes.’ The sexual abuse by penetration went on
for two years and stopped when Mary started menstruating. She spoke of
the impact it had on her relationships with men, as she was too afraid
to interact with older men and boys her own age repulsed her. It
wasn’t until she was in her early twenties, when she had left home,
that she entered a romantic relationship with a man for the first
time. According to her, this relationship was not successful, as her
partner was ‘always in charge’ and she felt ‘trapped’ in the
relationship. Through her description of this relationship it becomes
clear that she has been victimized, as every time she speaks of the
relationship the language she uses is indicative of an imbalance of
power. Through this period of her life, she entered therapy for the
first time, which lasted for four years and helped her to address and
process the abuse for the first time in a safe environment. This
process really helped her; she ended the relationship, found a better
job and later on met her future husband. Their relationship was,
according to Mary, ‘the most functional relationship I have ever
been a part of, there is respect, mutual understanding, trust, and
ummm, we really love each other’. Mary brings up their marital
problems at the beginning of our therapy process, and mentions their
sex life, or lack thereof, as central to their problems. ‘Our sex
life was never, you know, the biggest part of our relationship, we had
one but it was never my favourite thing about us, but for the past
year it’s like we have drifted apart and there’s nothing, I have
tried to make it happen again but haven’t succeeded really’. As
their marital problems were the main request that brought her to
therapy, we focused on them and collected information at the beginning
of the therapeutic process and three years on.
Materials
and methods
In
order to focus on Mary’s representations, her marital problems and
also explore the link between her marital problems and the sexual
abused she experienced in her adolescence we used during our second
session the Dyadic Adjustment Scale (DAS), The Experiences in Close
Relationships-Revised (ECR-R) Questionnaire and The Thematic
Apperception Test (TAT). Additionally we used the same tools at the
end of Mary’s psychotherapy in order to study the effects of
psychodynamic psychotherapy.
Dyadic
Adjustment Scale (DAS)
Dyadic
adjustment is evaluated using the Dyadic Adjustment Scale (DAS).38
This 32-item questionnaire assesses the degree of marital satisfaction
or of other similar dyads of the participants by providing a total
dyadic adjustment score ranging from 0 to 151.The 32-item scale is
designed for use with either married or unmarried cohabiting couples.
In terms of interpretation, the higher the total score, the more
satisfied the individual is with his relationship. Typically, an
individual score greater than or equal to 100 is used to differentiate
unsatisfied individuals from those satisfied with their relationship.
The Experiences in Close Relationships-Revised (ECR-R) questionnaire
In order to create a holistic framework that would allow us to
understand in depth Mary’s marital situation and evaluate her
attachment behaviors we used The Experiences in Close
Relationships-Revised (ECR-R) Questionnaire.39 This 36-item tool
measures two dimensions of loving attachment: anxiety of abandonment
and avoidance of intimacy. The dimension of anxiety of abandonment
makes it possible to define the cognitive representations that the
individual has of oneself and refers to the subject of abandonment or
rejection in the romantic relationship. The intimacy avoidance
dimension allows us to target the cognitive representations that the
individual has of his / her romantic partners and represents the level
of self-sufficiency, of discomfort regarding the intimacy and love
interdependence. The first 18 items comprise the attachment-related
anxiety scale. Items 19 – 36 comprise the attachment-related
avoidance scale. In real research, the order in which these items are
presented should be randomized. A total score greater than 3.5 on the
anxiety dimension of abandonment and 2.5 on the avoidance dimension of
intimacy reveals a high level of this dimension of attachment in the
internal representations of the individual. Thematic Apperception Test
(TAT) Thematic Apperception Test (TAT).40 Thematic Apperception Test,
as projective technique, results particularly rich since it allows to
explore the inner and intra-personal world, as well as interpersonal
couple, family or community functioning. In the TAT, the ambiguous
materials consist of a set of cards that portray human figures in a
variety of settings and situations. The subject is asked to tell the
tester a story about each card that includes the following elements:
the event shown in the picture; what has led up to it; what the
characters in the picture are feeling and thinking; and the outcome of
the event. The goal is to experiment a utilization of the test that
could contribute to the understanding of personalities and of how
these intertwine in couple interaction.41 In the relationship with the
partner, the personality takes new shapes, given personality and
character traits are strengthened, while others lose importance”.
Psychodynamic psychotherapy Mary engaged in psychodynamic
psychotherapy for a period of three years. The therapeutic process was
focused on unconscious processes, thus was mainly unstructured.
Nonetheless, we focused on certain elements that are central when
dealing with trauma and abuse. In detail, psychodynamic therapy
generally targets unconscious processes, which shape partly our
behavioural patterns. One of the goals of psychodynamic therapy is to
increase a client’s self-awareness and help them understand the
influence of their past experiences on present behavior. When working
with clients who have experienced severe trauma in the past, therapy
focuses on helping clients experience a remission of symptoms, develop
self-esteem, and improve their capacity for developing and maintaining
more satisfying relationships. Resource orientation, which was used
during Mary’s psychodynamic psychotherapy, is thus considered a
major element of the therapeutic approach. In terms of psychodynamic
ego psychology, activation of internal resources means enhancing the
patients’ mastering and coping competencies.42 In terms of
psychodynamic object-relations theory,43 it can be understood as a
process of restoring the ability to activate positive internalized
object relationships. This can be accomplished by evoking memories of
positive relationship experiences or by stimulating fantasies of
positive experiences. For example, evoking a memory of a personal
success aims at restoring self-esteem by actualizing an internalized
object relationship of a self being mirrored by a good object. As
trauma blocks the patients’ access to positive internalized object
relationships and the related positive emotions, the approach aims at
evoking in traumatized patients a psychological state of well-being.
Furthermore, it aims at improving coping strategies by directly
activating the respective ego functions and internalized object
relationships. Imaginative techniques are valuable tools to activate
positive resource states.44,45 The use of resource activation enabled
us to improve Mary’s emotional regulation. Thus the actualization of
internalized good object relationships became the central therapeutic
tool for improving emotion regulation. The resource activation can be
referred to as "activation of internal resources." All kinds
of positive memories, capacities, thoughts, memories, and fantasies
can be utilized as internal resources (as opposed to external
resources like helping persons, etc.). Whatever produces a positive
feeling state can be considered a resource. Practically, activation of
internal resources can include pursuing pleasant activities,
remembering positive experiences, and creating positive feeling states
by way of imagination. To that end, we systematically showed the
client how to identify, remember, and vividly imagine memories of
positive experiences, personal successes, and positive relationships.
To cope with current stressors and life problems, the client was asked
to identify those coping resources (capacities) needed to solve the
problem. In a next step, the client was encouraged to search for
situations in her life history where this resource was available.
Finally, she was asked to create a vivid imagination of the
resourceful scene.
Results
First phase
Dyadic adjustment
scale
Mary’s
score at the Dyadic Adjustment scale is 68/151, which indicates
her feelings of dissatisfaction regarding her relationship with her
partner.
|
Mary
after the scale mentioned that "We
often disagree with my husband because I cannot demonstrate
affection. It is because of me. I cannot be affective and there
are times that I cannot demonstrate my feelings to my husband.
He sometimes tries to talk to me about this but I cannot explain
to him why I am like that. [...] We also disagree about spending
time with other people…I don’t have many friends…I don’t
know why…I’d rather be alone. He doesn’t get it…and I
cannot understand why he wants to spend so much time with his
friends.
[...] Sex
relationship…oh it’s the main reason we fight. I feel
uncomfortable most of the time. I don’t like my body. I don’t
find it sexy...I don’t like it.
[...] We
don’t spend much time together. There are moments I want to be
alone. I feel upset and I want to be alone...And we do not kiss
very often….i think it’s again because of me…I’m often
too tired to have sex and I think that most of the time I’m
not showing love, but I love my husband.
The
Experiences in Close Relationships-Revised (ECR-R) questionnaire
The statements below
concern how Mary feels in her emotionally intimate relationship
with her partner. Thus, the items were used as a way to focus on
this particular relationship.
Mary’s
results (3,7) indicate a total score greater than 3.5 (cutoff)
on the anxiety dimension of abandonment and greater than 2.5 (cutoff)
on the avoidance dimension of intimacy (Mary’s score: 5,5)
revealing a high level of theses dimensions of attachment in the
internal representations of Mary. More specifically, Mary
presented anxiety related to abandonment, which is nevertheless
close to the cutoff (3,5). However, her score regarding the
avoidance dimension of intimacy is much greater (5,5) than the
cutoff (2,5) indicating her mental representations and avoiding
behavior toward her husband. This result is in line with the
result obtained in the Dyadic Adjustment Scale.
Thematic
Apperception Test (TAT)
Card
1: ‘I
see a boy who is forced to take violin lessons by his parents.
He clearly doesn’t want to, but has to obey them anyway. The
child seems distressed and tired, probably from the many hours
he has had to play the violin.’
In this
description, Mary presents her parents as sovereign and
authoritarian, while she, as the child, complies. Τhe
physical condition of the child as described by Mary is related
to the image of the body and of the self; she communicated that
the way she feels about her body is that she sees it as tired,
exhausted and forced to do things she doesn’t want it to.
Card
2: ‘The
woman in the middle wants to leave her family, does not feel
good when she is with them. They make her work in the field even
if she begs them not to; she cries and asks for them to let her
leave, it is too painful to be there with them. She wants to
change her life. She wants to be alone and start again.’
In this
picture, Mary makes a clear statement about her wish to
differentiate from her family, and the feeling of pain she
endures when she is with them. The way she described the woman’s
reaction to her family asking of her to work with them is
indicative of the traumatic experiences she has had in her
family; the words beg, cry, and painful demonstrate a person who
is deeply traumatized from their relationship with their family.
He wish to leave and start over on her own is a sign of healthy
adjustment and an indication of a potential to not follow and
reproduce the toxic patterns she had been exposed to as a child.
Card
3GF: ‘I
see a young woman who is upset and has given up. She feels as if
there is no reason for her to keep trying, everything is futile
and she is thinking of putting an end to her life with that gun
that is lying next to her.’
Mary’s
interpretation of this card clearly indicates her feelings of
desperation and her inability to cope efficiently with
situations that seem to cause her negative feelings. The fact
that she mentioned that the woman would end her life is
indicative of the trauma she has endured and the deep
existential anxiety this has brought upon her.
Card
4: ‘The
guy has decided to leave his partner cause he’s tired of her,
and she is trying her hardest to make him stay, because she
cannot imagine her life without him. He has made up his mind,
which scares her because she doesn’t want to be on her own
after all these years they have spent together.’
Mary’s description of
this card speaks on the problems she is facing right now with
her partner, and her very conscious fear that he will leave her
because she is not good enough for him. Moreover, she
communicates her fear of being on her own, which lets us know
that her
relationship with her husband is a dependent one.
Card
6BM: ‘This
guy here is the son of this woman and has approached her to
announce that he is leaving the family home and will, from now
on, live in his own. His mother is not happy to hear that he is
about to leave, so she turns her back at him to show she is
unhappy and disappointed in him.’
Here Mary
communicates her fear to differentiate from her family, her fear
to disappoint her mother and ultimately, on an intrapersonal
level, her fear to disappoint herself by not obeying to the
wishes of her family. It is also indicative of the difficulties
she is facing with communicating her feelings honestly and
relating in a direct way.
Card
6GF: ‘A
woman is sitting on the couch watching tv and trying to relax.
Suddenly this older guy shows up behind her and tries to say
something inappropriate, looking at her in an inappropriate way,
and blows smoke on her face. She is appalled by him and doesn’t
know how to react to his presence, she feels violated by the
smoke that is blown onto her face and wants him to go away, but
doesn’t how to make him do that. She tries to tell him that
but he doesn’t seem to listen.’
Feelings
related to her abuse are clearly emerging through this card, as
she identifies with the woman who feels violated by the older
man. She visualizes herself as an object that receives sexual
attention in a passive, violent way, using indirect language ‘inappropriate’,
which shows that she is defensive in regards to themes of
sexuality and violence. Employing a Freudian analysis on the way
she perceives the male figure, we could argue that this is
projection of an unresolved Oedipal complex, where the father
figure - perpetrator in the case of Mary - threatens her and
violates her by blowing smoke from his pipe onto her face. The
sexual metaphor stemming from the pipe and the smoke is a direct
link to the experience of sexual abuse Mary has experienced from
her father, while the attempt of the woman in the picture to
distance herself from the older man refers to Mary’s traumatic
and unsuccessful attempts to put an end to the abuse. Moreover,
it is easy to notice her difficulty in relating with men, fact
that definitely impacts her relationship with her husband.
Card
13MF: ‘In
this card I see a woman lying on the bed, half-naked and
probably dead. Yes, she has obviously been killed by the man
standing in front of the bed, who pretends to feel remorse but
in reality he doesn’t really care, he killed her by strangling
her cause she wouldn’t do what he wanted in bed and now he
will go back home and pretend nothing’s wrong.’
The
violence Mary sees in this picture is indicative of the sexual
violence she has endured, and the fact she perceives the woman
as killed by the man could refer to the annihilating feelings
after the abuse she experienced. The interconnection of
sexuality and violence is characteristic of victims of sexual
abuse, and is a product of the trauma victims struggle to
process. Perceiving a male presence as threatening and capable
of extreme violence has a huge impact on the way Adrienne
relates to men in her life; therefore, it is not surprising that
she struggles to connect with her husband.
Card 14: ‘I’m
not sure what’s happening here, I think there’s a person
sitting by a window looking outside and thinking… Yeah,
thinking... Things are not going well for this person, his life
is not at a good point, he feels like he has failed and is not
happy with anything... He is contemplating jumping, he cannot
see any end to his suffering so maybe, umm he will jump at some
point.’
Clearly
Mary communicates depressive feelings she is dealing with; she
is identifying with the man, expressing despair and the wish to
give up. The way she speaks of the dead end she is facing is
indicative of a weak Ego that is unable to handle the reality
and is taken over by sadness and negative thoughts concerning
the future.
Blank
Card: ‘I
see nothing. Just emptiness.’
Her
inability to imagine anything when looking at the blank card is
indicative of her inability to symbolize. This could be a result
of the abuse, which has fractured her Ego and has immobilized
her in a state of anxiety and dread.
Card
20: ‘A
man is standing in the rain. It’s late at night and he is out
all alone waiting for something. He does not know what he is
waiting for, but he’s been waiting for a long time and it’s
probably futile. He is cold and really upset that he’s been
waiting around for nothing.’
The last
card, which usually allows patients to communicate feelings of
loneliness and abandonment, is seen by Adrienne in a similar
way; again, she lets us see how alone and abandoned she feels,
struggling with an inability to deal with the aftermaths of
abuse in an effective, mature way; instead, she feels
overwhelmed by her previous experiences and is unable to face
them in real time.
Second
phase
Dyadic
adjustment scale
Mary’s score at the
Dyadic Adjustment scale is 106/151, which indicates her feelings
of satisfaction regarding her relationship, contrary to the
first phase.
Mary’s results on the
anxiety dimension and on the avoidance dimension of intimacy are
lower compared to the first phase. Her result on the anxiety
dimension of abandonment (2,05) indicates a total score lower
than 3.5 (cutoff). Her score regarding the avoidance dimension
is also lower than the cutoff (2.5). Mary’s feeling of anxiety
and avoidance behavior toward her partner is now less presented.
This result is in line with the result obtained in the Dyadic
Adjustment Scale.
Thematic
Apperception Test (TAT)
The TAT
results after three years of psychodynamic psychotherapy are
indicative of the psychological changes Mary went through.
Card 1: ‘The
boy in this picture is sitting at a desk and contemplates
playing the violin. He has to study for his music lesson and he
doesn’t really feel like doing so, but he doesn’t want to
fail the exams that are coming up so he will start studying
soon.’
Mary’s
sense of responsibility has changed since the last time she took
the test. Her response to the card this time shows that she
feels more empowered and less dependent on her parental figures,
as she does not incorporate them in this picture; she envisions
herself as responsible for her own life - it is herself she does
not want to disappoint, not her parents. Thus, she has made
progress in terms of how she perceives herself and the way she
connects to others.
Card 2: ‘The
girl in the picture has decided to leave her house in the farm
and her family behind, to go to a big city and live her life the
way she wants to. Her mother knows that she is about to leave
and is happy about it, but her brother doesn’t really want her
to leave cause then they won’t have enough help around the
farm. She leaves anyway.’
Again,
there is a clear difference between the way Mary perceives this
picture three years in therapy. The wish to differentiate from
her family is obvious in both cases, but this time she presents
herself as more determined and empowered, and she seems ready to
realize her dreams, with the symbolic support of a mother
figure. In an intrapersonal level, this could represent a
turning point for her as different parts of her align and there
is less conflict and guilt regarding her choices. The male
figure that wants her to remain in the position and not evolve
could be a representation of her father that is not as strong
anymore since it does not affect her final decision.
Card 3GF: ‘The
woman here is extremely tired and wants to rest, because she
cannot deal with what’s happening to her at the moment. She
sits by her bed and cries, and is thinking of how much she needs
to sleep to get some rest.’
Although
feelings of tiredness and despair are prevalent in the way Mary
describes this picture, there is a difference in the way she
perceives the emotional state of the woman now and three years
ago, which lays in the intensity of negative feelings; the
previous time she visualized a woman wanting to kill herself,
but this time she sees a woman exhausted and in need of rest.
Card 4: ‘This
couple just had a fight, the guy is about to storm out and his
wife is trying to stop him because she wants to end things in
good terms, so she wants to continue talking to him and work
things out.’
In this
case Mary envisions a couple that fights, but the undertones of
her narrative indicate a relationship that is more stable that
the one she described last time, where the thought of breaking
up was present and frightening for her. This time the thought of
breaking up is not central to the narrative, and thought of ‘working
things out’ shows that she is more stable and secure in her
relationship with her husband.
Card 6BM: ‘This
guy has brought some bad news to his mother and she is really
upset upon hearing them, so she turns her back at him.
He is standing there feeling really uncomfortable for upsetting
his mother, but he had no choice but bringing her the news.’
Here Mary
describes a relationship with a maternal figure less frictioned,
where the worry of disappointing her mother is less present, as
if she has accepted the possibility of making choices that are
not accepted by her mother, without this having destructive
effects for their relationship.
Card 6GF:
‘A woman is sitting on the couch staring out the window, and
her boss walks in and approaches her to talk about an upcoming
project, but gets too close to her and scares her. She doesn’t
like when men get too close to her and makes her disdain clear,
hoping that he will notice and step back.’
In this
card Mary still experiences the male presence as aggressive and
unpleasant, but her feelings appear to be less strong than last
time. Moreover, the woman depicted in this case has a more
active attitude towards the man she finds threatening; instead
of being paralyzed by fear like in the previous testing, in this
case she is experiences ‘disdain’, not just fear, and
actually expresses her lack of comfort, which shows that she is
more responsible for her own feelings.
Card 13MF:
‘A man has just had sex with a prostitute and experiences
feelings of regret, because he will have to return home to his
wife afterwards. The woman, who enjoyed it a lot, lays on the
bed exhausted and wants to take a nap.’
The
positive feelings Mary attributes to the sexual act show a clear
improvement in the way she experiences her own sexuality; it is
the first time she refers to anything sexual as a source of
pleasure and joy, which is clearly emotional progress compared
to her last test when sexuality was intertwined with violence.
Card 14:
‘A man is sitting by the window looking outside and thinking
about his day, he had a big meeting at work and things didn’t
go as well as he wished. He is not so sure if he wants to remain
at the same job and he’s contemplating what’s best for his
career and his future.’
In this
card Mary seems to be dealing with a problem that she is
currently facing at work, and she has trouble finding the most
efficient way to resolve it. The fact that she no longer
attributes suicidal thoughts and feelings onto this card is
interpreted as an improvement to her emotional state.
Blank Card:
‘I see a white picture. That’s all.’
Once more,
Mary shows low imagination and difficulty in symbolizing, which
is not surprising given her previous experiences.
Card 20:
‘A man is standing next to a lamp on the street on a very cold
night. He has walked out his flat for a smoke and can’t wait
to get back in.’
Discussion
Through the tests used
throughout Mary’s therapy we observed her improvement
regarding her mental representations and her relationship with
her husband. In the Dyadic Adjustment Scale during the first
phase, Mary’s inability to show her affection for her husband
was demonstrated. She blamed herself for the distance between
her and her partner several times. According to her, her efforts
to improve their relationship do not succeed because she thinks
she cannot express herself or explain to him what happens to her.
Her tendency to distance herself is also clear in the test. This,
combined with other difficulties she is facing, such as also her
inability to understand her partner’s needs for socialization,
demonstrate her antisocial attitude. Additionally, Mary’s
attempts to avoid physical and sexual contact with her husband
are related to the disconnection she is experiencing in relation
to her body; similar to sexual abuse victims, she is unable to
experience sexual attraction towards others. Furthermore, the
results also demonstrated depressive symptoms, as Mary clearly
expressed feelings of sadness and a desire to remain isolated.
Through the results of the Experiences in Close
Relationships-Revised (ECR-R) Questionnaire during the first
phase we noticed Mary’s anxiety in regards to abandonment
through her avoidance behavior. In addition, we obtained a very
high score regarding the intimacy avoidance dimension which
allowed us to target the cognitive representations that Mary has
of her romantic partner and her levels of self-sufficiency,
discomfort regarding intimacy and love interdependence. Mary’s
results in these areas are in line with the results obtained in
the Dyadic Adjustment Scale. Besides this, through the Thematic
Apperception Test we observed Mary’s mental representations
and the link between her marital difficulties and the sexual
abused experienced during childhood. Mary referred to her family
and the sexual abuse she has endured from her father and she
identified herself with the woman who feels violated by an older
man (card 6GF). Through this projective test once again Mary
communicated the way she feels about her body which is that she
sees it as tired, exhausted and forced to do things she doesn’t
want it to. She made a clear statement about her wish to
differentiate from her family, and the feeling of pain she
endures when she is with them. The words beg, cry, and painful
used by Mary (card 2) demonstrate a person who is deeply
traumatized from her relationship with her family. Additionally,
her feelings of despair and her inability to cope efficiently
with situations that seem to cause her negative feelings are
also manifested and are linked to her experience of sexual abuse
and her actual marital situation. Mary’s mental
representations, insecure attachment style and marital situation
shifted throughout therapy as it was observed in the tests that
took place after three years of psychodynamic psychotherapy. The
results of the Dyadic Adjustment Scale that was completed during
the second phase showed Mary’s feelings of satisfaction
regarding her relationship with her partner. She was more able
to demonstrate affection and she was spending more time with her
partner. Her tendency to isolate herself was less present, as
she declared that she spent more time with her husband and with
her friends. She explained that she confides more often to her
husband and has sexual contact more often with him. She also
described her relationship as happy.
These results are in line
with those obtained in the Experiences in Close Relationships
Questionnaire in which the scores of the abandonment related
anxiety and intimacy avoidance dimensions were significantly
lower than in the first phase. Mary’s discomfort regarding her
partner and her mental representations has changed. She declared
being much closer to him and feeling more comfortable sharing
her private thoughts and feelings with him. Furthermore, she
revealed that it is easier than before for her to depend on her
husband, that she is more comfortable being close to him and
that she is more affectionate. Finally, the Thematic
Apperception Test showed that she feels more empowered and less
dependent on her parental figures. The wish to differentiate
from her family was obvious, but she presented herself as more
determined and empowered, and she seemed ready to realize her
dreams. We observed less intensity of negative feelings.
Mary still
experienced the male presence as aggressive and unpleasant (card
6GF), but her feelings appeared to be less strong than last
time. Moreover, Mary’s description of the woman in the card
6GF indicated that the woman has a more active attitude towards
the man she finds threatening instead of being paralyzed by fear
like in the previous testing. The positive feelings Mary
attributed to the sexual act in this second phase showed a clear
improvement in the way she experiences her own sexuality; it is
the first time she referred to anything sexual as a source of
pleasure and joy, which is clearly emotional progress compared
to her last test when sexuality was intertwined with violence.
Furthermore, she no longer expressed suicidal thoughts and
feelings.
Conclusion
In the
present article we examined the case of a young woman who had
experienced sexual abuse as child by her father, who molested
her for two years. The client visited our practice to receive
psychological support as her marriage was falling apart and she
was not able to handle the situation on her own. Through
psychodynamic psychotherapy it was revealed that the abuse had
shaped her attachment patterns and altered the way she connects
to others. We used a variety of methods to allow her to restore
her attachment style and reform her behavioral patterns, which
allowed her to improve her relationship with her husband. To
record this change, we present three tests she took at the
beginning and the end of the therapeutic process, namely the
Dyadic Adjustment Scale (DAS), the Experiences in Close
Relationships Questionnaire – Revised (ECR -R), and the
Thematic Apperception Test (TAT). The above tests allowed us to
examine closely her attachment patterns and her personal account
as a victim of abuse, and the results of both phases are
discussed in regards to her marital relationship.
|
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