A study of intensive outpatient psychotherapy with sexually abused children

This is a study of the usefulness of psychoanalytic psychotherapy in the treatment of a group of severely disturbed children, for each of whom there was good evidence of sexual abuse. This abuse had begun early in life; and had been perpetrated within a family by one or more male figures; in the presence of a mother who was unable to intervene. The purpose of the study was to examine whether, and how, such treatment could be of help to the child. It was felt necessary to approach the work via a small group of detailed case studies; partly because the children are uncommon, and a large statistical study would be difficult to organise (cf Trowell 2001). Further, the existence of a sort of diagnostic category to describe the children was really only elucidated by the process of making the detailed case studies in the therapy room and through supervision. Thus it was possible to make an examination of the mental and emotional processes which had brought about the children's condition and of approaches that were likely to help; and to review when and in what circumstances the child was helped. This approach was therefore more open-ended than a statistical study could be. Its similarities, for example, continuous review and triangulation, with the method defined by Glaser and Strauss (1967), in the field of Sociology, as Grounded Theory, are described below; as is the method of doing this via sessions with the child as part of his/her treatment, and the recording of an archive of notes (data collection); subsequent triangulation against the literature that was found to help; data analysis through first and second supervisions; and further review and analysis leading to conclusions and recommendations for practice. For this purpose, therefore, the case study technique was found to be more appropriate. Findings were that a group of children exists among those who have been sexually abused, who are not truly psychotic but who have precarious contact with reality. The precariousness of reality for them derives from the lack of emotional comprehension on the part of a mother figure, who, for reasons described below, has a heavy emotional investment in the child's abuse by a partner of hers - that is to say, the whole family group is involved in a dire failure of the oedipal triangle. This group of children, probably synonymous with the Tavistock Society's category of Multiple Traumatic Loss, defy understanding by experienced workers who rely on the child's having some trust in the strength and power of adults. They were better understood by the researcher when the concept of the Dangerous Inner Object became available (Dubinsky and Dubinsky 1998) - their distrust is so overwhelming, because their experiences are so adverse, that they have no hope of help, but have to learn about it, against all their beliefs. In the field of Attachment, such children are described as Disorganised, and as hating and fearing the simultaneously needed attachment figure. This description seems both apt and accurate from a descriptive and diagnostic point of view. It also enables links to be made with work published in the field of neuroscience by workers such as Schore (2001) and Siegel (1999) - see below; but the writer has found the Dangerous Object idea more helpful to the treatment process, in which the aim is for the child to acquire and to internalise over however long a time is needed, a different and more integrated kind of object development. Because of the difficulty of doing this work without considerable background in theory, and because of the intensity and time input needed, the researcher's conclusion was that lasting improvement, measured by the sense of relief in the child as well as improved functioning (but not measured in terms of ease of management by the adults) would only be achieved where psychotherapy was used. Naturally the child would also need a stable, understanding Holding Environment as well as educational facilities which could work with him/her; though it was found that the child's ability to make use of education and other sources of help improved with the therapeutic treatment