Mental Illness

SEX ABUSE OF KIDS

SEXUALLY ABUSED KIDS
Last week I published a tongue-in-cheek response to an op-ed I had read in the editorial page of our local newspaper. The admonishment of the writer of the op ed that we should limit our talk about childhood sexual abuse stirred up some painful memories for me of patients who were attempting to overcome the effects of childhood sexual abuse.

A True Story
One case in particular comes to mind. This patient was an attractive young woman who came to see me with vague complaints and reported she had come because: “I just want something for my nerves.” After initial hesitation, she was able to give a more detailed history. Her general presentation confirmed my initial impression that she was suffering from clinical depression. She seemed shy and avoided eye contact until I asked if she worked, at which time she looked directly at me as if to assess my response as she hesitantly told me she worked as an “exotic dancer.” Apparently, I passed the test, for at that point, she unloaded in great detail how she had chosen such a career, and how she hated it.
She grew up in a blue collar family. Her father was a factory worker who forbade his wife from working. Her dad was a periodic, episodic alcoholic, and when drunk, was violent and abusive. When sober he was easily provoked. Mother was cowed, totally submissive, and seemingly helpless to protect her children from her husband’s rages. My patient (we shall call her Mary) along with her two older brothers developed strategies to avoid Dad when he was expected to come home drunk. As Mary grew into adolescence, her father began to take notice of her, and finally on the return from one of his nightly drunken forays came into her room and raped her.

But this was not the end of the abuse for the old man had the temerity to excuse his behavior by telling Mary that it was only because he loved her that he was sexually attracted to her. She accepted his advances as she was terrified at the thought of his beating her as he periodically did her mother.

Think it couldn’t get any worse?
Think it could’t get worse than this? Wrong. Soon her brothers emulated their father and to make matters even more unbearable bragged about having sex with her to their friends at school. As you might expect, this led to pursuit by many of the boys at school who were convinced that she was an “easy lay.” And where was Mary’s mother while this was going on? Mary was convinced she was aware, and attempted to convince herself that mother was so beaten down as to be rendered helpless, but she was also horrified to think that her own mother might have offered Mary up to her father in order that she would not be a target of his rages.
Emotional Extortion
Mary’s father had promised all kinds of dire consequences if Mary should ever breathe a word to any one about his behaviors. She knew that she would get no support from her mother were she to seek outside help. By now, even Mary’s teachers were convinced that she had become a problem as they heard that she was promiscuous. There was a reluctance to tell anyone due to the intense feelings of shame she felt about the incestuous relationships. There was also that long held custom of blaming the female in such situations, of which Mary undoubtedly was well aware.

The Spiral
The effect of all these prohibitions was made evident as she several times during the session asked for reassurance of confidentiality. In such a situation, the only sensible thing for her to do was run away, which is what she did. From then until the time of our session, her chronology was a bit hazy. I suspect that some pimp thought he had struck it rich when he discovered this beautiful little runaway. Although she did not admit to such, it seems likely she did engage in prostitution. In any event, at this point I felt it not necessary to probe deeper into her past for I had already seen enough pain to last for the rest of the day. It is enough to say that somewhere along the line she did find a way to use the only tool available for her to make a living in a semi-legitimate manner by swinging around a pole naked. Unfortunately, I never saw her again but noted the “men’s club” where she had been working was closed down by the sheriff. Her name was not listed among those who were arrested.

Sex abuse survivors suffer long after the abuse ends 
You may be thinking stories of this kind unusual, but they are not rare. It has been several years since that day I saw Mary, but I still think of her occasionally and wonder what her life is like now. I hope she found a good guy to marry has a couple of kids and is living happily ever after. But in my heart of hearts I know that is very unlikely. Those who have suffered such abuse usually have serious trust issues which interfere with the formation of meaningful relationships. Even though they know on a rational level that the abuse they suffered was not their fault, they often blame themselves by questioning whether the assault was brought on by their seductiveness, which is reinforced by the oft heard “she must have done something to bring this on.” They lack self-esteem, devalue themselves, and feel unworthy. When shown attention, they may be suspicious and distance themselves while others may become promiscuous, feeling they have nothing to offer other than sex. In their search for love, they find themselves in a series of abusive relationships a la the repetition compulsion which Freud so eloquently described.
Meanwhile, I continue to fuss over the op ed that I sarcastically commented on in my most recent blog. I was curious when I first saw the title of Ms. Flowers piece, but as I read on I became so angry that I could have had a Lindsey Graham type temper tantrum on the spot. I immediately wrote a rebuttal in my passive aggressive style, which Maggie thought was worthy of publication however; I feel the subject of child abuse deserves something more than a few smart-ass comments. I felt that Mary’s story speaks eloquently as to the effects of childhood sexual abuse. Fortunately, most cases are not so horrifying as hers, yet even less aggressive acts can have long lasting effects.

More light required
Yes, I was angry with the writer for her blame the victim tactic, and her concern about Kavanaugh’s “pain” but not one kind word about Dr. Ford. But the clincher for me was closing statement in Ms. Flower’s op ed in which she writes: “That we have now reached the point that assaulted children are considered appropriate conversational tender sterilizes the soul and induces a nausea that can’t be eliminated…”I submit that such an attitude is a major contributor to child abuse. For too many years as with Mary, most such vile acts which have robbed many children of their innocence often leaving them significantly impaired with a lifetime of suffering have been carried out in secret.
There has been some progress in shining the light on the problem e.g. there are now mandatory reporting laws in most states which require physicians, nurses, social workers, emergency rooms, psychologists, etc., to report their suspicions that a child is being abused, and yes that includes the sexual abuse which Ms. Flowers insists should not be a subject of “civil discourse.” It is also encouraging that many charged with caring and working with kids are being prosecuted, and that the veil of secrecy that has surrounded the violation of children by priests is being lifted. However, the National Center for Victims of Crime reports some very disturbing statistics which confirm sexual abuse of children remains a serious problem:

  • 1 in 5 girls and 1 in 20 boys is a victim of child sexual abuse;
  • Self-report studies show that 20% of adult females and 5-10% of adult males recall a childhood sexual assault or sexual abuse incident;
  • During a one-year period in the U.S., 16% of youth ages 14 to 17 had been sexually victimized;
  • Over the course of their lifetime, 28% of U.S. youth ages 14 to 17 had been sexually victimized;
  • Children are most vulnerable between the ages of 7 and 13.
  • 75% are abused by people they know and often those whom they trust
  • 23% of reported cases are perpetrated by kids under the age of 18
  • 40 to 80% of such juvenile offenders have themselves been victims

As we have witnessed in that infamous recent Supreme Court hearing, many of the old habits which allowed such awful acts to be inflicted on our children are still in place. The issue must not be swept under the rug as Ms. Flowers suggests but should be considered “civil discourse” of the highest order. Pedophiles do not feature a sign on their foreheads announcing their sexual proclivities therefore; those to whom we entrust our children deserve careful scrutiny. My own experience in that regard accentuates that truth.

Wolf in Sheep’s Clothing
He was a person for whom I had a great deal of respect. We first met when I was a psychiatry resident, and I was impressed with his knowledge and competence as a board-certified child psychiatrist with many years of experience in institutional practice with a University affiliation.

Upon completion of my residency, he invited me and a couple of other recent graduates to join him and form a group practice. Fortunately for me, I received another offer for later I was shocked to find he was sentenced to a lengthy prison term for child sexual abuse. He had apparently managed to abuse children, in most cases, who were residing in institutions, where complaints would likely be ignored. Of course, no one knows how many lives he may have ruined. In retrospect I realized I had missed all the warning signs.
Yes, it is my most ardent belief that the problem of childhood sexual abuse deserves serious attention and more “civil discourse” not less of it.

FAMILIES

FAMILIES

In previous blogs I have discussed the importance of relationships in our lives; however none are more important than our relationships with our family of origin. They will be a powerful influence as to how we view the world and other people.  More importantly, these experiences will be major determinants in the development of our personalities.  Those fortunate enough to grow up in nurturing environments will find it easier to nurture their offspring.   To feel loved is likely to protect one’s self-esteem, and allow one to experience the joy of loving others.  Our values are in many ways shaped by family for even if one is rebellious and rejects what he has been taught, his new found truths often originate from the nature of his family relationships.

Apprenticeship to Adulthood

We humans are unique among mammals in the length of time required for us to reach maturity. Not only is our rate of growth slow, but there is much to learn if we are to survive and thrive in a complex society.  Although much is determined by our genetic make-up, we learn behaviors and perceptions primarily by unconsciously mimicking others.  In that sense, growing up is much like an apprenticeship.

The 21st Century Family

An accurate definition of family is now difficult to pin down. There are no longer traditional roles for family members, such as were the norm in my generation.  Since most parents work, there are fewer stay-at-home moms.   We now see an occasional stay-at-home dad, something unheard of in my time.  Other than widows, single mothers were not nearly as prevalent during my youth as they now are.  Modern mobility has limited the number of nuclear families who can experience the support of extended family members.  Many of our children grow up barely even knowing the names of their cousins.  Blended families composed of his, hers and their children can face special challenges.

The Power of the Family Bond

In spite of these changes, the bonds between family members are among the strongest of all our relationships. This is evidenced by the fact that one of the first phases of recruitment by cultists is to alienate the prospect from family members, usually leaving siblings and parents confused and devastated.  The same tactics are used by those who would attempt to relieve the elderly and infirm of their possessions.  In both cases, they discredit the families of origin and attempt to break the bonds between the victim and the victim’s biological family.  Those in positions of leadership of all stripes realize the strength of familial relationships, and seek to provide an atmosphere in which a surrogate family can develop.  Street gangs likewise are said to provide family like bonds, which have been lacking in the lives of those they recruit.  The search for the type of relationships found in families seems to be a common human need.

“I found it difficult to remain therapeutic while feeling homicidal.”

Although families offer the best environment for rearing children, they can also be the scene of horribly abusive behaviors. I have had little experience dealing with such problems, especially when they involve children.  I generally avoided treating such cases as I found it difficult to remain therapeutic while feeling homicidal.  In like manner I find that the understanding of other cultural practices such as honor killings, genital mutilation and such to be way above my pay grade, and in spite of being paid quite well.  Consequently, I will confine my remarks to treatment of more mundane problems.

Who is the “real” patient?

Most families seeking help are usually concerned about the behavior or mental status of one of their members. They are often coerced into treatment by the identified patient’s therapist.  That term (identified patient) is useful in that one may find that the person in treatment may be the healthiest member of the family, and labeled as sick because he is out of step with the rest of the family (i.e., the identified patient is actually the most emotionally healthy of the group who is reacting to an unhealthy family dynamic).

The importance of family therapy

There are multiple reasons that I believe involvement of family is critical in the treatment process:

  1. Family members may be able to provide valuable information about the patient’s behaviors.
  2. It allows the therapist to view family relationships first hand and thus provide insights as to the stresses in the patient’s environment.
  3. Family members may provide a more complete family history
  4. It allows the therapist to assess the level of support available, and to encourage such support
  5. Perhaps most importantly, it is a mechanism in which the dilemma of providing family with needed information about their loved one’s illness without violating the confidentiality inherent in the doctor-patient relationship. This becomes even more important in those cases where there are paranoid tendencies, or there has been a great deal of conflict.

The Complexity of Family Relationships

Although the average family size has shrunk considerably over the last century, relationships between members can still be complex. It must come as no surprise that there are often conflicts within families.  Since it is difficult to walk away from one’s family, those conflicts are not easily resolved, and over time may escalate.  To be chronically angry can be debilitating and painful, and as such, blaming another for those feelings comes easily.

The Blame Game

As mentioned in previous blogs it is important that the therapist avoid joining in the search to establish who is at fault, for to do so merely perpetuates the problem. He must be able to analyze the problem from the outside looking in, that is, learn how to be a meta-communicator. Hopefully, the members will find it difficult to continue blaming each other if the therapist redefines the problem as blaming rather than defining the problem as identification of who is at fault.

The Power of Brevity

In order for the therapist’s comments to be effective, they must be brief if they are to be remembered. The importance of brevity as with most things in my practice was learned from a former patient during a chance encounter, during which he thanked me for having helped him several years previously.  He credited his recovery to one statement of mine.  He said: “The thing that helped me most was when you said ‘you think too much’ and now whenever I start to worry about all the things which could go wrong those four words come into my head and I am able to move on.”  I cannot take credit for any brilliant insights for I didn’t even remember the incident, but it is an example of how an offhand comment may be more effective than hours of therapy.  The same principle applies to our everyday lives, as the most memorable comments are those expressed in a few words.  The lengthy ones are often forgotten before they are completed.

Obviously there are many reasons for families to seek counseling other than to deal with hostility, but no matter the problem it is helpful to look at it as a communication system gone awry. Imbedded in many different behaviors is a message, and thus can be seen as a form of communication.  For example, what is the message being sent by a teenager who is acting out?  It could be that they are angry about limits set, unrealistic expectations from parents, lack of trust by parents, sibling rivalry, or resentful that not enough limits have been set, or for reasons which have nothing to do with the family.  Of course, the teenager is almost certain to be the last person likely to divulge such information.  Disclosure can many times offer a pathway to an understanding, which may be therapeutic.

Can’t see the forest for the trees

It was not my intent for this paper to be a treatise on family therapy; however I thought it might be useful to see how some of the concepts could be useful in understanding not only our own families, but relationships in general. As I mentioned in a past blog as with marital relationships, it is almost inevitable that one will be so caught up in seeing the trees that he will become oblivious to the forest.  That is, he will not realize what is going on even though he can hear the words.  This was brought home to me several years ago when following a party a colleague said “Smith I can’t believe how you treat your wife.”   I was shocked, could he be talking to me, the couples therapy and family expert?  After all, I had no doubt that I was among the world’s best husbands, but Barb later confirmed that my friend was correct in his assessment.  As has been said, “None are so blind a those who will not see.”

Reframing

For example though all have separate personalities, they also have different roles to play as family members. For example it is common for families to have a star and a black sheep.  Parents may lament that they don’t understand why the black sheep can’t be more like the star, and continue listing all of black sheep’s misdeeds and faults.  In such a case the therapist might address the black sheep kid by saying, “That is such a loving thing, doing all that stuff to make your sibling look good.” No matter the response the system is changed, and this is apt to open up some different dialogue. This is a process therapists call “reframing.”

Scripting

There are many roles that kids and parents may unconsciously adopt. There are the placaters or people pleasers, the mascot or clown, the lost child or withdrawn person, and as mentioned in the previous vignette the hero or achiever, and the black sheep or scapegoat, to mention a few.  Family roles may develop in order to fill a need or may come about by the process of scripting.  I mentioned previously the role families play in the development of our identity, and when they convince us we are a certain type of person, we are apt to follow that script.  Some have gone so far as to say if you can convince someone he is a homicidal rapist, he is apt to become a homicidal rapist.  Obviously, there are many influences other than our families which affect our identity; however, the opinions of our parents and siblings are undoubtedly the most powerful.

Disagreements

In this time of rapidly changing mores, it is not surprising that there will be frequent disagreements between we old folks and the kids. Of course disagreements between siblings seem to be written into their DNA, and disagreements between parents is certainly not unusual.  When family members cannot agree to disagree, an argument is likely to occur, and such arguments often lead to verbal or even physical attacks.  I don’t mean to suggest that disagreements are all bad for as Walter Lippmann famously said, “Where all think alike, no one thinks very much”.  When we tell our kids what to think while telling them we want them to learn to think for themselves it is little wonder they become frustrated for that is a classic double bind, or in today’s vernacular a no win situation.

Systems of Conflict Resolution

If a disagreement reaches the point that one feels threatened or under attack, either verbally or physically, he may respond in a variety of ways.

Attack/Attack system

He may retaliate in kind which is an attack-attack system. This is almost guaranteed to increase the level of anger, as each participant attempts to outdo the other.  These are the types of interaction which can lead to violence.

Attack/Placate system

The attack-placate system is often seen in cases of spouse abuse, when the abused attempts to talk hubby out of his anger by reassuring him and in other ways spreading oil over the troubled waters. This too usually fails as the abuser may feel patronized.

Attack/Divert System

Another type is the attack-divert system which as you might imagine can become rather bizarre. This might be effective in minor skirmishes, but simply changing the subject in the face of overt hostility is weird, and leaves the problem unresolved.

Acknowledge the Affect

For the best method to deal with such emotionally laden situations, I hearken back to my mantra of “acknowledge the affect.” In such cases, the message the attacker is trying to send is that he is feeling some kind of negative affect such as: anger, hurt, envy, jealousy, or fear.  Statements such as “I can see you really feel strongly about that” or “are you angry with me?” will often defuse the situation.  It is not necessary to change your opinion or point of view, but simply to communicate that you understand how he feels.  If your attacker’s affect is not available then one can use his own such as: “I feel …………” The concept has wider application, for in any emotionally charged situation it only makes sense to deal with the emotions rather than to ignore them.

What’s Next?

In my next blog, I plan to focus on child rearing. I am well aware there are probably hundreds of books written by people who are convinced they know better than you how you should raise your kids.  I don’t plan to do that since I have made plenty of mistakes in that department; although my kids all turned out well in spite of my screw-ups.   Rather than directions as to how one can raise perfect little people, I plan to provide helpful hints on how to screw up your kids lives: I call it “How to screw up your kids without even trying.”

Thanks for reading!