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The following example illustrates how unresolved issues and problems in the family can negatively affect a child and his capacity to recover from the abuse. The majority of the therapeutic work was not directly related to the child’s victimization. Tony was seen for over 18 months for weekly individual sessions:
Tony, aged four, was brought into treatment following several incidents where a neighbor's boy (aged eight) had fondled him and made him perform oral sex. The older boy, John, threatened to hurt Tony and his father if Tony disclosed the abuse. Following the abuse Tony had become more aggressive at home and at his playgroup. His father, Peter, eventually found out about the abuse from Tony and sought treatment for him.
Tony was an unhappy and angry boy. His mother, Rita, was a drug addict who had abandoned him on several occasions beginning when he was six months old. Peter, a recovering alcoholic, had poor parenting skills. Rita had recently abandoned Tony at precisely the time the sexual abuse began. Tony believed that the two incidents were linked somehow. He also believed his mother had left him because she knew about the abuse and thought he was bad or disgusting.
Tony felt frightened and powerless due to the sexual abuse. He frequently engaged in aggressive tantrums at home. He was also traumatized by his mother's sporadic abandonment. Tony was troubled by his father's alcoholism, manifesting itself in his father’s emotional unavailability and depression. Peter had been unable to soothe or nurture Tony and unable to set appropriate boundaries for him particularly in relation to his aggressive tantrums. Furthermore, Rita had been allowed to enter and exit Tony’s life with no consequences for her irresponsible behavior. This was in large part due to Peter's collusion in the denial of Rita’s addictive behavior. It was also due in part to her constant promise that she was trying to get better.
At the start of each session, the therapist entered the waiting room and invited Tony to join her in the therapy room, but he refused. Next, the therapist would tell him to come when he felt ready and then go into the room and begin to set up toys and play. Within a few minutes, Tony shyly peered round the door and reluctantly entered. He then stood and watched for a short time before joining in. This ritual went on for the first two months of therapy. Understandably, people coming and leaving were emotionally laden issues for him and had to be handled sensitively. In addition, it was his way of being in control and rejecting the therapist before she had the opportunity to reject him.
Tony suffered from physical symptoms, such as stomach pains and headaches, which were alleviated in the first few months of treatment. He also suffered nightmares, which he processed utilizing drawing and coloring. He changed these nightmares into stories in which he eventually became the heroic figure who annihilated the various monsters. In these pictures, he became very large and the ‘bad’ figures diminished in size. His nightmares began to cease at that time.
During the first five months of therapy, Tony had tantrums. His play contained angry and aggressive themes, often revolving around him being violent and seriously injuring others, the violence being directed at his abuser. The therapist set limits and boundaries around his behavior, letting him know that it was safe to express his anger, but that he could not destroy objects hurt himself or the therapist in any way. After a few months of therapy, there was reparation after his violent play themes. This play paralleled a decrease in aggressive tendencies at home.
By this point, the father had become better at setting boundaries and containing his son. Tony was bright for his age and was able to understand, in a limited capacity, that his 'acting out' was related to feelings of hurt, sadness, and powerlessness. He became aware of previously repressed affects and began portraying some of these feelings during the therapeutic work. As a result, his feelings of loss and powerlessness, relating largely to abandonment by his mother, were the central issues next manifested in the play therapy sessions. Tony wanted to play a game he entitled ‘animals’. This game was repeated over and over during a six month period. The therapist would be an animal of his choosing, trapped in a cage. He pretended to be asleep (defenseless) but he woke and captured the therapist animal whenever she tried to escape. He pretended to cry if it took him a while to catch her but inevitably was able to capture her every time.
Tony was determined to play hide and seek with objects at every session. He became frustrated and angry if he could not find the object immediately. His level of frustration-tolerance increased over time, and he was gradually able to trust that the object was present even though it was not within his eye's view (object constancy).
Peter was also actively involved in Tony’s treatment. Much of the adjunctive therapy focused on assisting him to develop healthy parenting skills. This work helped him to become more confident, so that his self-esteem improved. Peter engaged in Alcoholics Anonymous, and was able to remain abstinent from alcohol and deal with many of his own unresolved childhood issues.
Peter was finally able to set boundaries and limits for Rita as well. She was given an ultimatum that she needed to seek professional treatment and get better, or she could not be involved in Tony’s life. Peter maintained full custodial rights. Rita was unable to follow through with any treatment and was therefore unable to see Tony any more.
An important piece of the subsequent therapeutic work with Tony was grief work involving the loss of his mother, helping him to realize that his mother had a problem and that he was not the problem. Tony had been continuously re-traumatized by his mother's appearances and disappearances. He had felt rejected, hurt and powerless, which manifested in his aggressive behavior. Tony had previously been unable to rely on his father for appropriate parenting. Tony’s self-esteem had been very poor before the victimization, and it had plummeted following his abuse.
After a year, Tony’s favorite game became 'baby,' in which he was the baby and the therapist the mother. He sucked on the baby bottle and lay under the table. His therapist sang or spoke to him in comforting tones. Tony expressed feelings of loss related to his mother and sadness about what she had been unable to give him, particularly consistent affection.
Tony made use of the play telephone to communicate his feelings to his absent mother, feelings that he had been unable or afraid to express because of his fear of her leaving him if he displeased her. Towards the end of therapy, Tony sometimes played the mother figure, and the therapist was directed to be the baby. He sang and spoke in a soothing caring voice, which indicated that he had internalized the experience of being nurtured and could be nurturing as well. His father validated this hypothesis by saying that at home Tony was able to stay at one activity for longer and was playing in a gentler, calmer fashion.
Tony utilized therapy successfully. A bright and sensitive child, he worked hard in the therapy process. His self-esteem improved considerably, and his range of affect broadened. The aggressiveness and fear that he felt upon his arrival in therapy was strongly alleviated. Much of this can be attributed to the work done with his father, both in the adjunctive therapy and in his own process. Over the period of Tony’s treatment, the father became a much more competent parent on whom Tony could now rely and depend for nurturing and support.
Reflection Exercise #1