Wednesday, September 15, 2010

Childhood Sexual Abuse Taken out of Context

Albert Einstein was said to have had a sign over his office at Princeton that said, “Everything that counts cannot be counted and everything that can be counted does not count.” When it comes to studying the long-term psychiatric effects of child sexual abuse (CSA), it is wise to keep this in mind.

CSA, particularly within an individual’s family of origin, has been implicated as a risk factor for a wide variety of adult psychiatric diagnoses and behavioral problems, including borderline personality disorder (BPD), dissociative identity disorder, depressive disorders, anxiety disorders, alcoholism, eating disorders, somatization disorder, sexual dysfunction, and suicide attempts.

The nature and effects of interpersonal relationship patterns, such as those that transpire in the families of CSA victims, are so complex and unique that it is almost impossible to quantify them for an “empirical” study or “proof” of the causation of a specific psychiatric problem.

Biological and genetic factors almost certainly play a significant factor in predisposing a victim to one or another psychiatric problem. However, that is not the complete answer to two questions: why do certain individuals develop one disorder while seemingly similar individuals develop a different one, and why do some individuals who appear to have suffered severe abuse develop no psychiatric problems at all, while others who seem to have had relatively minor abuse develop several disorders?

Studies that examine psychological and social variables in CSA tend to focus on factors such as who the perpetrator was, what type of abuse was suffered (penetration vs. fondling, for example), the severity and frequency of the abuse, and whether the social welfare or criminal justice system became involved. Rarely, the response of non-abusive relatives to CSA victims, usually the mother, is examined. Most results of such studies have been disappointing regarding finding links between specific psychiatric disorders and these variables.

Often the backgrounds of CSA victims are also characterized by several other types of adverse childhood experiences or generally chaotic family relationships. Not only is that fact often ignored by those who study CSA, but these investigators usually ignore the entire environmental context in which CSA takes place.

Clearly, most of the victim’s interactions with perpetrators and bystanders alike occur at times when abuse is not occurring, and these other parts of such relationships may also have profound effects on the victim’s later relationships and self image. Again, due to their staggering complexity and intermittent nature, they are difficult to study using statistical techniques.

Contextual factors include the entire history of the relationship between the victim and the perpetrator: what is said during, before, and after the abuse; what the relationship between victim and perpetrators is like when the abuse is not taking place; what other people in the family are doing at the time of the abuse and at other times; how each family member relates to the victim; who if anybody knows what is going on and whether or not they intervene; and a whole host of other characteristics of the interpersonal environment of the victim.

The context of the abuse is made even more complex due to the effect of chaos, the theory of which predicts that even small differences in environmental conditions can have large future effects. The so called butterfly effect would occur when small differences in the interpersonal environment of a child lead to a cascade of events which will be somewhat unique to each individual and greatly impact the exact nature of any psychiatric responses to the CSA.

Even during abuse, a victim’s interactions with a perpetrator is not limited to the sex act alone. Words may be spoken; other activities may occur right before, right after, and even simultaneously. For example, personality theorist Lorna Smith Benjamin discussed how the nature of verbal interactions with the perpetrator at the time of the abuse may influence the production of later BPD symptoms. The tendency of some BPD patients to have unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation, for example, might result from a case in which a father “directly instructed her [the incest victim] in how to shift from idealization to devaluation.

“Early in a night visit, the father may say, ‘You are the light of my life; I live for these times together…’ Then, after the incestual attack, he might say, “It’s your fault. You bitch. You whore. You’re filthy. Go take a shower’” (Interpersonal Diagnosis and Treatment of Personality Disorders, 1st edition, p.119).

In helping to create another BPD symptom, at times (other than those times in which CSA takes place), the BPD patient’s autonomy may be attacked by either or both parents, with an accusation of disloyalty if the victim tries to assert her or his independence. This may lead to the type of self-sabotage often seen in BPD patients.

Other and different types of dysfunctional interactions may lead to the development of still other BPD symptoms, leading not only to the unique clinical picture of each individual CSA victim, but to the different combinations of DSM criteria seen in different patients with BPD.

In getting a full description of patients of the entire family context in which CSA takes place, and also tracing back the family context in which the parents grew up (genograms), it becomes possible to make an educated guess about exactly why a given patient developed particular coping skills. The particulars will be different with every patient and every family, but certain themes do come up again and again in patients who develop certain disorders like BPD.

1 comment:

  1. Having just come away from a session with my mother where she places the blame on everyone else but herself, I am the difficult child and was only lovable when my second husband was alive as she adored him, in fact he was able to control her vicious tongue by a few words and was protective of me but in a gentle way. I react to her sarcasm and lack of warmth badly and only stand up to her occasionally as normally I treat her as a patient/client. There is no emotional bond as I do not trust her because previous disclosures have been discussed with 'best friends' and leave me fragile. She states I am secretive. I believe I am an open person with people who I trust, which does not include her or my siblings.