By Ann Rose Simon, LCSW
The trauma of childhood sexual abuse has a devastating impact on the development of the child. This early experience of intermingled terror, helplessness, betrayal, and loss of control, infused with feelings of shame and guilt, is a deadly mix of overwhelming physical and emotional events which impede the child’s evolving sense of self. This damage is further compounded when there is no opportunity for the abused child to receive support and understanding from loving, comforting adults in his environment. The child senses his isolation, quiets his voice and stifles his screams. Knowing that his environment requires secrecy and silence, the child disconnects from the full impact of what is happening to him. This process of “dissociation” is a method of survival for the child and a way to distance himself from the unbearable pain of the experience.
Although dissociation allows the child to temper the pain of the maltreatment, it does not totally erase the memory of the abuse. The memory remains powerful in the form of nonverbal body memories throughout the childhood years, and often into adult life. These body memories often find expression in bodily symptoms, emotional and cognitive restrictions, and in impulse control problems, all of which seem to the adult as unrelated to the childhood abuse.
The case material which follows tells of my five years of psychoanalytic work with a man whose experience of childhood sexual abuse, combined with his stultifying family environment, had robbed him of his ability to give voice to his pain. Although he had a conscious memory of his abuse, he shaped his life to avoid confronting the full range of affects that this trauma had evoked. Instead, through dissociation he disconnected his memory from the anguish which haunted the rest of his life. Over the years his body became the vehicle through which he experienced and expressed his feelings of shame, fury and betrayal.
When Ed walked into my consulting office, I did not know that he was a victim of childhood sexual abuse. His presenting problem was a serious depression with frequent thoughts of suicide which emerged after the failure of his business. When Ed entered my office I saw a nice looking, impeccably dressed man. He wore monogrammed cuffs on his well starched shirt, had manicured nails and a handsome, expensive watch, all of which gave him the appearance of a man of means. He had a friendly, likeable manner, and a charming and sometimes endearing sense of humor.
Although Ed had never been in therapy before, he seemed comfortable with the role of patient and from the beginning came three times a week and used the couch. Ed had no difficulty finding words to fill his sessions. He talked about his depression, his regret about his business failure and his feelings of helplessness and desperation. When he lost his business, he was left with a debt of about $80,000. This was devastating to him. To earn money to pay off his debt and support his family of a wife and two adolescent children, he took a job as a salesman in a clothing store, a role which felt totally humiliating to him.
Although he did not state it as a problem initially, he soon told me about the longstanding problems in his marriage of 20 years. He and his wife rarely spoke and had not had sex for over a year. Over the last nine years he had had three extramarital affairs the most recent and ongoing one being about seven years old.
During the first few weeks of our work together, I learned how Ed used his body to contain and express his many longstanding anxieties and conflicts. He had a history of headaches since childhood and had for years been taking daily doses of an over-the-counter pain medication to treat them. In addition, he had chronic sleep problems and 11 years ago developed an ulcer.
Ed also told me about his addictive tendencies and impulse control problems. He smoked three or four pack of cigarettes a day for most of his adult life and has had several violent outbursts where he has broken something or felt that he wanted to kill someone.
As I began to work with Ed, I wondered what combination of family dynamics and life circumstances contributed to bringing this man to the point where his love and his work life were in a shambles, his physical health compromised, and his sense of personal integration shattered. During the first few months I learned that Ed grew up in a working class family in an environment which he described as emotionally impoverished with little interaction, sparse conversation, and no displays of affection.
Ed remembered his mother as a simple, dependent woman who had trouble with English even after being in this country for many years. Ed remembered her as a “stone faced” woman who was not shown respect by her family and who seemed to suffer a great deal from a number of physical ailments. She died five years before Ed began his analysis.
The picture that Ed painted of his father emerged more slowly. Over time Ed described a very weak, passive, dependent man who was taken care of by his wife. The family story was that Ed’s father had been manipulated by his older brother who somehow managed to keep his job while Ed’s father ended up on unemployment. He was a religiously observant man and Ed suspected that he wanted to be a rabbi. But since this did not happen, he had strong hopes of Ed becoming a rabbi. There was no family discussion, but from age seven to sixteen Ed studied Hebrew as his father required. His father was still alive when Ed entered treatment.
Ed had a married older sister. During adolescence Ed learned that he had a brother who died in infancy 10 years before Ed was born. His sister showed him a familiar family photo of his parents which had been trimmed to eliminate the picture of the infant brother who died. Until then, no one in Ed’s family talked about the baby’s existence. Thus we discovered that Ed’s home environment was one in which intense emotions were handled by massive denial.
Ed learned the language of his family, the language of silence. As a child he was a quiet, compliant, “good boy” who, Ed told me, was sometimes viewed as “an angel” by his parents. He was a mediocre student and was socially very shy. He studied Hebrew although looking back he realizes that he “hated every minute of it.” Ed remembered this childhood as lonely and bleak. Thus we see that Ed learned to silence his voice, to stifle his initiative, and to bury his defiance.
Phase I: The First Year of Treatment
From the beginning Ed had a positive transference toward me and talked freely about the pain of his present life. I began to see that talking was an important aspect of his charm and one of his most valuable assets in his work as a salesman. But talking was also one of Ed’s most pervasive resistances. Ed’s charming, chatty, often humorous approach was quite adaptive in his life, but he used his words to avoid and obscure experiencing and expressing the feelings between himself and the person he was interacting with. He used words to please, appease, amuse, and to avoid unpleasant thought or feelings with me and with others.
During the first three months of Ed’s analysis, as he spoke primarily about his current life, he was disturbed by the realization that he remembered so little of the details of his childhood. In his fourth month of treatment as he was talking about not being able to do anything in his current life and feeling as if he was in limbo with no direction, I asked if he remembered ever having this inhibition in his early life. He thought for a moment and remembered his fifth grade schoolteacher who used to say that Ed “had potential,” but needed “a bomb” put under him. He then went on to recall and describe a number of classmates in rather uncharacteristic vivid detail. At one point he smiled and said, “Funny how you can remember.” This was the first session in which Ed allowed himself to feel safe with his memories.
The next day he reported that he enjoyed the previous session. He continued to recall teachers and classmates and had a memory of his family moving to a different neighborhood shortly after his bar mitzvah. Then he became silent. This was the first time words did not flow. When I asked him where his thoughts were he told me for the first time about Robert, a young man 10 or so years older than himself with whom he had a childhood sexual relationship from age seven to thirteen. I asked what he remembered. He had some memory of mutual masturbation, but his thoughts went quickly to the part played by Robert in his life and in the life of his family. He had the feeling that Robert “was always there—he was like the adopted son.” Ed felt that Robert took good care of him by taking him to baseball games and hanging out with him after school. “He would have run through a burning building for me” were words that Ed said then and repeated many times thereafter. As he spoke these words for the first time, his carotid artery started to pound, a physical symptom which occurred from time to time when powerful memories emerged. I wondered what words Ed’s body was speaking that his mouth could not utter.
Ed then told me that I was the only person he had ever told about this relationship. I wondered to myself where his parents were during these years of abuse.
This revelation intensified the positive transference. He now talked about how he looked forward to coming to sessions—“I walk around depressed until I come here,” he would say. He referred to my office as his “sanctuary.” He was relieved that telling me about Robert had the effect of diminishing his longstanding fear that he was homosexual. He was now able to go to the gym without the anxiety which he had previously experienced.
Alongside the positive transference toward me, we began to get glimpses of the fury that lay buried within Ed. Ed had told me that he never dreamed, but in the tenth session he brought in a dream fragment. He said that all he remembered was that there was a dog that was black. Then he said, “I had another dream that I don’t remember, but I know it was a violent dream—not violent, but it had action. I could kick myself for not writing it down.” Ed’s associations were that he was not a violent person. He became silent, thought for a moment and then said, “Unless I’m pushed.” He went on to describe two incidents where there was some provocation by another man and Ed became violent. He then talked about his girlfriend’s prying making him uncomfortable, and then about two business associates who are not honoring a financial commitment to him. He said, “It’s at the point where they have their hands on me. I’d be out to get them if I weren’t in such a bad financial situation.” He then remembered an elementary school incident in which he “almost killed” a bully by pounding his head against the ground.
Ed’s associations allowed us to begin to explore early in his treatment two conflicting experiences of himself; that is, his experience of himself as “not violent,” and his potential for fury with its murderous wishes and aggressive behavior.
Ed began to enjoy the experience of looking more deeply within himself. A few weeks later he brought in another dream. Ed dreamed that his left arm was cut open like a French bread and he was dabbing it. He woke with a start. Ed associated to his left arm being his weaker one. He went on to talk about how important it is to present himself well to the world and to look better than the guys he works with. Although the potential richness of this dream, that is, its allusions to castration, homosexuality, bisexuality and masturbation, were set aside for the moment, Ed began to observe through this dream that his experience of himself as powerful or powerless, active or passive, proud or shamed is modulated through how he presents his body to the world.
Early Negative Transference
As the weeks passed I began to notice subtle negative elements in the transference. When Ed said that he was changing coffee shops because he felt that the waitress was getting to know him too well, was he expressing his anxiety that I would become too intrusive? When Ed commented that he didn’t really know what he was paying his accountant for, was he expressing his fear that I might exploit him? Some early attempts to explore his negative feelings were met with denial. He could not utter words to me that acknowledged to himself any feelings of anger, mistrust or fear of betrayal.
Intensification of Mother Transference
Finally, several months into treatment I interpreted an uncharacteristic silence to mean he might be having thoughts about me. Ed said that he was upset because he understood a comment I had made about him “evaluating” his treatment to mean that I was evaluating him and was going to send him away because he was not making enough progress and because he was not paying a high enough fee. In other words, he feared that I would use him narcissistically, as Robert had. From this we were able to explore his feelings that he had to “produce” and to “give” in order for people to value him and to give to him. When he became aware that his fear was the result of his expectation rather than my intention, he was very moved. His eyes welled with tears and he said he was greatly relieved. He was flooded with memories of his mother. He pictured her grave, felt that he missed her and talked about how hard she worked to pay for his bar mitzvah. The more negative transferential feelings were replaced by the good mother memories and transference. At the end of the next session, he commented that he wished he could stay in my office to make his business calls. Ed’s response led me to speculate that his mother did provide a good enough nurturing environment in Ed’s early development.
The positive mother transference intensified to such a point that his anticipation of my five-week summer break brought on a feeling of panic. Ed dreamed that he was in a hotel and the bellhop could not find room #3. He ended up in a dining room and was screaming at the waiter because he wanted dinner sent up to his room but they couldn’t find the room. He woke up in a sweat. He associated to our three sessions per week and wondered if he had a right to depend on me while I am away. Ed was afraid that he would not be protected, fed or heard during my vacation. He once again denied any anger at me for leaving.
My countertransference during this first phase was that I really liked Ed and felt pleased to have a very interesting analytic case. He became rather special to me. I was particularly aware of this and wondered if I would be drawn into an enactment in which I would make him my good boy/my good patient and perhaps overvalue his productions.
Diagnostically I was uncertain about Ed at this point. The person that Ed tried to present to the world had strong phallic traits. He was resolute, self assured, and sometimes reckless in business and in his driving. But this was only a veneer and a defense against a deeper passivity. I was also beginning to see that his intact outward appearance truly masked an emptiness inside, an intense vulnerability, impulsive behavior, and object relations that were shallow, need gratifying, and transferential.
It appeared that the cumulative trauma of his home environment, as well as the trauma of sexual abuse during latency, had led to a massive repression of powerful pre-oedipal longings and conflicts and robbed him of his voice to express the intensity of both his love and his hate. The analytic situation was a totally new kind of relationship for Ed and I felt he was using it to reclaim his voice and bring these conflicts and longings to the fore. In the transference he was making me into the early nurturing mother, but came to recognize his fear that I would pull him from my breast too soon, and that I would use him narcissistically, to satisfy my needs.
Phase II: The Second Year of Treatment
During the second year the transference shifted between me being the good breast mother, Robert, and later, the critical father. When Ed returned from the summer break he informed me that he could not continue treatment because his financial situation was so strained. Although there seemed to be much truth in this, I feel that he was presenting himself to me as the needy child to see if I would take care of him. The trust and comfort which had been established during the first year enabled him to test whether it would be safe to move into a deeper level of transference, that level of masochistically exposing his cravings to be fed and taken care of. After two weeks of exploring these needs I did lower his fee. Although I realize that this was a parameter, I felt that Ed was truly in crisis and we did define it as a temporary measure. With the fee reduction Ed felt grateful, but humiliated. During the next few months he became more passive in his life outside and in the analysis.
In one session he talked about wanting to call me but not doing it. I said, “You feel like a helpless child. You’d like to feel I would be there and that you’d have total access to me, but you are afraid you’d get no response.” He began to sob and said, “Yes, I think I just want to call out for help. I don’t know why I need it.” I feel that the lowering of the fee allowed Ed to loosen his defenses against his longing for attachment and containment and to experience them with me in the transference.
Lifting of Repression: Gagging
At this point the Robert transference began to intensify. Ed again began to question if he was homosexual and actually bought some gay magazines. His memories of the Robert experience became more vivid and he was able to think about and give voice to some of the details of the sexual relationship. In one session Ed’s associations went from having a cold, to his tendency to gag, to his inability to floss on his left side of his mouth, to his dentist’s comment that it was a good thing he’s not a woman because he would not be able to have oral sex. I said I was reminded of his sexual experience with Robert and asked what he remembered. He immediately said, “I gagged! I tried to do it several times, but I gagged!” This memory led to other memories of Robert showing him pornographic pictures and of Robert’s hands being all over him. He had vivid memories of Robert’s face, but was struck by his inability to remember Robert’s mouth, an interesting example of Ed’s use of visual denial.
Masochistic Identification with Father
About a month later I began to realize that although Ed’s words flowed, his life changed very little. He complained endlessly about his wife, his business partner, his children and his girlfriend. He was paying off his debts regularly, yet he spoke as if his financial burden was increasing. My countertransference was at first that I felt sorry for him. I felt it was time to raise his fee, but I did not bring it up. I wanted to continue to be the good breast mother. Before long my feelings changed to frustration and then to irritation. I then realized that Ed’s feelings of suffering and powerlessness were being used to defeat the analysis and to sadistically torture me. Ed was locked into a powerful resistance, a masochistic identification with his father.
In one session Ed was bemoaning the fact that his son did not qualify for financial aid at college and that his wife refused to dip into savings to pay off some bills. My efforts to clarify or to empathize seemed to fail. I realized that I had to confront as resistance not only his helplessness, but also his sadism. I went out on a limb and said, using his verbal style, “Ed, you bullshit yourself a lot, and now you are trying to bullshit me. I think the reality of owing what you owe is not as awful as you make it. I think you have a need to see yourself and keep yourself in this powerless, suffering position.” Ed was quiet for a moment and then said, “Maybe I do.” He thought for a moment and then wondered aloud why he needed to suffer. This was the first time Ed asked “Why?” He was quiet for a moment and then said that somehow he felt better. He felt he had something to think about. “Sometimes when I leave here I just turn off—I don’t think about anything we’ve talked about.”
This I believe was the first example of our working alliance. Ed was able to use my interpretation that his suffering was a resistance and was able to identify for himself another resistance of isolating the analysis. In subsequent sessions Ed was able to explore that when he feels powerless he behaves just as his passive father did. I was then able to suggest that perhaps he felt he had to suffer and act powerless with me, as he had done with his father and with Robert. He had to behave masochistically to hold on to these relationship and to insure that I would continue to be there to take care of him.
Intensification of the Negative Transference
About two weeks later a dramatic shift in the transference occurred. I wondered aloud if a series of incidents including a last minute session cancellation might be an expression of aggression to me. I said that with me and with others Ed often feels like the victim, but his behavior is sometimes hostile and provocative. He responded by berating himself and then began to have difficulty breathing. He left the session a few minutes early saying that the room was closing in on him. I was not sure what had happened at this point. I thought I might have been too harsh on his frail ego and that he might not return. But he did return the next day, and was able to talk about how my being critical of him was like his father being critical of him for not becoming a rabbi. This opened up a whole segment of Ed’s history: his going along until age16 with the charade that he would become a rabbi, how much pleasure this would have given his parents, and how he felt he had deeply disappointed them, especially his father. But Ed’s most painful realization was that the only access he had to his father was their praying together, and that other than his studying his Hebrew and his goal of becoming a rabbi, nothing else that Ed did mattered to his father.
Inability to Speak Hebrew
This history helped us to understand another aspect of Ed’s silence. Ed had reported early on being baffled by his inability for many years to read Hebrew aloud, while he could read it to himself and he could read aloud a transliteration. As we explored the complexity of his feelings toward his father, we learned that his silence, his inability to speak the Hebrew letters, was a silent expression of his fury at and retaliation toward his father. It was an angry rejection of the only words his father could ever say freely to him. Through his silence Ed was saying, “If I can’t say what I need to say (his anger, feelings, and needs), I will not say what you need me to say (the Hebrew letters).”
I realized that the implications of this speech inhibition on Ed’s ego development were far reaching. First of all, since it became generalized to “having nothing to say” to his parents, it was a regressive giving up of an ego function. In a family in which putting things into words was considered an aggressive act, his inhibition of speech was a primitive defense against assertion and the expected rejection. Secondly, it affected his object relations in that the growth of an interactive empathic process was stunted and an isolated narcissistic position was maintained. Since Ed could never check out someone else’s feelings, a self referential system developed which was cut off and lonely and much of his experience remained unprocessed. Thirdly, secondary process thinking was limited and thinking was therefore impaired. Finally, his impulse control was affected. Since words bind affects, there was a need for powerful, archaic control.
Repeating the Past
Another important dynamic which emerged during Ed’s second phase of treatment was a repetition compulsion which pervaded his entire life. As I got to know Ed and the nature of his relationships, I realized that despite his outwardly warm and engaging manner, his object relations were shallow, barren, stereotyped, and unchanging. In this way he was reliving the relationships of his childhood. His wife was like his mother—childlike, dependent, turning to Ed to take care of her. She was also like his father in her inability to empathize with Ed’s suffering. Like the child, Ed could not verbalize his dissatisfaction nor could he leave this unhappy situation. His extramarital affairs were the escape which provided the talking, the affection, the sex, and some degree of understanding outside the home that he had had with Robert. But he complained that his girlfriend was too intrusive, just as Robert had been.
Another aspect of this repetition compulsion was that Ed spent his life looking for a father who would be caring, strong, and protective. In his childhood, Robert was the substitute father who was “always there” for Ed. But at the same time, Robert ended up disappointing and betraying him. In Ed’s analysis we came to see how there were a series of men in his life, beginning with Robert, whom he viewed as father figures. We were able to trace how each of these men disappointed him and how each came to “screw” him in different ways.
A Shift in the Transference
Toward the end of the second year Ed went alone to see the Jackie Mason Show and brought me back a book, a transcript of the show, with the inscription inside, “To Ann, Best Wishes, Jackie Mason.” I commented that Jackie Mason had studied to be a rabbi, but became a successful comedian. Ed laughed and said that perhaps he was like Jackie Mason in some ways. I generally do not accept gifts; however, I accepted this book and told Ed I would keep it in the office to remind us of its significance to Ed.
The work during the second year began to really take hold. Ed’s growing awareness of the impact of both his father and Robert on him seemed to free him from the suffocating embrace of these identifications. Ed became markedly less passive in his life outside and in the transference. My diagnosis of Ed changed during this second year as I watched the analytic process reveal a much more intact ego than I had previously thought.
Phase III: The Third to Fifth Year of Treatment
The Working Alliance
The third year of Ed’s analysis heralded the development of a true working alliance. Denial had been replaced by comments like “I find it very exciting to find out things about myself.” This alliance allowed Ed to have the following session.
Ed told me about an almost violent argument he had with his business partner. When I asked him what he thought about it he said, “Child Stuff! We were like two kids…” He paused and then said, “But if he had taken another step I would have killed him!” I asked him how he felt about such fury over a relatively trivial issue. He was silent for a few moments. Then he said, “I think I should have fought Robert. I should have picked up one of his weights and hit him on the head! I can picture myself doing it.” He began to sob loudly. He got up from the couch, still crying, and began pounding the wooden sill near the window shouting, “I should have killed him! I should have killed him! I should have killed him!” He continued to sob. After a few moments he sat down apologizing profusely for his outburst. Then he told me again about the man he almost killed a number of years ago. “Maybe that’s why I let him beat me, so I could fight back.” We were able to explore how Ed’s unconscious shame about his relationship with Robert kept him from fighting back and kept him from speaking the words he had just spoken. The dramatic eruption of Ed’s fury toward Robert finally put words to his feelings.
This dramatic session heralded important changes in the nature of Ed’s treatment as he began to become aware of the richness of his unconscious fantasy life. Through the exploration of his fantasies, it became clearer that the sexually abusive relationship with Robert had a pervasive influence on Ed. Although we had long known that he both longed for and feared being passive and being taken care of, Ed discovered that he feared passivity because it meant he was castrated and feminine. He told me that after waking up from knee surgery, he was in a panic for a few seconds because he feared they had cut his legs off. Ed came to feel that so many things he did in his life had been done to prove that he was not homosexual—getting married, having extramarital affairs, and even accumulating money.
Over the next two years of Ed’s analysis, a number of changes occurred in Ed’s life. His depression lifted, as did his intermittent suicidal thoughts. His headaches decreased markedly. He felt he was able to listen better to the people in his life and to concentrate more on his work and when listening to music. He became better able to empathize with his girlfriend and his children, and sometimes even his wife. But what was of greatest delight to Ed was when at the Passover Seder he was once again able to read aloud the Hebrew words. After more than 30 years of silence, Ed was able to reclaim his voice.
Ann Rose Simon, LCSW is a psychoanalyst in Scarsdale, NY and NYC where she works with adults, adolescents and children in individual, family and couple therapy. Her areas of interest are childhood sexual abuse, eating disorders, body image, relationship problems, career issues and brain injured patients and their caretakers. She is a graduate of NPAP and the Object Relations Institute. At NPAP she serves as V P of the Training Institute and a member of the Training Committee. At ORI she serves on the Board of Directors, is Chair of the Education Committee, and a member of the Training Committee. She is a supervisor and Training Analyst at both institutes and on the faculty of ORI. She is a member of the Steering Committee of the Neuropsychoanalytic Clinical Study Center of NPAP which provides psychotherapy for patients with focal brain lesions and strokes.