Child Sexual Abuse and Unresolved Trauma: A Case Study

Rabeea Irfan*

Department of Clinical Psychology, School of Professional Psychology, University of Management & Technology, Lahore, Pakistan

*Corresponding Author: [email protected]

Abstract

Child sexual abuse is one of the most traumatic incidents that can alter the course of life of an individual. This article highlights the case of a 52-year-old man who was having difficulties in managing his anger, with complaints of anger management issues and dealing with repetitive and intrusive thoughts. A thorough investigation revealed that the client had been a victim of sexual abuse for years during his childhood, and all the symptoms stemmed from unresolved conflicts of the past trauma. A comprehensive management plan including behavioral, emotional and cognitive strategies was devised. Pre and post -management assessments indicated a marked improvement in the client's symptoms. This case focuses on the role of parents and society in providing an empathizing network to the victims, and a need to educate the children about sexual education and rights.

Keywords: child abuse, pedophilia, restructuring of early memories, sexual abuse, trauma, unresolved issues

Introduction

Sexual abuse towards children is a reality worldwide (Barth et al., 2013). The World Health Organization (WHO) defines child sexual abuse as ‘'the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. This may include but is not limited to the inducement or coercion of a child to engage in any unlawful sexual activity; the exploitative use of a child in prostitution or other unlawful sexual practices; the exploitative use of children in pornographic performances and materials" (Rizvi et al., 2023).

During the last two decades, extensive work has been done to establish links between childhood abuse or maltreatment and adulthood psychological and psychiatric repercussions (Loveday et al., 2022). It has been established that child abuse may lead to mood and anxiety disorders, post-traumatic stress disorder, and personality disorders including antisocial and borderline personality (Lippard & Nemeroff, 2020). The psychological distress caused by child abuse has been found to have an indirect effect on academic performance in school children by Gresham and Karatekin (2023). In addition, sexual abuse during early childhood has also been linked with substance abuse (Hogarth et al., 2019).

Apart from these devastating consequences, social and familial support has emerged as a strong predictor for post-traumatic growth and wellness (Lynskey & Fergusson, 1997). Furthermore, the presence of a compassionate and warm parent and teacher figure in the life of a victim has also been reported to have a positive impact on the individual (Stice et al., 2004(. Herd et al. (2022) attempted to identify the individual and social risk and protective factors as predictors of trajectories of post-traumatic stress symptoms in adolescents. The results revealed that a high trajectory was characterized by the absence of physical/sexual abuse and other traumatic events, along with emotional regulation, higher self-esteem, less risky peers, and emotionally stable parents.

In Pakistan, the plight faced by victims of child sexual abuse has increased tenfold due to the denial by the general population of the traumatizing truth. Frequently, the victims are abused by predators within the family (Avais et al., 2020). Acceptance of the existence of such an issue threatens to tear at the social fabric of extended family culture, which is why the first instinct of the victims' parents is often to brush the event under the rug. Alternatively, there are cases reported in which the victim was blamed and shamed by the family for abuse (Gillani, 2009). Combined with a lack of sexual knowledge and rights among children, this environment forces abused children to hide their turmoil from their families (Pratiwi & Asyary, 2017). Over the years, child sexual abuse creates unresolved conflicts among the victims, and it has been shown to affect the behavior, emotions as well and relationships of victims in adulthood (Hall & Hall, 2011). Children with a history of child abuse are likely to show differentiated reactions to happiness, fear and anger (Berube et al., 2023). Specifically, negative emotions such as anger, fear and anxiety are readily detected and expressed by the adult victims of child abuse, whereas positive emotions such as happiness often receive a tapered-down response (Najman et al., 2020).

Lack of awareness about sexual health and body autonomy combined with an authoritative culture where adult figures are expected to be obeyed and respected creates an opportunity for predators (Gillani, 2009). The victim child is left bewildered and confused, often trapped in a vicious circle of abuse with no understanding of the trauma, or no familial or social support (Downey & Crummy, 2022). This cycle often continues for years, and victim experiences a plethora of psychological consequences.

While victims of child sexual abuse sometimes ruminate with their demons for years or even decades before approaching mental health providers, there is evidence that different types of therapies, including CBT and REBT, have been proven quite effective in helping the clients break free from their unresolved traumas (Somers et al., 2022). In addition, techniques from the psychodynamic and gestalt schools of thought have also been reported to have a positive impact on the mental well-being of victims (Bar-Tur, 2023). Barglow (2014) elucidated a comprehensive management plan in his case study of a woman, victim of sexual assault and unresolved rape trauma. The victim was presented with a feeling of "being numb" after rape. A psychodynamic approach was charted, and the patient displayed improvement after undergoing several sessions. Barglow (2014) maintained that psychological numbing is the mind's attempt to escape the pain. Due to this, a psychodynamic approach is far best suited to deal with such cases (Ulman & Brothers, 1988).

The current study is based on the case of a 52-years old man who presented with the complaints of aggression, repetitive and intrusive thoughts, and relationship issues. The study aims to highlight the effectiveness of using an eclectic approach for dealing with the symptoms and to highlight the devastating effects of unresolved child sexual abuse, along with the management strategies that proved to be effective in alleviating the symptoms.

Case Report: History of Present Illness

The client of the current case study was a 52-years old man who was having difficulties in managing his anger and dealing with repetitive and intrusive thoughts. A detailed interview revealed that he was being abused sexually at the age of 10-15 by a neighbor, a 25-years old (approximately) married woman living alone because her husband worked overseas. The Client's parents used to send him to the offender to help her out various chores. The client reported feeling perplexed at the initial encounter as he had no prior knowledge of sexual relations. He did not divulge the incident to anyone in the family as his father was quite strict and the client was afraid of being blamed and beaten for the incident. The client reported, after a few incidents, he became interested in the activity, as the offender gave him money, toys and eatables every time he visited. The abuse continued for approximately 5 years, after which the offender left the neighborhood.

Afterwards, the client had multiple relationships in which he was physically involved. At the age of 30 years, he got married. Irrespective of his marriage, he had two extramarital relationships which lasted for the initial 10 years of his marriage. The client reported that for the last few years, he found himself thinking about his offender all the time. He often felt angry at being abused at such a young age, but his anger was directed inward as well for enjoying the ordeal. He also felt guilty for his life choices but was not successful in letting go of the past. At present, the client reported trying to distract himself from troubling thoughts related to his past relationship with the offender women, by engaging himself in different activities. However, he mostly found it impossible to break the chain of thoughts. The client reported disturbed sleep, declining performance at work and a disturbed relationship with his wife, as a result of intrusive thoughts about the offender that had almost all day long. It also rendered him unable to work.

Method

Research Design

A single-case experimental design was used for the current research.

Measures

For assessment, behavioral observation, detailed clinical interview, baseline chart for assessment of aggression, thought record form, and tally for intrusive/ repetitive thoughts were used in addition to the scales given below.

Depression Anxiety and Stress Scale-21 (DASS-21)

The DASS-21 is a set of three subscales namely Depression, Anxiety and Stress (Lovibond & Lovibond, 1995). This scale was used to assess the symptoms of depression, anxiety and stress in the client. Each scale has 7 items which makes for a total of 21 items. It is a four-point Likert rating scale. It has a good internal consistency of all three subscales, with Chronbach alpha values of 0.87, 0.92 and 0.89 respectively for the subscales of anxiety, depression and stress. (Thiyagarajan et al., 2022).

Repetitive Thinking Questionnaire (RTQ)

The Repetitive Thinking Questionnaire (RTQ, McEvoy et al., 2010) is a transdiagnostic scale used to assess the repetitive worrisome thinking about self and others. It has 31 items. This questionnaire was used to evaluate the presence and extent of repetitive thoughts of the client.

Ethical Considerations

The client was provided with information about the purpose of the study and the process to ensure his voluntary participation. He also signed an informed consent before he participated in the study. The rationale for administering each therapeutic intervention used was explained to the client. In addition, he was closely monitored throughout the sessions for any signs of distress.

Table 1

Case Formulation of Client According to Biopsychosocial Model

Table 1 shows the case formulation, in which the predisposing, precipitating and perpetuating factors are listed and explained through the biopsychosocial model. The protective factors which were deemed beneficial for the outcome of therapy are also mentioned in the table. The comprehensive case formulation assisted in eliciting the areas which required therapeutic management. In the current case, a traumatic incident in the early years of a client's life was found to be exacerbated due to multiple factors, one of which was the authoritarian parenting style exercised by the client's parents. Due to the strict attitude of the client's parents, especially his father, the client could not confide in the parents about his abuse. Furthermore, the lack of sex education led to confusion and self-blame in the client, who could not understand what was happening to him in the beginning. The fact that the victim was a boy and sexual abuse was perpetrated by a woman indicates that the client was more prone towards feelings of shame, guilt, and stigmatization by family and society The general attitude of society towards child sexual abuse victims kept the client from seeking help and guidance in dealing with the aftermath of abuse due to fear of stigmatization by family as well as society. It led towards forced suppression of emotions for years which eventually resurfaced many decades later.

As a result of all these factors combined, the client found himself dealing with unresolved issues, aggression, feelings of guilt, and turbulent relationships with significant ones in his life.

Therapeutic Intervention

For the management of symptoms, several strategies were used. From the assessment, it was deduced that all the symptoms were caused by the adverse event of abuse during childhood. Therefore, the focus of management was twofold: To provide resolution to unresolved trauma, and to take concrete steps for alleviating symptoms currently afflicting the client. To achieve this goal, an eclectic approach was adopted, combining the principles of behavioral, cognitive and psychodynamic schools of thought.

Psycho-education

Psycho-education is the process of systematic, comprehensive, and structured transfer of information and knowledge from the therapist to the client. This process makes it easy for the client to "make sense" of why he is feeling or behaving in a certain way. In this case, the client was psycho-educated about the impact of unresolved traumatic events on his current life.

Activity Scheduling

Through assessment, it was found out that the client often ruminated about his past when he had nothing to do. To decrease the frequency of ruminating thoughts, he was asked to fill his schedule with multiple tasks which occupied him physically as well as mentally. Through activity scheduling, the client engaged in many activities including physical exercise and teaching mathematics and science to his children. After the addition of these activities, the client reported a decline in intrusive thoughts.

Mindfulness Techniques for Intrusive Thoughts

The client was taught mindfulness strategies for persistent thoughts. In past, he tried hard to "fight" disturbing memories unsuccessfully. The mindfulness strategies of letting the thoughts and memories "wash over him" and "fade away" proved very beneficial, and the client reported improved control over his thoughts.

Role Plays for Aggressive Behavior

The client had episodes of aggressive behavior, for which a few role plays were conducted. Through role-play, the client was encouraged to experience assertive, aggressive, and passive behavior. The role of tone, words and body posture was also discussed. His aggression was monitored with baseline charts throughout management sessions and an improvement was observed in his behavior.

Restructuring of Early Memories

For the past trauma, restructuring of early memories was conducted to provide the client with a new narrative to look, at his past (Edwards, 1990). This technique uses the principles of psychodrama and CBT, combined to make a powerful tool to "restructure" or "reform" emotionally charged memories. The client had been struggling with guilt and was holding himself responsible for all the traumas he went through as a child. The restructuring was carried out during three sessions. Before embarking upon this intense route, the client was first taught progressive muscle relaxation. The imagery technique was practiced to take the client back in memory to his childhood, where he experienced and witnessed the events surrounding his abuse. It was an emotionally taxing experience for the client, due to which the restructuring strategy was paused several times to relax the client using progressive muscular relaxation. Once the client could face the past without experiencing distress, a discourse was held using the CBT principles of Guided Questioning. With the restructuring of early memories, he was successful in finding out a different perspective; one in which a child was failed by adults surrounding him. This strategy was beneficial for the client because it absolved him of the guilt he had carried along for decades.

Letter to the Offender

Finally, to provide the client with a firm "closure" of the traumatic event of the past, he was encouraged to write a letter to the offender. This strategy provided the client with an outlet for channeling out all the aggressive thoughts he had towards his offender. The client reported difficulty in initiating this letter but felt emotionally relieved after this exercise.

Results

The assessment was conducted both pre- and post-management to observe the efficacy of the management strategies.

Figure 1 shows that the management provided proved to be effective in reducing the worrisome repetitive thoughts that the client had about himself and the world. The pre-trial rating was 122, which dropped to 62 after the management sessions.

Figure 1

Pre and Post-Management Evaluation of Repetitive Thinking Questionnaire (RTQ)

Figure 2

Pre and Post-Management Evaluation of DASS-21

The DASS-21 was re-administered after the management sessions, which showed a decrease in symptoms of anxiety, depression and stress. As shown in Table 1 above, the symptoms of depression decreased the most, from 25 in pre-trial to 13 in the post-trial assessment. Stress was also reduced from 24 to 14 after management sessions. The symptoms of anxiety were also observed to be reduced, albeit a little one.

Figure 3

Pre and Post-Management Evaluation of Intrusive Thoughts and Aggression of Subjective Rating Scale

The subjective rating scale was re-administered after the management sessions to evaluate and measure the changes brought about. The client reported a significant decrease in both intrusive thoughts and aggression, where the rating of intrusive thoughts reduced from 10 to 3 and for Aggression the score decreased from 8 to 4.

The post-management evaluations elaborated above indicate a decrease in presenting complaints of the client. Therefore, it can be concluded that the use of an eclectic approach to target specific issues was efficacious in reducing the symptoms.

Discussion

The insights provided by this case are twofold: For clinical psychologists as well as for the general public. For the former, this case exhibits the effectiveness of using an eclectic approach, when the need arises. Restructuring of earlier memories, the central strategy used in this case borrows heavily from the psychoanalytic and cognitive behavioral schools of thought, thus making a formidable combination of a therapy that can be a very effective tool for clients dealing with unresolved traumas of the past.

The case portrays a unique picture of child sexual abuse as the predator was a woman abusing a boy. This presentation of pedophilia is quite underreported, especially in Pakistan (Avais et al., 2020). Hence, there is a dearth of available data on the threats posed to pre-pubescent boys in Pakistan, and the issues faced by the victims afterwards (Gillani, 2009). Due to the conservative and patriarchal nature of society, the notion that a boy can be abused by a woman is not readily acceptable to the masses. The victims readily learn to silence their objections because of fear of being scoffed or ridiculed by society and peers. Combined with authoritarian parenting, men being victims of child abuse find themselves in a dilemma:; they have an issue at hand but there is no one to turn to.

The events often take a turn for the worse when the victim is deprived of sexual education. This leads to a child being repeatedly abused, with no information of what is happening, to no one available with whom he can freely talk. The victim eventually learns to "cope" with the situation, but more often than not, he employs unhealthy or inefficient coping mechanisms, and slowly but steadily his life begins to crumble (Hall & Hall, 2011).

This case also narrates the aftereffects of undergoing a traumatic event and leaving it unresolved for decades. A rather bleak picture of society is depicted in this case, in which parents and caregivers are seemingly oblivious to the threats posed to young children.

There is evidence of using cognitive approaches, rational emotive strategies, and psychodynamic techniques (McTavish et al., 2021; Bar-Tur, 2023) for dealing with long-term unresolved issues of individuals. Furthermore, evidence also provides the efficacy of using restructuring of early memories with clients dealing with traumatic events for which they hold themselves responsible (Edwards, 1990). Based on evidence from the literature, a comprehensive management plan was devised based on strategies that targeted the client's symptoms and issues. The post-management evaluation revealed a significant decrease in the intensity of presenting complaints, which indicates the effectiveness of the management plan.

Conclusion

This case presents evidence in favor of using an eclectic approach based on personalized therapeutic techniques. Further studies can be conducted with clients having similar issues to establish the generalizability of an eclectic approach as a therapeutic measure for clients with unresolved trauma of childhood sexual abuse. Furthermore, this case also indicates the dire need for comprehensive sex education for children, provided by a responsible adult. An atmosphere of understanding and care needs to be perpetuated between children and parents as well. As long as children will fear discussing their problems with their parents due to fear of repercussions, predators and pedophiles will continue making use of this emotional distance for their benefit.

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