Object Relations in Severe Trauma: Psychotherapy of the Sexually Abused Child (Book Review)

Author:  Prior, Stephen 
Publisher: Jason Aronson
Reviewed By: Catherine Bianchi, PhD, Winter 2006, pp. 57-58

In Object Relations in Severe Trauma: Psychotherapy of the Sexually Abused Child, Stephen Prior writes about “dynamic theory without trauma and trauma theory without depth…” (p. 6). He contends that traditional psychoanalytic writing about severely disturbed children hasn’t taken into account the devastating effects of actual traumatic events as they influence child development. He reviews the existing literature about severely disturbed children, citing works on the “borderline child,” works by object relations theorists who focus on fantasied internal object relations, as well as Kernberg’s writing about constitutional weaknesses in metabolizing internalized bad objects. He concludes that none of this literature adequately addresses the etiology of severe disturbance in children, because some works emphasize constitutional differences between individuals and others completely leave out a discussion of etiology.

Prior also reviews the recent trauma literature and concludes that it focuses instead on externally observable symptoms at the expense of more fully elaborating the subjective states of these children and the extent of the disturbance caused by abuse. He points out that none of the available literature addresses how real events can shape the development of object relations in the child. He states that neither the writing on dynamics nor the writing on trauma adequately accounts for the failures in development of a healthy sense of self and relatedness in children who have suffered interpersonal trauma.

To address this gap in our understanding, he elaborates a clinical theory regarding the developmental consequences of sexual trauma to children. He synthesizes material from the bodies of literature cited above to paint a poignant picture of the object relations of the severely abused child. He writes, “This theory attempts to go beyond description of the symptomatic effects of sexual abuse, toward an explanation of why sexual traumatization produces certain central effects and not others, why it so profoundly affects the child, how it distorts the dynamics and structure of the child’s psyche, and how sexual traumatization can be understood in relation to neglect and the child’s underlying relational needs” (p.5).

Prior arrives at his conclusions by synthesizing clinical material from the many severely abused boys he has treated in light of his understanding of the available literature and by developing a relational theory that describes the impact of severe sexual trauma on the development of object relations. He then sets out to integrate what we know about trauma with what we know about object relations.

Borrowing the concept of “working models of relationships” from attachment theory, and citing the sparse literature on the dynamics of the sexually abused child, Prior’s work emphasizes the relational dilemmas these children constantly re-enact. He describes their core relational constellations as based in painful conflict arising from: “…repetition of abusive relational patterns, identification with the aggressor, self-blame, and the seeking of object contact through sexual or violent means. These factors are understood as deeply entrenched defenses against annihilation anxiety” (p. viii).

The child can be either victim or victimizer in his relationships. If he is victim, he faces unbearable feelings of powerlessness and vulnerability. To protect against these feelings, he may identify with the aggressor and enact the role of the victimizer. He will then feel intolerably bad as he must psychologically become the very thing he hates the most. If he does this, he will believe he deserved his abuse. Furthermore, guilt will force the child to take out on himself the rage he feels towards the perpetrator. If he does not internalize the others around him, he will feel empty. No child can bear to be alone and unconnected to others, so he uses perverse and aggressive means to seek contact, because he knows no other way. He is then “either nothing or he is bad.” He is forced to choose these negative models to ward off the more unbearable experience of feeling his self disintegrate under the intolerable pressure of annihilation anxiety.

In Prior’s viewpoint, these relational stances alternate rapidly with each other, based on identifications with the abuser as a deeply needed parent or parental figure. (He does not address the impact of abuse by strangers in this book.) The relational stances are re-enacted constantly because they provide the only possible working models of relationships. As each dilemma is reenacted it forces the child into the next, because each is too painful to sustain. The child then demonstrates labile, unstable functioning as he vacillates from one model to the next in rapid succession. Each is in itself a defensive constellation against the unbearable prospect of the emptiness, loneliness, and fear of annihilation that confronts a child who must face the evidence that his caretakers do not actually care for him. The rapidly shifting, un-integrated identifications that underlie the disturbed behavior of these children and the “perverse” means in which they have learned to seek contact with others account for the depth of the disturbance they present in clinical settings.

The articulate way in which the author illuminates the internal lives of these children is in and of itself an important contribution. However, he goes further and presents deeply empathic case material to illustrate how their play re-enacts the “relational dilemmas” he describes in his theoretical chapters. He offers vivid clinical vignettes about how he works with them in the playroom to do the necessary work of metabolizing their internalized bad objects. These case examples offer intriguing insights into the techniques most effective in working with these children.

In the chapter, “The Dilemma of Therapy and the Uses of Violence,” Prior emphasizes the transference fears and relational longings with which these children enter therapy and the counter-transference dilemmas faced by the therapist. He explains how the boys he has treated use “violent” and “perverse” means to frantically seek contact with and convey their relational dilemmas to the therapist. He explains that while they may display chaotically violent or sexualized ways of seeking contact, these children are terrified that if they reveal their true feelings they will be abandoned by the therapist. The abused child patient is also likely to believe that he can get the therapist to abuse and abandon him and that he has the power to damage the therapist. These are all variations on the basic relational dilemmas described earlier in the book.

In response, the therapist must decide how to set containing limits on these behaviors and how to engage in play that can at times be graphic, horrifying and repulsive. Prior states that the violent play is in itself a sign of a therapeutic alliance, because it is evidence that the child is taking a risk to show both his good and bad selves in the treatment. That insight alone makes the book worth reading. The author writes, “The therapist who fears retraumatizing the child with exposure to violent memories and impulses may actually run the risk of retraumatizing the child by rejecting the only way the child knows to convey the reality of his experience” (p.130). If the therapist seems to reject the primitive play, he may confirm the child’s fear that he (the child) is bad and that revealing who he is will cause him to be abandoned again, while also confirming the fear that his bad self has the power to damage the therapist.

Thus there is a central transference–countertransference dilemma in therapy with these children. If the therapist mistakenly appeases the child’s transference fear of being rejected for his badness by unconsciously colluding with the child in presenting only his good self or together “hating” the bad self, the therapy will not reach the parts of the child’s identity and real history that are encoded by his bad self. The therapy will then have the illusion of progressing at the expense of never allowing the child to deeply access and metabolize his negative introjects. The therapist must therefore take an active stance in finding safe and contained ways to engage with the child in these modes of contact so as not to unconsciously collude with the child in “walling off a bad self.” At the same time he must understand painfully conflicting transference fears about potentially being abused and abandoned by the therapist and being able to abuse the therapist.

In summary, this is an interesting, accessible account of the internal lives of the traumatized children so many of us struggle to treat. Dr. Prior presents a relational theory to explain the depth of disturbance in these children: rapidly shifting identifications that become constellations of defense against more profound annihilation anxiety. He also illuminates the subjectivity of these children’s inner lives brilliantly. The chapters on play therapy are compelling and valuable.

This was a thought-provoking book, and one is left with several reflections. Among them: although Prior states he wishes to address structure, he elaborates a quintessentially relational theory in which shifting identifications account for disturbance and motivations, defenses, conflicts, and anxieties are all embedded within the relational matrix. Theoretical purists may quibble, but the book has clinical utility that may be implemented by therapists of any persuasion.

Additionally, Prior carefully limits his theoretical generalizations to boys in order to stay close to his empirical data. This is good practice in a field plagued by criticism for lacking hard scientific data. (As if the human tragedy he describes could be measured.) However, in his asides, he makes the disclaimer that object relations may develop differently in girls. He seems to unquestioningly subscribe to the notion rampant in Freudian literature, despite his thorough familiarity with contemporary theories, that girls must somehow go through a different process of development than do boys. The implication, as in classical oedipal theory, is that the processes of development must progress differently because gender will influence potential identifications and their enactments.

It would be a contribution to see this work extended to girls and women with a history of abuse. Many of us have observed female patients of all ages who stay in a masochistic position and are terrified of any expression of aggression. It is as if they cannot bear to enact an identification with the aggressor for fear of losing control of their own rage or recognizing any likeness to their abuser. Evidently they are missing the experience and boundaries to know that not all expressions of aggression must be violent and destructive. This, however, does not seem to imply that they do not have an internal identification with the aggressor, but rather that they are somehow reluctant to acknowledge and express it for fear of enacting the role of victimizer themselves. It also does not preclude the possibility of finding males who present with the same conflicts and defensive constellations.

In short, although it is academically rigorous of Prior to limit his theorizing to the boys he treated, it would be interesting to see his theory expanded to girls. Dr. Prior has much to contribute to both our theoretical and clinical discourse. Many of us cherish the hope of giving even one of these children a chance at a satisfying life. Evidently he has helped many of them and has given the rest of us a powerful tool for helping still more. A book by Stephen Prior on techniques of play therapy would also be a significant contribution to the literature about children.

Reviewer Note

Catherine Bianchi is a psychoanalytic candidate who practices in Morristown, NJ.

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