Treatment Issues

Some therapy goals for the adolescent at this stage are to form a therapeutic, trusting relationship with the therapist, use therapy to talk about sexual urges and learn appropriate strategies for dealing with these urges, explore feelings and make connections between past and current relationships, and define future goals and set attainable short-term goals. Other treatment goals will need to be individualized for particular clients.

The adolescent consolidates an integrated and organized representation of himself or herself in relation to the past, present, and future. Understanding and integrating a variety of variables, including discordant ones, helps the adolescent rectify identity issues (Greenspan, 1979).

A collage entitled “How I See Myself’ brought forth a number of insights related to her past for 15-year-old Shelly. She found the words “Underneath it all, she’s a skilled actress,” which she said related to herself becoming an actress when she got sexually abused, and her feeling now that she is very good at it. The phrase “Too close for comfort” related to her not liking to get close to people, which she connected to past hurts. The words “Running away” led to an insight that she does not run to anything or away from anything but just runs. These insights, which pulled together the past with the present, helped this adolescent continue her quest through identity issues.

Trust becomes a major therapeutic issue that is dealt with in the transference and in the sessions directly. The adolescent may attempt to set up power struggles, which should be avoided at all costs. A good rule when working therapeutically with an adolescent is never to ask a question to which the child may lie in response. In other words, don’t ask a lot of questions and never ask things like, “Are you sexually active?” or “Do you do drugs?” If the child answers in a lie, it sets up a precedent that therapy is not truthful. A therapist can talk about any issue without ever asking the question. More often than not, when approached without being asked the question, the adolescent volunteers the information. The trust that is established in the course of therapy will be one of the curative factors. For children who have been lied to and betrayed in other ways, this trust and honesty is one of the most difficult things to establish.

This leads back to the idea that in abuse cases it is the betrayal of the relationship that is the deepest part of the wound. The child has long since gotten over the physical scars and trauma, but the betrayals, lies, and mixed messages cannot be easily overcome. The betrayal has taught the child not to dare to trust, for fear of being hurt. It also teaches the adolescent to actively avoid intense emotional relationships for fear of the pain evoked by them.

Shelly phoned her mother from the group home where she lived for the past 4 years, hoping that perhaps her mother would want her now. During the course of the conversation, her mother told her she wished Shelly had never been born. Shelly took a knife and slashed at her forearms that weekend, causing multiple superficial wounds. Several weeks later, in group art therapy, the directive was for each of the four girls to create a “self-symbol.” Shelly drew a heart with a knife in it (Figure 8.2) and disclosed that she was sexually abused throughout her early years and was gang-raped at knifepoint at age 12. “I tried to forget it for a long time. I won’t ever trust because I trusted once before and got burned.” Shelly protects herself from ever feeling the pain by not getting attached. She numbs herself from feelings, but then she creates physical pain by cutting.

When a child is engaging in self-mutilation while numbed from emotional pain, the first thing the therapist needs to do is find a place where the

Shelly's "self-symbol"

Figure 8.2. Shelly's "self-symbol"

feelings inside can be expressed. Adolescents often write poetry because it offers some distance to their emotions. For adolescents who have difficulty verbalizing, this kind of an outlet can be safer.

The place where Shelly appears to be able to get in touch with her feelings in an appropriate way is through poetry and art. She writes painful poems of her deep feelings and fears. About once a month she delivers a stack of poetry to her group therapy members, which is her way of connecting with them. She is unable to talk about these poems, such as this one:

Can you keep a secret, if I tell you what I feel?

Can you keep a secret, if I tell you this is real?

Can you keep a secret and promise not to laugh? Will you understand if I tell you that it hurts?

Will you hold my hand if I tell you what is wrong? Will you say I lie, even as I cry?

Will you be angry if I make a mistake?

Will you understand if I tell you there’s not much more I can take?

Are you strong enough to understand and still believe in me?

Will you laugh, tease, and run if I tell you that I bleed?

Can you keep a secret, if I tell you of the past?

Will you still be around, will the friendship last?

Can you keep a secret if I tell you why I cry?

Will you understand that I need you by my side?

Can you keep a secret, if I tell you how I see?

Will you try to understand, and still believe in me?

The fact that Shelly has this outlet for her inner feelings makes the prognosis better than if she were totally numbing herself from all feelings and only using self-mutilation to feel. That she can touch and put words on her feelings through poetry gives the therapist a place from which to begin working with her. Through poetry, she experiments with sharing what is inside. When it is accepted, not only by the therapist but by her other group members, she is encouraged to continue this self-exploration. Her primary art preference is collage, and she makes collages both in art therapy and at home. This process allows her to cut in an appropriate way. She finds images and words in magazines that relate to her own issues, and she communicates them safely through this method.

Group therapy is a key strategy in working with adolescents. Often, they can help each other more than the therapist can help them. Sharing feelings, processing relationships and sexual issues, making connections between past and present behavior, and identifying with the group helps adolescents sort through their conflicting feelings.

At this stage, the adolescent is capable of making connections between an abusive past and present sexuality, as exemplified by 14-year-old Ginny.

Ginny came into therapy one week complaining of menstrual cramps, which led to her drawing an abstract picture about being female and having periods. She drew pain and drew what she termed the cycles of the day. “It begins okay, then there is pain, there is embarrassment, and then it’s okay again at night.” This led into a second abstract picture about female sexuality and disclosure of past abuse. The pastel drawing, which symbolized her life as being colorful and happy up until age 9, shows a diagonal slash over a rainbow, which she said was indicative of her trauma (Figure 8.3).

As she drew, Ginny disclosed that when she was 9 her mother owed someone money for drugs and sold her daughter for sex to pay the

Fourteen-year-old Ginny's pastel picture, "Trust at Eight, Hatred at Nine"

Figure 8.3. Fourteen-year-old Ginny's pastel picture, "Trust at Eight, Hatred at Nine"

debt. A large brown penis and hand extend into the right of the picture frame. She talked about her current feelings about sexuality and the effect that the abuse has on her now. She said she was confused, embarrassed, angry, and had difficulty with trust and hate.

She titled the picture, “Trust at Eight, Hatred at Nine.” Ginny also talked about her recent pelvic exam and said that she “leaves her body” to get through it. This awareness of her ability to dissociate suggests that she has defense mechanisms that worked well for her and that continue to be called upon when necessary. Her advanced understanding of her own sexuality comes with the maturity of adolescence.

Dissociation, which in the past may have been symptomatic, is used as a barometer of a good defense structure when it can be called upon to assist the client in dealing with stress. The fact that this adolescent is aware of its use, but is not a slave to it, suggests her maturity and health. She can now talk about the trauma and use art to abstractly represent feelings evoked by it.

At this stage of development, the adolescent can integrate many concepts that were formerly elusive. For example, feelings about a perpetrator can be processed in a more sophisticated way. The adolescent can assign multiple feelings to the same person, can hypothesize why the perpetrator acted as such, and can assimilate past, present and future. They are not held to the fear and helplessness felt previously but are more able to fantasize how to handle future encounters. With this ability, the adolescent can integrate what happened in the past with present reality and can use this information to formulate future ideals.

The adolescent can also process behavior in a more sophisticated way. For a child who is acting out inappropriately, the issues can be dealt with directly, once a relationship based upon honesty has been established. Issues do not need to be couched in metaphor or expressed symbolically anymore.

This same ability to integrate feelings and actions can help the sexually acting-out adolescent to assimilate new coping skills by identifying past situations that caused the acting out behavior and formulate new solutions to those situations.

I asked 12-year-old Johanna to think about what kinds of situations stimulated her to act out sexually with her younger sister at night and to draw a picture of hypothetical solutions. The situation she drew involved herself hearing her mother and mother’s boyfriend having sex during the night. This would stimulate Johanna’s sexual urges and would cause her to go to her sister’s bed and initiate sexual activity. The picture shows her standing outside the door and thinking, “Why do they do it so long? Don’t they know how to sleep? Why do they make those noises? I wish they would stop! They are going to break the bed down! They always do that! He is hitting mommy!

I’m knocking on the door.” The anxiety this evoked was clear. Her solutions, derived with my help, were to close the door and turn on the radio, read a book, or masturbate instead of acting out with her sister. This picture also made me aware of the need to work with the mother on more discretion in her sexual activity. The child’s ability to fantasize how she would handle a future encounter helped her strategize and take responsibility for her own treatment. The child and I became team members.

Sexual acting out is a normal developmental progression that occurs during adolescence, and the child who wishes to act out sexually can usually find willing partners. A distinction needs to be made between sexual behavior that is consensual and that which is coerced. Consequences for perpetrating or coercion become even more severe. The parental figure or person who discovers the perpetrating behavior needs to up the ante of the consequence and give a clear message that any perpetrating behavior will not be tolerated. It is no longer enough to use time-outs and withdrawal of privileges. The police and/or child abuse hotline should be called for any perpetrating behavior, particularly if it occurs with a younger child.

In the case of consensual sexual behavior, the rules can be unclear for the adolescent. It is a time to begin talking about sex, choices, relationships, and promiscuity, and the consequences of disease and pregnancy. The adolescent is making choices about sexual relationships and frequently needs education.

During early adolescence, relationships with the opposite sex become a key issue. In the normal course of development, these relationships are often fleeting, as the child is experimenting with codes of behavior, trust, sexuality, and dependency versus autonomy. During later adolescence, intimacy and object choice become more important. The child may be ready to explore why he or she chooses partners who are abusive, indifferent, or losers.

Elsa, at age 14, asks why every boy she gets involved with is “such a jerk,” yet she continues to choose boyfriends who lie to her, cheat, and disrespect her, and the focus of her relationships is primarily sexual. Elsa and Shelly are in group therapy, and both ask the same question: “Why are guys such assholes?” Another group member, further along in her treatment, asks, “No, why are we attracted to such assholes?”

Adolescents with early unmet attachment issues, male and female, may fantasize about having a baby, which ties in with intimacy issues. The search for love compels the adolescent to create someone who will love him or her. The realization that the baby cannot meet these needs often comes too late. When this young parent finds it difficult to bond with the baby, the cycle of poor attachments continues into another generation.

Yet in another scenario, as adolescents mature into adulthood they develop better reason and information-processing skills, are capable of insight into their own behavior, and can use the higher cortical regions of the brain to make more rational decisions. Getting through adolescence is a little bit of luck and a lot of work. Some of the deepest issues of severe trauma will not be fully approached and processed until adulthood.

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