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LUCID PAGES
DOCTOR IN PSYCHOTHERAPY

I WANT TO BE A DOCTOR

So many times we hear this statement from suffering children of the Third World. The harsh social environment evokes compassion in the young members of the society. They want to help others despite needing help themselves. Their living conditions are far worse than those of children in rich countries. Nevertheless, sexually abused children from both rich and poor countries develop the same mentality and want to heal others.


As the abused child reaches young adulthood, her idyllic vision of a healer is soon replaced by the reality of the occupation. Healing is an incredibly demanding vocation, both mentally and physically. Years in medical school are filled with constant stress as the to-be-doctor is trying to absorb professional knowledge. Then comes internship. These years are stressful, too. The young doctor is responsible for the health of patients and also must deal with the red tape and very long shifts. There seems to be no end to either. The doctor works constantly, makes a lot of money, and exposes herself to a lifestyle that is anything but healthful. She has no personal life outside her practice. She becomes Doctor Smith. That is how everyone in her social environment refers to her, and she has no idea what it would be like if she were not needed by everyone, if she were not in charge, and if someone addressed her as Susan, and not Doctor Smith.

In general, doctors fall in two categories. One consists of unassuming healers of the Mother Teresa type. The other category, which is more prevalent, includes all-knowing, stuck-up doctors who associate their occupation with money, prestige, and power, commodities they so badly lacked as children. These are the usual trends in the medical industry, but healers of sexually abused children face additional challenges that are associated with this unique profession.



TAKING CARE OF BUSINESS

Since doctors choose their occupation because of traumatic childhood, it is essential that doctors identify the subconscious motivators and deal with them before trying to help others. The therapist's inability to resolve her own problems is harmful to both her and her patients. Most alcohol, drug, and sex awareness educators are drawn to these helping jobs because of childhood sexual abuse. The professionals may have overcome the consequences of their childhood abuse in some areas, but may have developed harmful habits or addictions. Some helpers have compensated for their alcoholism with workaholism, some have dealt with their unconsciously remembered traumas by expressing them through the pain of patients, and some have subconsciously transformed their forgotten childhood abuse into child protection. The old traumas have not been resolved despite being masked by semblance of normal behaviors. Unlike prostitutes, whose occupation clearly points at incest and serious psychological problems with personal worth and boundaries, doctors appear mentally healthy. Interestingly, almost every nurse or doctor exhibits plentiful symptoms of incest along with neuropsychological consequences that lead to psychopathology.

Because of unresolved childhood abuse, some therapists feel sorry for child rapists and want to heal them. This is a variation of the desire of an incest victim to protect her rapist against the world. When such notions emerge, the therapist should seriously evaluate her mental condition and ask herself: "If he were a serial murderer, would I want to treat him? Why am I thinking about treating a serial rapist? Why am I not thinking about healing more common mentally sick people, such as liars, politicians, crooks, thieves, or batterers. Why have I chosen rapists? Why did I want to become a therapist of sexually abused children in the first place? Why am I attracted to rapists and incest victims? Why do I want to save them? Could there be something in my past that makes me behave this way? Am I subconsciously reacting to my forgotten childhood abuse? Shouldn't I get help for myself?"

Overcoming one's harmful addictions, dissociation, and multiple personality is the hardest issue a therapist can face. The doctor should be completely healed before she starts working with other incest victims. If she does not put her mind in order, she will dissociate, run away from sensitive problems, and substitute supernatural and naive beliefs for science and psychology.


Quite frequently, we encounter a social worker with severe dissociative disorders. The woman is usually deeply religious, has naive opinion about the world, and perceives everything in very positive terms. Because of her consciously inaccessible traumatic memories of her abuse, she wants to protect children and care for them the best she can. The healer may recognize that a low-life abuser of a child committed an evil act, but the woman is incapable of feeling any animosity toward him. The healer may have a peculiar attitude toward a sexual abuser in a position of fame, power, or father figure. The dissociated healer is unable, despite overwhelming evidence, to accept that the man would be such a monster and fails to recognize the obvious signs of incest in the man's child. The brain-damaged healer often associates with the powerful abuser, stands behind him, perceives him as honorable and very likable, and vigorously defends him against harm to his reputation or person. This mentality becomes prominent when such a healer is presented with physical evidence (blood, semen, venereal disease, or the child's torn hymen) of an alleged rape. The healer ignores all the meticulously gathered evidence and does not believe that any of the presented "artifacts" have any "scientific merit." The social worker defines in her mind what is scientific and what is not, and let's everyone know the "facts." And the absolutely worst aspect of the healer's pathology comes forth when the perpetrator confesses to the rape in a courtroom. The woman may exclaim, "No, that is not true! He is lying!" And she runs to the defendant, kneels in front of him, grabs his hands, and begs him, "Please, say it is not true." This might seem like a Hollywood comedy if the scene did not reflect real life. A healer of this type is more dangerous than the rapist himself.

Failures to resolve one's own issues are all too common. Dr. Susan Forward was giving advice to others, but neglected the problems in her marriage. Nancy Reagan was telling the nation "Just say no to drugs," but failed to educate her own children. Mother Teresa was nice to all the children in India, but was unable to be nice to the abused little girl inside her. The therapist should get help first.

Belief in the supernatural is a clear indicator of dissociation. If the therapist does not get over this mental condition, she can NOT be an effective healer. The issue is not belief in the supernatural, but neuropsychological damage and loss of emotional intelligence, which religious beliefs manifest. The doctor's reasoning and behaviors are driven by her unconscious mind, and the participation of her prefrontal cortices is limited. She may have an IQ of 200, but lacks the ability to recognize and interpret the patient's subtle body language, may dismiss the stories she hears, may rationalize the reasons for various patient's behaviors, or may avoid sensitive topics that cause her unbearable pain by addressing the memories of her childhood abuse.

Naturally, religious healers of sexually abused children attract their own kind of patients. The treatment is superficial, does not get to the core issues, and preserves a distorted view of the world. The patient has no incentive to engage the neural circuits of her emotional intelligence because the therapist encourages her to think in magical terms and blindly trust in God. Since God unconsciously represents the incestuous abuser, the therapist teaches the patient to accept her abuser as her savior and succumb to his power. This is the right opposite of what the patient needs.

Therapy encased in religion tends to replace some patently harmful forms of dissociation by other forms, but the symbolic image of the child rapist remains immaculate and in charge of the victim's mental life. The key issues are not resolved. The patient and the therapist may feel good about the "progress," which is measured by the degree of the patient's lack of pain and by her improved ability to dissociate from the emotional meaning of her traumatic experiences. But the patient retains her unproductive ways of coping with problems by means of dissociation. This strategy is no better than burying one's head in the sand. Dissociation was the way the patient reacted to her abuse before therapy, and religious therapy only encourages her to master this unproductive technique. Such learned helplessness is welcome by any man who wishes to rape an adult incest victim. She freezes and lets him do to her anything he wants to. In addition, because of dissociation, she may be unable to remember the abusive act, or identify her rapist in a lineup, or testify against him in a court of law.

Indicators that the helper has not resolved her own childhood problems are the following:
  • She knows all; nobody can teach her anything new.
  • She categorically denies the existence of multiple personality disorder.
  • She stands in line to shake the hand of a visiting politician.
  • She writes to her senator to solve a national problem.
  • She customarily applauds a person she does not like.
  • She has pictures of angels or Teddy bears on her business stationery.
  • She believes that no one will hurt her if she hurts no one.
  • She knows that gays are perverts.
  • She does not have sex; she makes love.
  • Her first name is Doctor; her last name is Ph.D.
  • All her friends have the same first and last names.
Despite the patients' needs, the therapist should always have supreme loyalty to herself and NOT to her patients. This counterintuitive rule makes sense in schizophrenia. A doctor can do her best, but may be unable to heal a schizophrenic. The same issue arises in the work with survivors of childhood sexual abuse. They knowingly or unknowingly lie, suffer from harmful addictions, self-injurious tendencies, bursts of misdirected rage, and multiple personality. Treating such patients is extremely difficult. The therapist must first ensure her personal safety, and only then can she consider helping the patient. If the doctor cannot guarantee her invulnerability (bodily, mental, financial, or professional), she should dump the patient, if at all possible. A doctor who succumbs to her sacrificial tendencies may end up being raped, killed, sued, harassed, stalked, or otherwise harmed by her patient. There are limits to what a psychotherapist can do and, if a foolish therapist tries to go beyond the limits, she is guaranteed to get seriously hurt. It is one thing to help a drowning man, but it is a different thing to be pulled under the water with him. Personal safety of the therapist must be her top concern.



A PATIENT HAS ARRIVED

Very few men or women enter therapy with the goal to be treated for sexual abuse. Most have no idea where their numerous problems originate from. All the patients want is quick help. Give me a magic pill that will get me over this one difficulty. The therapist starts probing, and the difficulties grow in size and number. These introductory sessions are very important for proper diagnosis. The patient is new to the therapist, and the therapist pays extra attention to the patient's appearance, habits, and peculiarities. After several interactions, the therapist becomes familiar with the patient and is much less likely to notice nuances in the patient's behavior.

Ability to read the patient's body language has major impact on diagnosis and treatment. The patient may believe and say one thing, but her body language may reveal another. If the therapist fails to read between the lines and focuses just on one problem or on spoken words, she may get paid for the job she does, but the patient will benefit little. The very fact that the patient needs some mental therapeutic help should be a sufficient reason to suspect severe childhood abuse.

The patient's arrival at the healer's office is a sign of reaching for help. At this time, the patient typically does not know what to expect. Neither does the doctor, but this will change quickly. The therapist should make sure that she informs the patient about what to expect. The patient is overwhelmed by the world and needs some stability. The therapist should introduce a clear treatment plan and periodically discuss it with the patient to let her know where she is, how far she has gone, and what she needs to do to complete therapy.

In the beginning, the patient will need to know what to expect today and the next session, but telling the patient too much is not a good idea. The patient could be confused by the details or might later blame the therapist for not living up to her promises. The attention span and the long-term vision of most incest victims are similar to those of children, and the information about the treatment plan should reflect this reality. The information should be global and positive, and specific only about the upcoming session.

One of the first things the therapist should do is thorough medical examination of the patient. This should reveal psychosomatic problems, neurological illnesses, and indicators of abuse. The next important step is to ask the patient to bring in the pictures of her family, as many photos as possible. The family dynamics are captured in the photos. If it is apparent that the patient is being abused even now, the patient must be placed in a safe environment. This could mean moving to another place, stopping regular visits of the family of origin, or changing the telephone number. If the patient still has daily contact with her abuser and he controls her life, the best therapeutic techniques are likely to fail. Surprisingly, even experienced therapists working in the hospital often ignore the patient's natural living environment. Much to the surprise of such experts, they may discover that the outpatient has become pregnant by her father while undergoing treatment for childhood sexual abuse.



MEDICAL EXAMINATION
 
Most therapists do not conduct medical examination of their patients. The professionals may see no reason to examine a patient, or feel unqualified, or are afraid that the patient will suffer unnecessary distress. This approach is not helpful. The therapist misses a chance to learn important information about the patient, information the patient's mind may be unable to provide. The therapist may spend several years before she uncovers what she could have learned in a few minutes, or she may never find out. This is why medical examination should become a routine part of the first or second patient's visit.

"But I am not a medical doctor," the therapist may object. No, but every therapist knows what the human body looks like. The professional can tell what is typical and what is abnormal. The patient's body is like an open book. It bears many symptoms of her past abuse and her current problems. Some of the symptoms may indicate a life-threatening illness. If the therapist pays attention only to the patient's mind, she may learn one day that the patient has died of a medical condition that could have been uncovered, confirmed by a medical expert, and successfully treated.

During the examination, the patient needs to take off her blouse, pants, or skirt. If the patient does not agree to this gross intrusion, negotiation is the way to go. Is it really necessary to see the patient's legs or is it enough to examine her torso? Is it really necessary to see her belly and chest or is it sufficient to examine her head and neck?

What should the professional be looking for? Anything that indicates the patient's general health, anything that reveals the state of her deep subconscious mind, and anything that reveals the condition of her cognitive mind. To be effective, the medical examination has to be combined with a questionnaire. It is better when the questionnaire precedes the medical examination. This way, the therapist already knows the patient's history and health problems, and can detect inconsistencies between the seen facts and the patient's claims. During the interview, the healer should concentrate on the following:
  • The patient's personal history
  • Information about her extended family
  • Routine events: holidays, family visits, vacations, business travel
  • Occupations and their contradictions (banker/farmer or gambler/safety inspector)
  • Substance abuse
  • Health problems
  • Patient's sex life
  • Major illnesses in the family
  • Mental illnesses
  • Hospitalizations and healing of family members
  • Age and cause of death of family members
Getting this information may take a while, and no time may be left for the actual medical examination during the first session. In the next session, the therapist will look for the signs of incest and post-traumatic stress. After the examination, the therapist will need to sit down and compare her findings with the statements made by the patient. The therapist should consider things like these:
  • The patient told me that she is a good catholic girl, but she has a tattoo.
  • She told me that she drinks no alcohol, but she has blackened tooth enamel.
  • She told me that she cannot stand fast cars, but she has this "cosmic" hairstyle.
  • She told me that she does not exercise, but she has these strong arms.
  • She told me that she was never seriously injured, but she cannot explain her 2-inch scar.
  • She told me that she eats a balanced diet, but her nails reveal nutritional deficiency.
  • She told me that she is shy, but spontaneously showed me her augmented breasts.
  • She told me that she is not afraid of being naked, but her eyes are fearful as she says it.
  • She told me that she does not like sharp things, but she has a pierced tongue.
The discourse between the patient's claims and behaviors needs to be explained. Does she express herself in ways that do not clearly reflect her thoughts or does she have a dissociative illness? What condition is the discord caused by? Is it rationalization, or is she confabulating, or does she have multiple personality disorder? The doctor needs to explore these possibilities.

One frequent trait of victims healing from incestuous child rape is somatization. The patients make all kinds of nonspecific complaints about pain and strange feelings in various parts of their bodies. The somatic sensations are produced by mental reactions to the experienced sexual abuse or to the reminders of the violations. Somatization is a symptom of a very serious condition that usually occurs together with depression and hysteria. Both conditions are the result of severe dissociation and neuropsychological damage, and should automatically alert the doctor to the likelihood of multiple personality disorder or the existence of complex dissociative disorders (bipolar disorder, borderline personality disorder, Parkinson's disease or Alzheimer's disease).



STABILIZATION OF THE PATIENT

A critical part of treatment is preparation of the patient for the disclosures about her past traumas. If therapy is started without understanding the patient's current life, many unforeseen problems may hamper therapy, and the therapist may not even recognize that anything is out of order. In the most severe cases, the patient may still have regular sexual intercourse with her abuser. Or she may live with the abuser under one roof. Or she may have a domineering husband who has sex with their children. Or both parents from her family of origin still have strong control over the patient's mental world. Or the patient has multiple personality and is unable to respond to therapy as other patients do. Or the patient is a drug addict. Or she works in a job that depends on her sanity. Or she is in a dire financial situation and is unlikely to stay in therapy. Or she is delusional and suffers from self-injurious tendencies. Or she is psychotic and wants to murder every male.

The above possibilities hint that some patients are not ready to start therapy for incest. The subjects first need to take care of their current problems. If this important step is skipped, the patients may spend years in therapy and achieve no progress. Or the patients may end up dead or in prison. There is no way to predict how long the stabilization period may last, but 6 to 12 months should be considered about typical with difficult patients. It is possible that some patients will never be ready to start therapy for incest. In such a case, it may be best to never start and only deal with the most serious contemporary problems the patient has.



TREATMENT

The easiest way of finding out whether or not a patient is an incest victim is to ask her. And, naturally, this technique fails in more than two-thirds of all cases, as incest statistics collected by means of this method indicate. Even the one-third that has some awareness of inappropriate sexual exposure or incestuous contact in childhood may have only one fragmentary memory of countless traumatic experiences. In this case, the "just ask her" method is inadequate.

The longer time passes between the abusive years and the present, the less it is likely that the victim will remember her abuse when asked. She may retrieve only one traumatic memory, when uncle Fred approached her from behind and grabbed her breasts in joke. But she is totally oblivious to the regular rape several times a week by her biological father. The "horrible trauma" associated with uncle's hands on her breasts is reported to the therapist as the form of the patient's abuse and is blamed for the many problems she has in adulthood. The conclusion is that even a one-time abuse that does not involve penetration can affect the victim for life.

A therapist who hears the story about uncle Fred may start working with the patient on the resolution of the specific traumatic experience. The patient gets over it in six months and goes home healed. From now on, she makes sure that she never stays with uncle Fred alone, tries to keep away from the pervert, and forges a much stronger bond with her dad, whom she perceives as her protector.

Such a treatment is considered a success, but the victim of incest fails to recognize her father as the supreme evil and becomes even more dependent on his presence and his daily control over her. She believes that he is trying to help her, while he dominates every aspect of her existence. And she loves him so much and would do anything in the world for him. He is the only man who has ever treated her nice. Her uncle, her boyfriends, and her former husbands only misused her. Dad has always been wonderful. Such a seriously damaged patient is difficult to fix. A common therapist may not even suspect that there might be more than the patient reports.

The two-thirds of the general public who initially have no memories of previous abuse are enigmatic. They may have suffered only mild sexual abuse and may have repressed their memories of the traumas, and now may remember the events in therapy. Also incest victims who were brutally raped throughout childhood may have no memories of their abuse at first. In therapy, they may recall only the mild abuse, or none, or everything. The outcome varies from patient to patient. Sadly, the therapist is often unable to help the patient remember. Beyond verbal cues, there may be no practical way to activate the patient's memories. The patient has to retrieve the memories on her own.

The therapist may chose to remain passive while the patient is trying to remember the past. The therapist may worry that any attempt to lead the patient might result in false memories. But false cues by the therapist will not produce false positives if nothing traumatic happened at all. On the other hand, the patient may recall distorted memories of actual events under the influence of the therapist's guidance. The distortion can become severe when the patient is under hypnosis. By contrast, EMDR is likely to access traumatic memories with no or minimum distortion. But even this technique has limitations.

Some patients may get stuck in therapy and may make no progress for months. The subjects are locked in their repetitive responses to their abusive experiences, but are unable to consciously acknowledge which experiences trigger such behaviors. When this state lasts more than 6 months, it is unlikely that the patient will recover the memories behind the repetitive responses, or that she changes her unconsciously driven behaviors. If the repetitive behaviors persist despite the best psychological intervention, they are possibly indicative of serious neural damage. Such a patient may never fully recover and regain her full mental potential. She will always have decreased emotional intelligence and will be emotionally stupid to some degree. Because of her neural damage, she will not be entirely successful in resolving her past traumas. She needs her emotional intelligence to interpret and understand her abuse and her current harmful behaviors so that she can take care of herself. Without her emotional intelligence (not emotions; they are something else), the therapist will be unable to bring up the patient to normal functioning. Psychotherapy can usually access information or reprocess it, but is often ineffective in repairing the patient's damaged brain. Some repair is possible thanks to residual brain plasticity even in adulthood, but some patients may fail to heal.

Despite some unavoidable therapeutic failures, one of the best approaches that have emerged over the last 20 years is the work of Kate Chard. In contrast to traditional therapies, which recapitulate traumatic events as a first-person in present tense (which makes the victims feel as if the abuse were happening right now), Chard allows the victims some distance by writing the account in past tense [1]. The minor differences between the past versus the present, and between I versus she may seem inconsequential, but are critical because they cater to the physiology of the brain. You can access the whole article about Chard's work and her therapeutic philosophy by following this external link:

http://www.research.uky.edu/odyssey/spring03/puttingaway.html

Chard's technique is superior to most other approaches during initial exposure to forgotten traumas because the conscious mind is better able to tolerate the pain of the abuse. Unfortunately, this wonderful technique is counterproductive later in therapy when a patient with multiple personality attempts to fuse her many personalities into one psychological unit. Fusion requires conscious acknowledgment and full ownership of the trauma, and there is no way around it. But this is not the whole story. Even a violated personality has abused and nonabused components [Dak, 2005]. Applying Chard's technique by making this distinction makes all the difference in the world. The "here and now" part can be used as a reference of present safety and normalcy, and can help the abused part of the past get over the traumatic experience. This mechanism works well in common PTSD, but a severely abused subject may only benefit from the current healthy component after fusion of her parts.



COMMON PROBLEMS IN THERAPY

A frequent issue in therapy with victims of sexual coercion, exploitation, and assault is misdiagnosis. The therapist fails to recognize the full extent of the victim's abuse and the full extent of the impact. As a minimum, the victim will have some degree of dissociation, in addition to the pain and suffering of the immediate abusive experience. Failure to recognize dissociation and treat it will make the therapy ineffective.

The next troubling matter is premature exposure of the patient to her traumas. An abused person usually seek help only when she is overwhelmed. She may be suicidal, may suffer from nightmares, and may be depressed. This is no time to give her the correct diagnosis and deal with the causes of her upheaval.

Another frequent problem is a failure to fully acknowledge and work through the victim's traumatic experience and the resulting feelings. The therapist may rush to substitute the victim's perceptions with a rosy picture of the present, while keeping the trauma suppressed and unresolved.

Surprisingly, the most baffling therapeutic failure involves even the best experts. They try to stop the patient from acting out her sexual impulses with strangers, but do not insist on total avoidance of sex. What the victim needs is a break from sex until she resolves her traumas, understands who she is, restores her relationship with herself, recognizes her self-worth as a human being, and transforms her sexualized values and habits into a positive self-image. Any sex act (even with a loving partner) destabilizes the patient and disrupts her healing. Naturally, total ban on sex makes no sense in patients who are not treatable. They would have to abstain from sex for the rest of their lives.



TREATMENT METHODS

There are dozens schools of psychology and psychotherapy. None of them is perfect, and most approaches combine various therapeutic philosophies. If one approach fails, a therapist may select another one to get a shot at progress in therapy. There is some truth in every method, and every method falls short of being universally applicable. The imperfect treatment outcome is cause by poor understanding of the brain organization and function. Anyone who attempts to treat victims of incest by ignoring brain functions is predictably lost throughout the therapeutic process. Knowing how the damaged and the surviving parts of the brain affect the internal life and behaviors of the victim is of utmost importance. The therapist may have to throw away most of the psychological teachings she was exposed to in school, and relearn the relationships between the brain, mind, and behavior.




UNEXPLAINED BEHAVIORS

Treatment of a victim of childhood sexual abuse requires a good deal of the therapist's imagination. The victim often shows peculiar behaviors that are puzzling at first. And just when the doctor thinks that she gained some understanding of the patient, he or she switches to another personality, and the therapist is lost again. For this reason, the cardinal rule of psychotherapy with incest victims should be the assumption that the patient has multiple personality, even if the doctor is unable to make the diagnosis.

Because of
high prevalence of dissociative disorders  (See the page Multiple Personality Disorder), the therapist should never take for granted that the patient has truly resolved her traumatic experiences or that she understands them. The doctor needs to make sure that the patient is aware of the facts that were stated in therapy. The best way to perform this check is to ask the patient to describe what she has learned. The therapist may receive a reassuring answer that everything has been understood and that the patient got over it. And days or weeks later, the therapist is shocked to learn that the patient (her other personality) has never heard of the reportedly discussed and resolved issues. Even worse, the patient's body language and anxiety may reveal that she truly had no emotional awareness of the issue up till now. This very problem can happen after disclosure of the MPD diagnosis to the patient. She is told that she has multiple personality disorder, but some of her personalities never get the message and behave as usual many months thereafter.

The same kind of difficulties can emerge in other dissociative disorders, such as bipolar disorder and borderline personality disorder. Also these subjects are unable to store and recall continuous biographical memories. And even if the patient demonstrates perfect knowledge of the information, there is no guarantee that the patient understands the emotional meaning of the knowledge, or that the doctor deals with the correct neuropsychological entity. Both bipolar and borderline personality disorders are frequently accompanied by multiple personality disorder, and the combination of all three disorders makes therapy impossible. The patients typically do not want to be in therapy. They constantly dismiss the doctor's observations as something that does not apply to them. They repeatedly tell the healer that they are smart, sharp, and fast, and have no mental problem. They are offended by the topic of child sexual abuse, do not want to discuss it, not even in general and impersonal terms, and if the therapist pushes the difficult and unwilling patient to become engaged in therapy, the doctor is playing with fire. The doctor will always lose, and the patient may even mock her. The patient has suffered irreversible neuropsychological damage, has lost a great deal of her emotional intelligence, and her condition is getting worse from day to day. With the exception of medicating the patient, you can do nothing for her. But she will not agree to take medication either, because she is sure that her mind is working properly and needs no "professional help."



ISSUES OF TRUST

Trust in the therapist is absolutely necessary for progress in treatment. Only when the patient feels safe, can she start removing her dissociative barriers. This fact alone allows access to the traumatic material. Paradoxically, the more the patient trusts her healer, the more "vocal" she becomes in expressing her misdirected rage and the more she may fear the therapist. Concurrently, she may place high demands on the professional. This development is a positive sign of progress, but the doctor feels terrible, barely keeping up with the patient's changes. The doctor constantly needs to look for sudden mood swings and contradictory behaviors, and learn the identities of the personalities she works with.

After months of therapy, the patient may finally develop a degree of trust in the healer. But the therapist's trust in the patient may reach a low point. The doctor has learned that she cannot believe anything the patient tells her. The subject has lied countless times, has broken promises, has missed appointments, and has been a terrible pain; she is a typical difficult patient. The therapist is ready to give up on the patient, while the patient is just getting ready for serious therapy.

The patient is now discovering more about her traumas, and she suffers from recurrent nightmares and panic attacks. She may accuse the therapist of causing her undue pain and discomfort, and the doctor walks a thin line between the patient's ability to tolerate her suffering and staying in therapy. This tense period may lead to gradual improvement of the therapeutic relationship, or may produce stronger mutual animosity between the patient and the therapist. The patient may threaten to quit therapy or to sue the therapist for malpractice. Such threats further freeze the therapeutic relationship and may result in a breakdown of therapy. The patient may leave and never come back.

The therapeutic failure may have nothing to do with the therapist, but she still blames herself for not being better than perfect. The outcome affects the therapist's practice for a long time. One more difficult patient like the last one, and the therapist is ready to give up on ever treating another incest victim. From now on, she does perfunctory therapy involving kindergarten psychology, tells patients how strong and smart they are, and avoids anything associated with incest or multiple personality. Life is so much easier for her now.



REACTIONS TO DISCLOSURE

Few incest victims recall their traumas without the therapist's coaching, but leading the survivor to the desired conclusion is not enough. Because of dissociation, the patient cannot use his or her emotional intelligence. The suspicion of childhood abuse has to be spelled out clearly, and the reactions are unpredictable. Some individuals may shut down their senses and enter trance. Some may hysterically laugh. Some become seductive and will lead the doctor away from the key issue. Some start rationalizing and explaining that it happened a long time ago and it has no effect on their current lives. And if the doctor is not a highly qualified expert in multiple personality, she will probably miss the detail that the speaking personality of the patient has no idea what "it" stands for. Or, the patient may get very angry with the therapist for reminding her violated personalities of the abuse. The doctor must be ready for anything and should not become frustrated when the patient repeatedly denies her violation. Most victims need six to twelve months before they recall or accept the simple idea that they might be victims of incest. At this time, they still lack many facts, but whatever they recall may make the difference between partial awareness and total denial. This recognition does not come in a linear fashion. During the seventh month of therapy, the patient may be in complete denial and may praise her abuser for being the greatest dad on earth. She comes back three days later, and she is overwhelmed; she knows the truth.



FISHING IN THE DARK
 
Recall of sexual traumas is fragmented and distorted. The patient's claims are not in agreement with her older statements, and the therapist can do little to improve the survivor's recall. Attempts to learn more about a painful episode often result in the patient's emotional shutdown. Avoidance of reminders of the past traumas is a recurrent problem. The helper must have endless patience and be ready to face the patient's anger or request for help. The therapist may be feared, mocked, put down, laughed at, stalked, or reported to the authorities for malpractice.

The therapist may do her best, but her suggestions to the victim may not produce the desired results. In some cases, the victim may recall a few mildly negative traits of the abuser, but fails to consciously retrieve any information about her sexual abuse. Concurrently, her body language may show that something in her mind emotionally reacts to past traumatic experiences. The patient has no awareness of her body language; she only knows that the therapy is making her very sick. Not just her mind, but also her body. The therapist can make a suggestion to stimulate the patient's memory, but the patient may fail to follow the ideas or to retrieve any relevant information. Even hypnosis and dreams may be of no help, because the patient may be unable to validate the retrieved memories when she returns to full consciousness. She may know what happened in hypnosis and dreams, but the material evokes no recognition of the portrayed events when she is conscious. These limitations may be impossible to overcome.

If such problems persist, the therapist should try EMDR (Eye Movement Desensitization and Reprocessing). This remarkable technique, discovered by Francine Shapiro in 1989, manifests one of the main control mechanisms in the brain. The technique is particularly suitable for situations when the patient has some but very limited knowledge of her trauma, or when she has no conscious knowledge but reveals her abuse under hypnosis. Unfortunately, EMDR is very difficult to apply successfully, and the technique may produce catastrophic consequences if it is not used with great caution.



HYPNOSIS

The general notion among therapists is that hypnosis is the only effective way of getting to the forgotten early memories. This idea is false. Hypnosis is only one of several suitable therapeutic tools. In many instances, other methods may work better than hypnosis, mainly because the patient may be skeptical and may automatically reject anything that was recovered in the state of "altered consciousness." Even a patient who believes in hypnosis may have no use for the recovered memories. The episodes may fail the patient's reality check after return to consciousness and are treated as a dream; they are rejected. Some patients may have difficulty with reality checking and may believe that the recovered memories have been implanted by the therapist. This self-deception provides the patient with a convenient escape from reality, and a reason to quit therapy.

The potential difficulties do not mean that hypnosis is totally useless. Hypnosis can stimulate memory in a way that would not be possible if the patient were fully conscious. The conscious patient then has to process the information and generate the appropriate "memory addresses." Some addressed memories are painful, and the patient dissociates from the information even before it reaches her consciousness. By contrast, hypnosis deactivates the patient's emotions. She can tolerate even the most painful memories. In addition, the hypnotist can stimulate the subject with ideas that the patient would be unable to generate or process in full consciousness. However, hypnosis comes with severe limitations and problems when the patient has multiple personality.

The obvious disadvantage of hypnosis is distortion of facts. Healthy individuals can tell whether the memories retrieved under hypnosis are real or not after return to full consciousness. By contrast, incestuously abused subjects often have severe neuropsychological damage and are unable to distinguish between experienced reality and stories they form in their minds, or dream about, or hear, or read, or view in movies. President Ronald Reagan suffered from this very disorder. On one occasion, he described a story from a movie and reported it as his personal experience.



DOCTOR-PATIENT RELATIONSHIP

Therapy for childhood sexual abuse is difficult for both the patient and the therapist. The nature of the therapeutic relationship is such that the doctor is unable to rigidly maintain her professional, psychological, and physical boundaries. If she wants to be a good healer, she has to become honest, open, let down her guard, and mirror the patient's emotions. Similarly, a good therapist cannot sit behind her desk and keep the patient at the opposite end, more than four feet away. The therapist needs to have somatic contact with the patient to deliver sympathy and encouragement through touch. Such forms of interactions are conducive to developing a personal relationship with the patient. The patient is not just some stranger who came from the street and needs a pill for her flu. Because of transference and countertransference, the patient becomes part of the therapist's mental life, and also the patient considers the therapist part of her life. If such a level of relationship develops in therapy, it is wonderful. The trouble is that this carefully crafted relationship may become unmanageable; the relationship may control the doctor and the patient.

What could possibly happen that could turn the wonderful working relationship into something less than perfect? All kinds of things.

Best Friends
The relationship may turn out so well that the doctor and the patient become close friends. Sadly, the friendship is now an obstacle in therapy. The doctor may be unwilling to drag the patient through the horrors of her childhood traumas and may give her a break. The therapist's judgment becomes affected by the relationship. She no longer can make the best decisions in the patient's interest despite liking the patient and wanting to help her with all her heart. The relationship may also become a distractor from therapy. The doctor and the patient now spend more time on sharing their personal stories and impressions, and therapy gets less time.

The mutual, unconsciously driven attraction between the doctor and the patient also indicates that both parties have similar values and mentality. The couple unconsciously encourage each other to behave in certain ways. If the patient does not want to work through the details of her childhood rape, she sends unconscious cues to the therapist. The doctor unconsciously picks up the cues and responds in kind. The critical issues are put aside, and the doctor works on less important topics not to disturb the patient "unnecessarily." The doctor may accept this version of her justification and does not realize that her mind is clouded and she can not choose the best therapeutic approaches.

When a friendship becomes this good, chances are that the friendship will grow, but therapy will suffer more and more. After some time, both the therapist and the friend may incorrectly decide that there is no more need to work on the childhood traumas. The patient is cured only partly and may retain many of her undesirable aftereffects.

Best Man
Imagine this scenario. She is in her late twenties, rather pretty. Therapy is what she always wanted to do. Unfortunately, she has never worked through her incestuous rape by her biological father. She does not even remember it. All that she knows is that she wants to meet the right man, marry him, and have children. Yes, she is caring. That is why she has become a therapist. And then, one day, a tall handsome stranger enters her office. She can instantly sense that he is the man.

The therapist starts working with the patient. His father died two weeks ago, and the patient has been unable to sleep ever since. Gradually, the patient discovers the hidden memories of his childhood abuse. And the therapist feels sorry for him and wants to rescue him.

The patient remembers more and more about his abuse and suffers enormously. The compassionate healer hold his hands, caresses his hair, and talks to him gently. He suffers so much and needs help. Through him, she reactivates the memories of her childhood abuse, but they remain unknown to her consciousness.

The therapy progresses and acquires almost ritualized behaviors. He cries, and she embraces him, puts his head to her chest or in her lap, and feels so sorry for him. How can someone so gentle suffer so much? she wonders, and her heart aches. During these compassionate encounters, she does not even realize that there has been a complete breakdown of professional and personal boundaries between her and the patient.

The recovery of the traumatic details continues, and the patient is extremely needy. The therapist is no longer a doctor, but an angel of mercy who does her best to help him. And all the talking about child rape and molestation stimulates the minds of both participants sexually. And before they know it, they are on the sofa engaged in sexual intercourse. The downward spiral continues, and sex becomes an inseparable part of the therapy. The doctor senses that she did something improper, but is unable to stop her behavior. She rationalizes it. She believes that he needs her to help him relieve the stress of therapy.

At this point, a supervisor may intervene. If there is no supervisor, the relationship goes on for a while. The outcome can acquire many forms, but the sure thing is that the therapist is no more able to function as a doctor. She becomes ineffective and fails to heal the patient. Even if she marries him, the same problem of unresolved childhood abuse will continue to run the lives of the couple. Their children will have an extremely high chance of being sexually abused by either parent.

Some moralists might argue that the doctor abrogated her duty and harmed the patient. Maybe so. But she is also an incest victim and is controlled by similar unconscious forces of unresolved childhood traumas. Of course, she would get fired if her supervisors found out. On the other hand, the patient is equally responsible. The only difference between these two incestuously damaged individuals (who should both get treatment) is that one entered the therapeutic relationship from the position of a healer, and the other one from the position of a patient. Their neuropsychological damage is about equally significant and unconsciously runs their behaviors.

Best Woman
The best man scenario also frequently happens with the roles reversed. The therapist is a middle-aged male of considerable social stature. The patient is a ten years younger woman. Both are affected by their unresolved childhood issues. The therapist has acquired the morality of his incestuous father, and the incestuously abused patient is drawn to such traits. As in the previous case, there is breakdown of therapeutic and personal boundaries, and lack of responsibility for one's actions. The dissociated couple succumb to their unconscious forces and act them out by having intercourse. Again, the patient is not fully healed and continues her troubled life. The therapist is not healed either and continues having sex with his patients.

Acting Out
A conceptually identical scenario can play itself out between a doctor and a patient of the same sex. The relative number of male therapists who are homosexuals is unknown, but the Author's exposure to female psychologists and therapists hints at a very high ratio of lesbian women in these professions. Also in the case of same-sex therapy, the unresolved childhood abuse on part of the therapist and the patient becomes the unconscious driving force of the relationship. The patient and the doctor may enter a sexual relationship for reasons they can neither understand nor control. Even when both the patient and the doctor are heterosexual, they may, although much less likely, act out their unresolved childhood abuse by engaging in sexual contact. Sexualization of the relationship not only takes time away from therapy, but also perpetuates the unresolved traumatic behaviors and makes their influence on the lives of the doctor and the patient much stronger.

As the various scenarios suggest, breakdown of therapeutic and personal boundaries can harm both the doctor and the patient. A doctor who does not resolve her traumatic childhood is compelled to respond to her unconscious forces. They may affect her behavior in ways that could be not only unethical and unprofessional, but also criminal. The doctor may be working with a sexually abused child, may lose her behavioral control, and may reenact her abusive experiences with the child. When such behaviors take place, the doctor does not do her work, but uses her employment to gratify her need for power and control. She was exposed to them through sexual intercourse with her rapist, and she expresses them in the same way.

Having Favorites
Therapy with patients who have multiple personalities unavoidably leads to differential attitudes toward different personalities. Despite the therapist's best effort, she will not treat every personality the same way. The reason is that the therapist is a human being with values, feelings, sensitivities, and subconscious drives. The therapist will feel more comfortable with personalities who are beautiful, nice, amiable, reasonable, sociable, engaging, obedient, learning, and making progress. By contrast, she will be unwilling to work with personalities who are belligerent, oppositional, angry, furious, vengeful, mocking, unreliable, irrational, stupid, cheating, lying, aggressive, promiscuous, childish, immature, seductive, or stuck in their unchanging mental schemes despite months of therapy. But these social undesirables are the ones who need treatment most. They cause the patient daily problems. Success in therapy will ultimately depend on the degree of integration of these bad personalities into the whole psyche of the patient. Working with them will be a must, and the therapist will not like it. But then again, nobody ever said that work with multiples is easy.



PATIENTS QUITTING THERAPY

It is inevitable that some patients will quit therapy before the therapist concludes that the work is done. The reasons for leaving are many. Some reasons have nothing to do with the therapy. Here belongs relocation or the need to deal with more urgent matters, such as divorce, caring for a relative, or obeying the wishes of one's spouse. Many patients cannot afford the high cost of therapy and are forced to quit. Next to these objective problems, the therapist's attitude, style of work, pathology, or lack of expertise may be incompatible with the patient's taste or needs. Any of these factors can quickly end a therapeutic relationship.

For a therapist, it is not enough to believe in the existence of sexual abuse, learn about the symptoms, and master the mechanics of talk therapy. Experience has shown that therapy is rarely successful and never complete if the therapist does not address dissociative disorders, which are unavoidable consequences of severe traumas. Today's patients tend to learn about their problems from literature and quickly discern a therapist's outdated ideas. Some may put up with them for a short while, but a time will come when staying in therapy is counterproductive.

Another common disagreement between a therapist and patient is the healer's pathology. If he insists that problematic multiple personalities must be exorcised, or that personalities are only artificial products of the patient's imagination, or that only the host personality counts and others are unimportant, the patient is likely to leave such a therapist.

Naturally, it takes two to tango. If one member of the therapist-patient dyad does not like the other party, the therapy cannot be successful. In addition to liking each other, they need to develop a considerable degree of mutual trust. A patient who worries whether or not the therapist will disclose secrets to others is unlikely to engage in a meaningful therapeutic interaction. Similarly, a therapist who is afraid that the patient will sue him for causing her emotional pain will not dare to tread in the dangerous territory and will try to transfer the difficult patient to someone else.

Next to interpersonal dynamics, treatment formats and timing of events have major impact on the patient's ability to tolerate the discovery of forgotten traumas. A fragile patient who struggles to survive the day is likely to be overwhelmed by sudden facilitation of access to traumatic memories. Without stabilization and gradual grooming of the patient for the acceptance of the diagnosis, the patient is unlikely to tolerate the pain of the information. The same applies to exploration of traumas. The least traumatic events have to be recalled first and dealt with before more painful information is allowed to enter the patient's consciousness. A person with dissociative disorders lives in a chaotic mental world all the time, and the shocking awareness about one's abuse may not be tolerable. This is why reduction of dissociation and recovery of lost mental faculties should precede any serious exploration of forgotten traumas. Unfortunately, when children are involved, the therapist may be forced to disclose the traumatic experiences to the parents or to the authorities to prevent further abuse. By doing so, the therapist may indirectly expose the parents to their suffered childhood abuse, and thus turn them into patients against their will.



WHEN THERAPY HITS HOME

Doing therapy with adults sexually abused as children is "easy" when the doctor deals with the patient's problems. A challenge arises when the doctor realizes that she is an incest victim, or that someone else in her family was abused, or is a rapist. The doctor may slowly recognize the origin of her caring character. Unknowingly, the doctor has been trying to heal and protect the abused little girl she once was. The association is originally unclear and usually comes forth only through analysis of one's behavior by a third party. The doctor cannot find this association by direct reasoning. If the doctor ever makes the discovery herself, the realization only comes after a degree of detachment from her egocentric perspective, only when the doctor is able to look at herself from the viewpoint of another person. This requires well-developed emotional intelligence.

The doctor may now recognize that all her work in the field of sexual abuse of children has been a reaction to her childhood traumas. The news is devastating, and the great doctor who can usually heal any incest victim becomes just as needy and vulnerable as her patients are. In the past, she listened to the stories of her patients with academic interest and was able to solve their problems with a clear head. Now she is in the same position as her patients are, and her great academic insight is of no help to her. Telling others what to do in such a situation was easy. But when the pain is hers and she dissociates, she feels very different about the traumatic accounts. Likewise, when she recognizes that her child is abused, she often becomes unable to deal with the situation. Now it is she who needs help. Lots of it.

The first response to one's memories of childhood sexual abuse is sheer terror. Not too long after, the incest victim is flooded with additional worries. How could I have been so naive? How could I have believed that I was not abused as a child? How could I have written three national bestsellers about sexual abuse, claiming that I was not abused, when I was? Admitting the situation to oneself is very difficult. The immediate reaction is fear of being seen as incompetent by colleagues. The doctor also feels ashamed and starts blaming herself for having had sexual intercourse with her parent. Why did I not tell someone? Why did I protect him? I must have wanted it. I am the one to blame for what happened between me and Dad. How can I show in public? I cannot face the world. I seduced Dad.

Notice the sudden change in the therapist's demeanor. She, the greatest therapist on earth, told countless incest victims that the abuse was not their fault, and now she feels as they do: She blames herself. The situation is no different when the doctor discovers the rape of her child.

How could I have been so stupid and not seen that my husband has sex with our daughter? I am supposed to be an expert. Incest! In our family. Two doctors. And he rapes our daughter. It must be my fault. I must be lousy in bed. I must be a lousy wife and an even lousier mother.

Again, the doctor subconsciously blames herself. Awareness of the child's abuse activates the doctor's emotions relating to her childhood violation, but she is often unable to remember anything specific and recognize that she, too, was raped in childhood. She is not even able to positively respond to the abuse of her child. She only registers the fact that her child has sex with her husband, and the doctor-mother is overwhelmed by the discovery.

Luckily, it is only the daughter who is abused. Admission of the fact is horrifying, but the mother does not have to face the worst imaginable terror: HER ABUSE. She dissociates and stays protected from the memories of her childhood rape. Responding to the violation of her child is painful and devastating, but the mother is safe.

And even if the doctor does recall some hints of her childhood abuse, she is likely to dissociate and deny the truth to herself. Or she may switch to a different personality, and the whole issue ceases to exist. Or the healer rationalizes:

I am a doctor. I have been dealing with incest for too long and am predisposed to seeing it in everyone, including my children and myself. My worries are unfounded. I am from an honorable family of doctors, and there is no incest in our family.

A doctor who denies her abuse to herself not only lacks the emotional intelligence needed for the treatment of her patients, but is also prone to dissociate from such material. She may dismiss the stories she hears from her patients and does not really believe that the abuse took place. She watches the patient's every word and looks for discrepancies. It is inevitable that the patient will report some events that will not fit the previous statements. The errors will happen because of memory distortion, or because of the doctor's inability to concentrate on the emotional trauma. And the doctor uses these few discrepancies to reassure herself that the patient is confabulating. The reports are dismissed in their entirety. They have to be discounted. The doctor has to protect herself.

If a therapist does remember her childhood abuse, she can count on being incapacitated for weeks or months. In this state of mind, she is unable to heal others. She tries to keep distance from anything that is associated with childhood sexual abuse. She is barely able to make it through the day staying home. Working is out of the question. Hurrying back to work is not a good idea. She may need years to fully resolve her traumas. Her treatment may be the end of her career as a doctor. Or she may view her experience professionally, as practical work experience, and return to work with renewed energy. The outcome may go either way and is unpredictable.



BURNOUT
 
In light of the demands of psychotherapy with incest victims, it is a miracle that burnout of the doctor does not happen more often. The therapist may overwork herself to a point of no return easily, and burnout often comes when everything goes well. The therapist finishes her major case and leaves for a short vacation. When she comes back, she suffers a mental shock; the stress of her job is unbearable. The doctor may lose interest in her work and develop mental allergy (revulsion) to anything that reminds her of the therapeutic environment. At this point, a very long vacation or change of occupation may be the best solution. The doctor must first take care of herself.



DIFFICULT PATIENTS

The fact is that relatively few psychotherapists are trained and mentally ready for child abuse therapy. But even those who specialize in this type of patients will encounter insurmountable problems at times. One of the worst troubles is a Patient from Hell. The person can be male or female. The distinguishing feature of the subject is an attempt to dominate the therapy to meet his or her personal needs. Especially subjects with a condition the author labeled GCD are prone to place impossible demands on the healer. These people often cannot be satisfied by any means. The only sensible approach is to stop treating them or better yet never start. Luckily, GCD subjects and similar patients
almost never consider that they are mentally ill, and they rarely end up in therapy. But if they happen to cross the threshold of your office, you need to quickly identify them and send them away. Do not attempt to heal them for incest. Their excessive demands and pathology can turn you into a mental patient.

Another representative of a troublesome patient is one who knows everything. Experience shows that it is difficult to persuade naive subjects that they need therapy for incest. Those who do remember their abusive childhood are frequently unwilling to educate themselves outside therapy by reading literature. They are overwhelmed by their own pasts and find no inclination to learn about the ordeals of others. By contrast to these common patients, some will be highly intelligent savants with no affect. They will voraciously seek any available information about their conditions, and then will confront and challenge the therapist's expertise and style of therapy. The therapist may be shocked by the patient's extent of clinical and theoretical knowledge in the field where she is supposed to be the expert. She may feel like a pupil before her professor. To get over this problem, the therapist needs to realize what she is dealing with. Some savants are capable of learning a college course or a foreign language in a week. If the therapist tries to compete in theoretical knowledge and outsmart the patient, she will lose. The best approach is to recognize the patient's mental and neural deficits in emotional intelligence, rather than trying to match the patient's scholastic abilities. The seemingly unmanageable situation will suddenly make sense and restore the therapist's self-confidence.



IMPROVING PATIENT'S FUNCTIONALITY

In the early days of treatment for child sexual abuse and multiple personality disorder, therapists spent long time working through every major trauma with every alter (personality). This time-consuming approach has given way to rapid therapy in today's environment. These successes have been possible because of our better understanding of traumas and their resolutions. Therapists can now heal patients quickly and bring them up to normal functionality. Unfortunately, this optimistic scenario is unreal. Although the latest knowledge and techniques allow therapists to do away with manifestations of problems quickly, the external manifestations only poorly correlate with the patient's state of mind. And most health professionals are unaware of this relationship.

Treatment directed toward symptom-free patients is the dominant approach in today's medicine and is not limited just to mental disorders. Acupuncture has heavily relied on this mechanism by destroying neural circuits. Reduction of pain through destruction of neural circuits is considered success, but the patient loses his ability to discern pain and protect his body against excessive wear and tear. Similarly, many psychotherapists attempt and fail to heal childhood traumas by dismissing nightmares and specific memories of abuse. The patients are told that dreams or flashbacks about childhood abuse are confabulated memories. The patients are taught to believe only in good things and dismiss negative experiences. After a treatment, disturbing nightmares may reduce in frequency; the patient's response is viewed positively, and the treatment is terminated because the subject is now "healed." The same approach is preferred with hyperactive children. Reduction of the symptoms in response to medication is seen as a sign of successful outcome, and no one pauses at the detail that the patient has now been turned into a vegetable with no ability to perceive or comprehend the emotional valence of his stimuli. A related problem is suppression of alter personalities with medication. In reality, the symptom-free outcome does nothing to treat the inner life, the interactions, and the communication within the patient. These examples testify to the discrepancy between the patient's inner mental processes and the doctor's ability to discern a mental disorder. The doctor's lack of emotional intelligence along with his failure to discern neuropsychological problems does not constitute a treatment success. When a patient is truly healed, the excessive negative or positive symptoms disappear, and the patient's responses are proportional to the true valence of internal and external stimuli. Therapists unfamiliar with the cognitive organization of the human mind are easily fooled by the superficial behavioral improvements and believe that a successful psychotherapy requires nothing more.



TO HEAL OR NOT TO HEAL?

Treatment for incest and its neuropsychological consequences is a troublesome matter. The doctor can do her best, but may fail to undo all damage left behind by the sexual abuse. Because of this problem, an issue emerges whether a patient should be treated for sexual abuse at all. A patient who enters therapy with the knowledge of incest and seeks treatment for this particular reason clearly needs help. Her emotional upheaval has to be addressed and reduced so that she can function in daily life. The partly aware patient is ideally suited for EMDR therapy. But should the doctor try going deeper and dealing with the most traumatic episodes of the abuse? That is not easy to decide. Recovery of repressed memories leads to strong traumatic reactions that make the incest survivor feel very bad. She may become nonfunctional, use drugs, self-mutilate, or commit suicide. On the other side of the issue are the consequences of insufficient treatment.

A subject who is not healed has low emotional intelligence, which causes her countless problems in her daily life. Her repression makes her susceptible to re-enact her abusive experiences against children or makes her unable to detect their abuse by others. Similarly, her low emotional intelligence and her childhood conditioning through rape prevent her from appropriately punishing the children's abuser. She tends to feel sorry for him and protect him. To cope with her unresolved traumas, she may use drugs or may exhibit antisocial, self-defeating, or self-destructive behaviors. Her unresolved traumas often lead to serious dissociative, neurological, and psychosomatic illnesses. They are crippling her or killing her. For this reason, it is highly desirable to address the victim's childhood abuse in full scope. But this strategy may backfire and psychologically destroy a patient who cannot handle the re-exposure to her traumatic experiences. The doctor needs to decide whether to revive all memories of the patient's abuse or just treat her for the traumas she is aware of. This approach may be the best solution for both the doctor and the patient.

A different scenario exists when the patient has no knowledge of her abuse, appears functional, but suffers from some specific problem, such as depression. The unaware patient who is recognized as an incest victim may respond in many ways. Ideally, the patient should work through her most traumatic experiences and process them in full consciousness. In the end, the patient is free of her PTSD, dissociation, and multiple personality, and has healthy values. She can go on with her life and be sure that her past will not lead to further somatic, neural, and mental damage. By contrast, the naive patient who is exposed to incest therapy may become overwhelmed by her emerging experiences, but may not incorporate them into her personal history. The revived memories may cause her unbearable pain. Since it was the therapist who exposed the patient to the repressed traumas, both the patient and the therapist believe that the therapist has a moral obligation to heal the patient. And the more the patient is exposed to her memories of incest, the more traumatized she becomes. She may leave therapy, overdose on pills, commit suicide, or sue the doctor for malpractice. Thus, before the doctor exposes the naive patient to therapy for incest, the healer has to make a serious decision. Unfortunately, the outcome can only be known in the end.



HEALING THE ENEMY

Malpractice is a concern for most medical professionals. Apart from organized malpractice committed by the institutionalized medicine and protected by the legal system, a doctor must be careful not to deviate from the standard operating procedures. In the field of sexual abuse or MPD treatment, almost every therapeutic measure is new or out of the ordinary. Mistakes are likely to be made, and the doctor is going to feel it either emotionally or financially. Probably the most devastating outcome of a treatment is patient's suicide or an accusation that the therapist implanted false memories in the patient's mind. Lawsuits and loss of license are real possibilities. Paradoxically, the doctor may lose her license or be sued not because she committed malpractice, but because she did everything right.

Unlike many other health professionals, who reduce the pain of patients or repair their bodies while the patients are under anesthesia, psychotherapists have to work against the patient's immediate well-being to achieve improvement in the patient's functioning in the future. A therapist not only has to dig out the patient's traumatic experiences, but has to do so while the patient is conscious and pays attention. This approach, which is the only way to heal the patient, leads to re-experiencing of the original traumas along with the emotional and psychosomatic effects.

The patient dissociated from the traumatic experience during the original abuse to protect her mind against mental pain. Therapy tries to overcome the dissociative mechanisms and make the patient face her abuse. Of course, the re-experiencing is painful and traumatic. This is why the patient dissociated as she was subjected to abuse, and the pain is not getting any smaller now. If anything, the pain is bigger because the patient is acutely aware of every detail of the traumatic experience. The doctor knows that treatment is only possible when she re-exposes the patient to her traumas and helps her reprocess the experiences. This is where most problems in therapy arise. The patient hurts and is haunted by her flashbacks and dreams. She wants to run away from therapy, and the therapist does her best to expose the patient to the full emotional impact of the traumas. This is equivalent to treating a broken leg by breaking it again. Such a treatment may seem insane when it comes to the treatment of the human body, but is the best chance for the treatment of an incest victim.

Looking at the treatment from the viewpoint of the incest victim, her reactions are understandable. The "treatment" makes her feel worse. She is positive that she is being mistreated and wants to sue her doctor for causing her pain and suffering. And, naturally, medical bureaucrats as well as other child rapists are happy to shut down, prosecute, and imprison those healers who expose the crimes of rapists. The therapist needs to understand that all social institutions, including the medical field, are controlled by rapists or dissociated incest victims. They consider the healer an enemy and want to get rid of her by way of physical, professional, or financial annihilation. So, the doctor is attacked from all sides: by the incest victim, by her rapist, by incest victims and child rapists in social institutions, and even by her supervisor.

Yes, it is a paradox, but hospital supervisors can harm both patients and therapists. You know the psychiatrist who supervises you in the hospital. He is usually a domineering male. He reacts to his childhood abuse by being controlling. Devoid of emotional intelligence, he rigidly sticks to official protocols and does not want to hear that a patient might be an incest victim. Such thoughts subconsciously trigger the painful memories of his childhood traumas. In response, the psychiatrist in charge orders his subordinate colleagues to follow standard procedures and treat the patient only for specific complaints, and not for alleged complex aftereffects of incest. There is no such thing as shell shock. And there is certainly no such thing as incest. Not in this hospital, not ever.

In addition, the supervisor may order the use of medications that may render all psychotherapeutic measures ineffective. So, even if the therapist tried, she could not make much progress with a medicated patient. The patient's traumas remain unresolved, and the only way to deal with such a medicated subject is lifelong medication. And that is good. The psychiatrist is needed to write the prescription; the drug company has a stable market; the patient shows fewer deviant behaviors, and the patient's relatives are happy with the outcome because the patient is not a "problem."



FACING ORGANIZED CRIME

In most developed countries, a doctor is required to report the discovery of childhood sexual abuse to the appropriate authorities. The informed parties may include the clergy, police, or child protective services. A court action may follow. The therapist may be required to testify as a witness. The therapist feels that she did the right thing and expects that the government will solve the rest of the problem. Unfortunately, the therapist does not see the bigger picture.

Incest is an organized crime. Laws, values, beliefs, and religion manifest the ties among the criminals. The incestuous organization includes not just the perpetrators of the crime, but also their victims. In the courtroom, the child recants her previous testimony and "stabs the therapist in the back." The prosecution and defense look for legal technicalities, and the jurors unconsciously hate the child for reminding them about their abuse. The perpetrator may be found guilty of child molestation (a nice, sanitized expression for atrocities), and the judge may sentence the abuser to probation or dismiss the case due to the statute of limitation (a courtesy of state and federal legislators).

Treatment of survivors of incest is not only a demanding, but also a dangerous job. The therapist may be physically attacked by the patient or the abuser, but this is not the greatest danger. After the therapist realizes how many children of government officials have the visible symptoms of incest, she may get really scared. On the one hand, she is required to report her findings to the authorities, and on the other hand, she risks being persecuted, secretly imprisoned, or assassinated by her own government.

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Unpublished work 2002-2017 Martin Dak. All rights reserved.