In the present study the research focus is on the consequences of childhood sexual abuse in conjugal life and the effectiveness of psychodynamic psychotherapy in the case of a female survivor of childhood sexual abuse who experienced marital problems. The client engaged in three years of psychodynamic psychotherapy with the request of improving her relationship with her husband. Central to the problems she was facing in her marriage was the sexual abuse she endured as a teenager by her father, which is a main theme processed throughout the therapeutic process, as it has shaped her attachment style and has been an inhibitory factor in her relationships with men. In order to assess the impact of psychodynamic psychotherapy in the present case three tests were used in the beginning and the end of the therapy. To begin with, she completed the Dyadic Adjustment Scale (DAS), the Experiences in Close Relationships-Revised (ECR-R) Questionnaire, and the Thematic Apperception Test (TAT), which allowed us to understand in depth her attachment patterns, evaluate her marital situation and explore her inner and intra-personal world, as well as interpersonal couple and family functioning. The therapeutic approach employed in this case is discussed, as well as her responses to the above tests at the beginning and the end of therapy.

Keywords: child sexual abuse, conjugal life, attachment, psychodynamic psychotherapy

Child sexual abuse

Sexual abuse in childhood affects a large number of children across different countries and cultures. A common misconception about child sexual abuse (CSA) is that it is a rare event perpetrated against girls by male strangers in poor, inner-city areas. To the contrary, child sexual abuse affects children of sexes and all ages, races, ethnicities, cultures, and economic backgrounds. According to the US Centers for Disease Control and Prevention (CDC), child sexual abuse is “any completed or attempted (noncompleted) sexual act, sexual contact with, or exploitation (i.e, noncontact sexual interaction) of a child by a caregiver.”¹ The CDC distinguishes sexual acts as those involving penetration, abusive sexual contact as intentional touching with no penetration, and noncontact sexual abuse such as exposing a child to sexual activity, taking sexual photographs or videos of a child, sexual harassment, prostitution, or trafficking.¹

Epidemiology

The WHO 2002 World Report on Violence and Health suggests that cases reported to authorities may reflect a more physically violent subset with injuries requiring treatment, as these cases are less easily hidden. It likens the magnitude of CSA or sexual violence to an iceberg, in which only the smallest portion is reported to authorities, a larger yet still incomplete portion is reported on surveys, and an unquantifiable amount remains unreported because of shame, fear, or other factors.² The 2006 World Report on Violence against Children^3,4 provided estimates that in 2002 approximately 150 million girls and 73 million boys were subject to contact CSA worldwide, including 1.2 million trafficked children and 1.8 million exploited through prostitution or pornography.

Consequences of childhood and adolescent sexual abuse in adulthood

Before talking about the consequences in adulthood, it is important to refer very briefly to the short-term consequences children experience after facing CSA.

Short-term consequences

Consequences of sexual abuse experienced in childhood or adolescence are often manifested as psychological disorders (e.g., anxiety, depression, and somatization), outsourced disorders (e.g., aggression, opposition, problematic sexual behaviors) or mixed.^5,6 The clinical picture of survivors of sexual trauma remains heterogeneous and variations are associated with the socio-demographic or psychosocial characteristics of the victims (e.g., victim's age and sex, coping strategies), the severity or chronicity of assaults, the parental responses observed following disclosure, other forms of victimization experienced, and the quality of psychosocial services received by the child.^7,8 These data are based on the conclusive results of a series of cross-sectional and longitudinal studies and currently form the basis of a broad consensus within the international scientific community.⁶⁻¹⁰

Long-term consequences

In the long run, these effects seem to persist in adulthood and manifest themselves through a complex symptomatology that is strongly expressed in romantic relationships.^11,12 This preponderance of interpersonal effects is explained by the need, in adulthood, to reconcile the developmental tasks related to intimacy and sexuality in a context where the efforts of emotional regulation to deploy are sometimes complex. Sexual assault experienced at an early age causes an imbalance in the neurobiological systems that amplify sensitivity to the situations of treason, shame and helplessness that inevitably occur at different stages of the couple's life.⁶ In addition, sexual intercourse is based on transgressing the physical boundaries of the other, which requires an adequate metabolism of desire and aggression.¹³ These characteristics of adult sex exchanges are likely to provoke reactivation or intensification of the residues of past sexual assaults. They also lead to confusion between feelings of sexual desire and fears of exploitation.¹⁴ The after-effects of sexual assault can therefore play a key role in the process of forming a conjugal union and weakening it. Sexual abuse survivors present difficulties in trusting others, in having confidence in oneself and in their feelings and show an insecure attachment.¹⁵ In fact, the current scientific literature identifies higher rates of break-ups, unfaithful behavior, domestic violence, and marital or sexual dissatisfaction among these victims.¹⁶⁻²⁰ More recently, Miller et al.²¹ have shown that these marital difficulties persist even by controlling the effect of post-traumatic stress symptoms and additional traumas experienced in adulthood.

A body disconnected

Research in the field has shown that women who have experienced sexual abuse as children face difficulties in perceiving their bodies as sexual objects.²²The experience of sexuality is largely based on the experience of the body, which is greatly affected by the violence imposed on it. Indeed, abuse affects not only body image but also the way one connects to their body; the way they respond to bodily functions and responses such as sexual desire and stimulation. As a consequence, abuse victims fail to connect to their body sexually and thus experience an increased difficulty in connecting to others sexually as well.

Depression

In a recent study involving 732 Boston women who received therapy for depression, Wise et al.²³ found that 50% of them had experienced sexual abuse in childhood. "The earlier the incest takes place, the greater the risk of irreversible identity damage".²² The victim of sexual abuse is blocked in their identity construction at the age of the trauma. Most clinical observations highlight this aspect. Weiss et al.²⁴ conducted a review on the role of childhood sexual abuse in relation to the risk of later developing depression (7 community studies, 5 high school studies, and 9 clinical studies). It turns out that sexual abuse in childhood is a risk factor for both male and female victims.

Personality disorders

Various personality disorders are mentioned in the literature as the distant aftermath of sexual abuse during childhood. Most common among victims is borderline personality and antisocial personality disorder.^26,26 Luntz et al.²⁷ showed that in a group of 416 child victims of abuse / neglect, compared to 283 witnesses, child abuse and child sexual abuse were predictors of symptoms of antisocial personality or antisocial personality diagnosis. Similarly, Fox et al.²⁸ showed that child sexual abuse victims develop more empathy compared to adults who have not experienced abuse. The personality disorders caused by childhood abuse seem to depend on the nature of abuse. Thus, Jonhson et al.²⁹ have shown that, while child maltreatment generally increases the risk of a personality disorder in early adulthood, physical abuse is mostly associated with a risk of antisocial personality disorder and sexual abuse with borderline personality disorder.

Intra-familial and repeated sexual assaults related to marital difficulties

In general, in comparison to other forms of sexual abuse, intrafamilial sexual assault is associated with higher rates of marital distress, especially when such abuse is accompanied by anal or vaginal penetration. ^{29,30,16,19,20,31}. Watson & Halford,¹⁹ after recruiting a large sample of women, report that while all types of childhood sexual abuse are associated with marital problems in adulthood, abuse perpetrated by family members is specifically associated with a higher risk of future marital separation and marital dissatisfaction. In addition, Vaillancourt-Morel et al.³² through their study have shown that the abuse associated with penetration or perpetrated by a family member will be associated with higher rates of marital distress, psychological distress and insecure attachment among victims who have marital or relationship difficulties. Regarding relational proximity to the abuser, the results of Vaillancourt-Morel et al.³² reveal that victims who have been sexually abused by a parental figure present higher rates of psychological distress and anxiety than non-abused participants. This subgroup of victims is also more psychologically distressed than victims who have been sexually abused by a stranger and show more privacy avoidance than victims who have been sexually abused by strangers or acquaintances. From a clinical point of view, sexual acts by a person whose status involves affection, protection and care may elicit more conflicting or ambivalent emotions (eg, pleasure, love, shame, guilt, betrayal, anger). They also create great difficulties in reconciling the image of an abusive parent with the representation of a protective and loving parent. Thus to cope adequately with sexual abuse, the child faces great ambiguities. For example, they may be undecided about unveiling or experiencing conflicting feelings of pent-up anger and love for the abusive parent. This type of reaction among adult victims of childhood sexual abuse refers to the process of failure to mentalize a traumatic experience. This concept is well illustrated in the qualitative study by Berthelot et al.³³ reporting speeches by adult victims of child abuse who have difficulty mentalizing adequately the abusive experience. In addition, abuse by a parental figure often involves neglect or lack of protection of the non-abusive parent, which may increase feelings of betrayal and negative representations of oneself and others. Thus, the child may have to deal with the loss of a feeling of security in his family environment, a feeling that is necessary for the general development of the child, the specific development of a secure attachment and possible training of a loving union. In this sense, a recent article by Godbout³⁴ highlights the role played by attachment figures following trauma. They reveal that when the child or adolescent announce an abuse, the nature and strength of parental support impacts the subsequent psychosocial adjustment.

Finally, with regard to the frequency of sexual abuse, the results of Vaillancourt-Morel et al.³² show that victims of chronic sexual abuse have a higher degree of psychological distress than non-abused participants and that other victims of sexual abuse during childhood (ie: single episode, a few times). In terms of the type of sexual abuse suffered, their results indicate that victims who have experienced abuse with anal or vaginal penetration present more psychological and conjugal distress as well as more insecure representations of attachment compared to non-abused participants and other victims of sexual abuse. Indeed, this type of intrusive sexual abuse seems to have a significant effect on the impact noted in adulthood. These victims have greater marital distress and privacy avoidance than all other participants (non-abused and other victims). All of these results converge with those of previous studies interested in the characteristics of abuse that suggest that a victim of sexual abuse perpetrated by a parental figure,^19,35 with penetration³⁶ or chronic³⁷ will experience more severe intra- and interpersonal repercussions in adulthood than the others. In this same line of thought, Whisman²⁰ (2006) emphasized, based on a large probability sample of 5877 American, that penetrative sexual abuse is the only childhood trauma associated with separation and marital satisfaction, regardless of the relationship with the abuser and the number of abuses suffered. Fleming et al.³⁰ report that in a sample of 710 women representative of the Australian female population, sexual abuse involving anal or vaginal penetration, in comparison to other forms of abuse, is associated with higher risks of later relational difficulties. Finally, Liang et al.¹⁶ looked into the case of 136 American women who experienced sexual abuse during childhood. Their findings reveal that in cases of sexual abuse, penetration is associated with higher rates of marital dissatisfaction than other types of sexual assault. An overview of these studies also shows that until now, in adulthood, the association between the frequency of sexual abuse during childhood and marital consequences in adulthood has not been studied enough.

Patient’s history

Mary visited our practice requesting support as the status of her marriage was deteriorating and she felt she was unable to deal with it on her own. In her own words, ‘I don’t know what to do..Umm.. it’s like we’re drifting apart, and umm, there is this distance between us, I don’t really know why, I’ve tried everything and I’m feeling a bit lost, so I thought, cause the last time I tried therapy it was very helpful..’. Mary informed us from the first session she had received therapy in the past, and when asked about it she introduced us to her history of abuse. She grew up in the suburbs of Athens in a flat with her mother and father, who both worked full time, and had her grandmother help with her upbringing. According to Mary, her parents had a very stable relationship, with no fighting and friction, but with no intimacy either; ‘there was never any yelling at home…but it felt there was no real conversation going on either.. I remember them sitting at the kitchen table for dinner and talking about the weather, or mum’s work, or the neighbors’. She described herself as a very active kid, with many friends and many extracurricular activities she was thriving at, such as tennis, gymnastics, painting and learning foreign languages. ‘It was my mum who first wanted me to join the tennis club when I was in primary school, and I did really well there, so umm, as years went by I kept requesting to join more clubs, cause that meant I had to spend less and less time at home’. Mary mentioned she had really warm memories of her grandmother, who died when she was 5 years old, leaving her to spend a lot of time on her own at home when her parents were off at work. Before speaking of the abuse, Mary’s body language changes; she breaks eye contact, she locks her arms in a defensive position around her core, and she lowers her voice. ‘I still remember the first time he came into my room… I must have been 11 years old. It’s weird because I don’t remember much of this year of my life… It started happening on a weekly basis, he would come into my room late at night when mum was asleep and then leave without saying anything, or looking me in the eyes.’ The sexual abuse by penetration went on for two years and stopped when Mary started menstruating. She spoke of the impact it had on her relationships with men, as she was too afraid to interact with older men and boys her own age repulsed her. It wasn’t until she was in her early twenties, when she had left home, that she entered a romantic relationship with a man for the first time. According to her, this relationship was not successful, as her partner was ‘always in charge’ and she felt ‘trapped’ in the relationship. Through her description of this relationship it becomes clear that she has been victimized, as every time she speaks of the relationship the language she uses is indicative of an imbalance of power. Through this period of her life, she entered therapy for the first time, which lasted for four years and helped her to address and process the abuse for the first time in a safe environment. This process really helped her; she ended the relationship, found a better job and later on met her future husband. Their relationship was, according to Mary, ‘the most functional relationship I have ever been a part of, there is respect, mutual understanding, trust, and ummm, we really love each other’. Mary brings up their marital problems at the beginning of our therapy process, and mentions their sex life, or lack thereof, as central to their problems. ‘Our sex life was never, you know, the biggest part of our relationship, we had one but it was never my favourite thing about us, but for the past year it’s like we have drifted apart and there’s nothing, I have tried to make it happen again but haven't succeeded really’. As their marital problems were the main request that brought her to therapy, we focused on them and collected information at the beginning of the therapeutic process and three years on.

In order to focus on Mary’s representations, her marital problems and also explore the link between her marital problems and the sexual abused she experienced in her adolescence we used during our second session the Dyadic Adjustment Scale (DAS), The Experiences in Close Relationships-Revised (ECR-R) Questionnaire and The Thematic Apperception Test (TAT). Additionally we used the same tools at the end of Mary’s psychotherapy in order to study the effects of psychodynamic psychotherapy.

Dyadic Adjustment Scale (DAS)

Dyadic adjustment is evaluated using the Dyadic Adjustment Scale (DAS).³⁸ This 32-item questionnaire assesses the degree of marital satisfaction or of other similar dyads of the participants by providing a total dyadic adjustment score ranging from 0 to 151.The 32-item scale is designed for use with either married or unmarried cohabiting couples. In terms of interpretation, the higher the total score, the more satisfied the individual is with his relationship. Typically, an individual score greater than or equal to 100 is used to differentiate unsatisfied individuals from those satisfied with their relationship.

The Experiences in Close Relationships-Revised (ECR-R) questionnaire

In order to create a holistic framework that would allow us to understand in depth Mary’s marital situation and evaluate her attachment behaviors we used The Experiences in Close Relationships-Revised (ECR-R) Questionnaire.³⁹ This 36-item tool measures two dimensions of loving attachment: anxiety of abandonment and avoidance of intimacy. The dimension of anxiety of abandonment makes it possible to define the cognitive representations that the individual has of oneself and refers to the subject of abandonment or rejection in the romantic relationship. The intimacy avoidance dimension allows us to target the cognitive representations that the individual has of his / her romantic partners and represents the level of self-sufficiency, of discomfort regarding the intimacy and love interdependence. The first 18 items comprise the attachment-related anxiety scale. Items 19 – 36 comprise the attachment-related avoidance scale. In real research, the order in which these items are presented should be randomized. A total score greater than 3.5 on the anxiety dimension of abandonment and 2.5 on the avoidance dimension of intimacy reveals a high level of this dimension of attachment in the internal representations of the individual.

Thematic Apperception Test (TAT)

Thematic Apperception Test (TAT).⁴⁰ Thematic Apperception Test, as projective technique, results particularly rich since it allows to explore the inner and intra-personal world, as well as interpersonal couple, family or community functioning. In the TAT, the ambiguous materials consist of a set of cards that portray human figures in a variety of settings and situations. The subject is asked to tell the tester a story about each card that includes the following elements: the event shown in the picture; what has led up to it; what the characters in the picture are feeling and thinking; and the outcome of the event. The goal is to experiment a utilization of the test that could contribute to the understanding of personalities and of how these intertwine in couple interaction.⁴¹ In the relationship with the partner, the personality takes new shapes, given personality and character traits are strengthened, while others lose importance”.

Psychodynamic psychotherapy

Mary engaged in psychodynamic psychotherapy for a period of three years. The therapeutic process was focused on unconscious processes, thus was mainly unstructured. Nonetheless, we focused on certain elements that are central when dealing with trauma and abuse. In detail, psychodynamic therapy generally targets unconscious processes, which shape partly our behavioural patterns. One of the goals of psychodynamic therapy is to increase a client’s self-awareness and help them understand the influence of their past experiences on present behavior. When working with clients who have experienced severe trauma in the past, therapy focuses on helping clients experience a remission of symptoms, develop self-esteem, and improve their capacity for developing and maintaining more satisfying relationships. Resource orientation, which was used during Mary’s psychodynamic psychotherapy, is thus considered a major element of the therapeutic approach. In terms of psychodynamic ego psychology, activation of internal resources means enhancing the patients’ mastering and coping competencies.⁴² In terms of psychodynamic object-relations theory,⁴³ it can be understood as a process of restoring the ability to activate positive internalized object relationships. This can be accomplished by evoking memories of positive relationship experiences or by stimulating fantasies of positive experiences. For example, evoking a memory of a personal success aims at restoring self-esteem by actualizing an internalized object relationship of a self being mirrored by a good object. As trauma blocks the patients’ access to positive internalized object relationships and the related positive emotions, the approach aims at evoking in traumatized patients a psychological state of well-being. Furthermore, it aims at improving coping strategies by directly activating the respective ego functions and internalized object relationships. Imaginative techniques are valuable tools to activate positive resource states.^44,45 The use of resource activation enabled us to improve Mary’s emotional regulation. Thus the actualization of internalized good object relationships became the central therapeutic tool for improving emotion regulation. The resource activation can be referred to as “activation of internal resources.” All kinds of positive memories, capacities, thoughts, memories, and fantasies can be utilized as internal resources (as opposed to external resources like helping persons, etc.). Whatever produces a positive feeling state can be considered a resource. Practically, activation of internal resources can include pursuing pleasant activities, remembering positive experiences, and creating positive feeling states by way of imagination. To that end, we systematically showed the client how to identify, remember, and vividly imagine memories of positive experiences, personal successes, and positive relationships. To cope with current stressors and life problems, the client was asked to identify those coping resources (capacities) needed to solve the problem. In a next step, the client was encouraged to search for situations in her life history where this resource was available. Finally, she was asked to create a vivid imagination of the resourceful scene.

First phase

Dyadic adjustment scale

Mary’s score at the Dyadic Adjustment scale is 68/151, which indicates her feelings of dissatisfaction regarding her relationship with her partner.

Mary after the scale mentioned that “We often disagree with my husband because I cannot demonstrate affection. It is because of me. I cannot be affective and there are times that I cannot demonstrate my feelings to my husband. He sometimes tries to talk to me about this but I cannot explain to him why I am like that. [...] We also disagree about spending time with other people…I don’t have many friends…I don’t know why…I’d rather be alone. He doesn’t get it…and I cannot understand why he wants to spend so much time with his friends.

[...] Sex relationship…oh it’s the main reason we fight. I feel uncomfortable most of the time. I don’t like my body. I don’t find it sexy...I don’t like it.

[...] We don’t spend much time together. There are moments I want to be alone. I feel upset and I want to be alone...And we do not kiss very often….i think it’s again because of me…I’m often too tired to have sex and I think that most of the time I’m not showing love, but I love my husband.

The Experiences in Close Relationships-Revised (ECR-R) questionnaire
The statements below concern how Mary feels in her emotionally intimate relationship with her partner. Thus, the items were used as a way to focus on this particular relationship.

Mary’s results (3,7) indicate a total score greater than 3.5 (cutoff) on the anxiety dimension of abandonment and greater than 2.5 (cutoff) on the avoidance dimension of intimacy (Mary’s score: 5,5) revealing a high level of theses dimensions of attachment in the internal representations of Mary. More specifically, Mary presented anxiety related to abandonment, which is nevertheless close to the cutoff (3,5). However, her score regarding the avoidance dimension of intimacy is much greater (5,5) than the cutoff (2,5) indicating her mental representations and avoiding behavior toward her husband. This result is in line with the result obtained in the Dyadic Adjustment Scale.

Thematic Apperception Test (TAT)

Card 1: ‘I see a boy who is forced to take violin lessons by his parents. He clearly doesn’t want to, but has to obey them anyway. The child seems distressed and tired, probably from the many hours he has had to play the violin.’
In this description, Mary presents her parents as sovereign and authoritarian, while she, as the child, complies. Τhe physical condition of the child as described by Mary is related to the image of the body and of the self; she communicated that the way she feels about her body is that she sees it as tired, exhausted and forced to do things she doesn’t want it to.

Card 2: ‘The woman in the middle wants to leave her family, does not feel good when she is with them. They make her work in the field even if she begs them not to; she cries and asks for them to let her leave, it is too painful to be there with them. She wants to change her life. She wants to be alone and start again.’

In this picture, Mary makes a clear statement about her wish to differentiate from her family, and the feeling of pain she endures when she is with them. The way she described the woman’s reaction to her family asking of her to work with them is indicative of the traumatic experiences she has had in her family; the words beg, cry, and painful demonstrate a person who is deeply traumatized from their relationship with their family. He wish to leave and start over on her own is a sign of healthy adjustment and an indication of a potential to not follow and reproduce the toxic patterns she had been exposed to as a child.

Card 3GF: ‘I see a young woman who is upset and has given up. She feels as if there is no reason for her to keep trying, everything is futile and she is thinking of putting an end to her life with that gun that is lying next to her.’

Mary’s interpretation of this card clearly indicates her feelings of desperation and her inability to cope efficiently with situations that seem to cause her negative feelings. The fact that she mentioned that the woman would end her life is indicative of the trauma she has endured and the deep existential anxiety this has brought upon her.

Card 4: ‘The guy has decided to leave his partner cause he’s tired of her, and she is trying her hardest to make him stay, because she cannot imagine her life without him. He has made up his mind, which scares her because she doesn't want to be on her own after all these years they have spent together.’

Mary’s description of this card speaks on the problems she is facing right now with her partner, and her very conscious fear that he will leave her because she is not good enough for him. Moreover, she communicates her fear of being on her own, which lets us know that her relationship with her husband is a dependent one.

Card 6BM: ‘This guy here is the son of this woman and has approached her to announce that he is leaving the family home and will, from now on, live in his own. His mother is not happy to hear that he is about to leave, so she turns her back at him to show she is unhappy and disappointed in him.’

Here Mary communicates her fear to differentiate from her family, her fear to disappoint her mother and ultimately, on an intrapersonal level, her fear to disappoint herself by not obeying to the wishes of her family. It is also indicative of the difficulties she is facing with communicating her feelings honestly and relating in a direct way.

Card 6GF: ‘A woman is sitting on the couch watching tv and trying to relax. Suddenly this older guy shows up behind her and tries to say something inappropriate, looking at her in an inappropriate way, and blows smoke on her face. She is appalled by him and doesn't know how to react to his presence, she feels violated by the smoke that is blown onto her face and wants him to go away, but doesn't how to make him do that. She tries to tell him that but he doesn't seem to listen.’

Feelings related to her abuse are clearly emerging through this card, as she identifies with the woman who feels violated by the older man. She visualizes herself as an object that receives sexual attention in a passive, violent way, using indirect language ‘inappropriate’, which shows that she is defensive in regards to themes of sexuality and violence. Employing a Freudian analysis on the way she perceives the male figure, we could argue that this is projection of an unresolved Oedipal complex, where the father figure - perpetrator in the case of Mary - threatens her and violates her by blowing smoke from his pipe onto her face. The sexual metaphor stemming from the pipe and the smoke is a direct link to the experience of sexual abuse Mary has experienced from her father, while the attempt of the woman in the picture to distance herself from the older man refers to Mary’s traumatic and unsuccessful attempts to put an end to the abuse. Moreover, it is easy to notice her difficulty in relating with men, fact that definitely impacts her relationship with her husband.

Card 13MF: ‘In this card I see a woman lying on the bed, half-naked and probably dead. Yes, she has obviously been killed by the man standing in front of the bed, who pretends to feel remorse but in reality he doesn’t really care, he killed her by strangling her cause she wouldn’t do what he wanted in bed and now he will go back home and pretend nothing’s wrong.’

The violence Mary sees in this picture is indicative of the sexual violence she has endured, and the fact she perceives the woman as killed by the man could refer to the annihilating feelings after the abuse she experienced. The interconnection of sexuality and violence is characteristic of victims of sexual abuse, and is a product of the trauma victims struggle to process. Perceiving a male presence as threatening and capable of extreme violence has a huge impact on the way Adrienne relates to men in her life; therefore, it is not surprising that she struggles to connect with her husband.

Card 14: ‘I’m not sure what’s happening here, I think there’s a person sitting by a window looking outside and thinking… Yeah, thinking... Things are not going well for this person, his life is not at a good point, he feels like he has failed and is not happy with anything... He is contemplating jumping, he cannot see any end to his suffering so maybe, umm he will jump at some point.’

Clearly Mary communicates depressive feelings she is dealing with; she is identifying with the man, expressing despair and the wish to give up. The way she speaks of the dead end she is facing is indicative of a weak Ego that is unable to handle the reality and is taken over by sadness and negative thoughts concerning the future.

Blank Card: ‘I see nothing. Just emptiness.’

Her inability to imagine anything when looking at the blank card is indicative of her inability to symbolize. This could be a result of the abuse, which has fractured her Ego and has immobilized her in a state of anxiety and dread.

Card 20: ‘A man is standing in the rain. It’s late at night and he is out all alone waiting for something. He does not know what he is waiting for, but he’s been waiting for a long time and it’s probably futile. He is cold and really upset that he’s been waiting around for nothing.’

The last card, which usually allows patients to communicate feelings of loneliness and abandonment, is seen by Adrienne in a similar way; again, she lets us see how alone and abandoned she feels, struggling with an inability to deal with the aftermaths of abuse in an effective, mature way; instead, she feels overwhelmed by her previous experiences and is unable to face them in real time.

Second phase

Dyadic adjustment scale

Mary’s score at the Dyadic Adjustment scale is 106/151, which indicates her feelings of satisfaction regarding her relationship, contrary to the first phase.

The Experiences in Close Relationships-Revised (ECR-R) questionnaire

Mary’s results on the anxiety dimension and on the avoidance dimension of intimacy are lower compared to the first phase. Her result on the anxiety dimension of abandonment (2,05) indicates a total score lower than 3.5 (cutoff). Her score regarding the avoidance dimension is also lower than the cutoff (2.5). Mary’s feeling of anxiety and avoidance behavior toward her partner is now less presented. This result is in line with the result obtained in the Dyadic Adjustment Scale.

Thematic Apperception Test (TAT)

The TAT results after three years of psychodynamic psychotherapy are indicative of the psychological changes Mary went through.

Card 1: ‘The boy in this picture is sitting at a desk and contemplates playing the violin. He has to study for his music lesson and he doesn’t really feel like doing so, but he doesn’t want to fail the exams that are coming up so he will start studying soon.’

Mary’s sense of responsibility has changed since the last time she took the test. Her response to the card this time shows that she feels more empowered and less dependent on her parental figures, as she does not incorporate them in this picture; she envisions herself as responsible for her own life - it is herself she does not want to disappoint, not her parents. Thus, she has made progress in terms of how she perceives herself and the way she connects to others.

Card 2: ‘The girl in the picture has decided to leave her house in the farm and her family behind, to go to a big city and live her life the way she wants to. Her mother knows that she is about to leave and is happy about it, but her brother doesn’t really want her to leave cause then they won’t have enough help around the farm. She leaves anyway.’

Again, there is a clear difference between the way Mary perceives this picture three years in therapy. The wish to differentiate from her family is obvious in both cases, but this time she presents herself as more determined and empowered, and she seems ready to realize her dreams, with the symbolic support of a mother figure. In an intrapersonal level, this could represent a turning point for her as different parts of her align and there is less conflict and guilt regarding her choices. The male figure that wants her to remain in the position and not evolve could be a representation of her father that is not as strong anymore since it does not affect her final decision.

Card 3GF: ‘The woman here is extremely tired and wants to rest, because she cannot deal with what’s happening to her at the moment. She sits by her bed and cries, and is thinking of how much she needs to sleep to get some rest.’

Although feelings of tiredness and despair are prevalent in the way Mary describes this picture, there is a difference in the way she perceives the emotional state of the woman now and three years ago, which lays in the intensity of negative feelings; the previous time she visualized a woman wanting to kill herself, but this time she sees a woman exhausted and in need of rest.

Card 4: ‘This couple just had a fight, the guy is about to storm out and his wife is trying to stop him because she wants to end things in good terms, so she wants to continue talking to him and work things out.’

In this case Mary envisions a couple that fights, but the undertones of her narrative indicate a relationship that is more stable that the one she described last time, where the thought of breaking up was present and frightening for her. This time the thought of breaking up is not central to the narrative, and thought of ‘working things out’ shows that she is more stable and secure in her relationship with her husband.

Card 6BM: ‘This guy has brought some bad news to his mother and she is really upset upon hearing them, so she turns her back at him. He is standing there feeling really uncomfortable for upsetting his mother, but he had no choice but bringing her the news.’

Here Mary describes a relationship with a maternal figure less frictioned, where the worry of disappointing her mother is less present, as if she has accepted the possibility of making choices that are not accepted by her mother, without this having destructive effects for their relationship.

Card 6GF: ‘A woman is sitting on the couch staring out the window, and her boss walks in and approaches her to talk about an upcoming project, but gets too close to her and scares her. She doesn’t like when men get too close to her and makes her disdain clear, hoping that he will notice and step back.’

In this card Mary still experiences the male presence as aggressive and unpleasant, but her feelings appear to be less strong than last time. Moreover, the woman depicted in this case has a more active attitude towards the man she finds threatening; instead of being paralyzed by fear like in the previous testing, in this case she is experiences ‘disdain’, not just fear, and actually expresses her lack of comfort, which shows that she is more responsible for her own feelings.

Card 13MF: ‘A man has just had sex with a prostitute and experiences feelings of regret, because he will have to return home to his wife afterwards. The woman, who enjoyed it a lot, lays on the bed exhausted and wants to take a nap.’

The positive feelings Mary attributes to the sexual act show a clear improvement in the way she experiences her own sexuality; it is the first time she refers to anything sexual as a source of pleasure and joy, which is clearly emotional progress compared to her last test when sexuality was intertwined with violence.

Card 14: ‘A man is sitting by the window looking outside and thinking about his day, he had a big meeting at work and things didn't go as well as he wished. He is not so sure if he wants to remain at the same job and he’s contemplating what’s best for his career and his future.’

In this card Mary seems to be dealing with a problem that she is currently facing at work, and she has trouble finding the most efficient way to resolve it. The fact that she no longer attributes suicidal thoughts and feelings onto this card is interpreted as an improvement to her emotional state.

Blank Card: ‘I see a white picture. That’s all.’

Once more, Mary shows low imagination and difficulty in symbolizing, which is not surprising given her previous experiences.

Card 20: ‘A man is standing next to a lamp on the street on a very cold night. He has walked out his flat for a smoke and can’t wait to get back in.’

Through the tests used throughout Mary’s therapy we observed her improvement regarding her mental representations and her relationship with her husband. In the Dyadic Adjustment Scale during the first phase, Mary’s inability to show her affection for her husband was demonstrated. She blamed herself for the distance between her and her partner several times. According to her, her efforts to improve their relationship do not succeed because she thinks she cannot express herself or explain to him what happens to her. Her tendency to distance herself is also clear in the test. This, combined with other difficulties she is facing, such as also her inability to understand her partner’s needs for socialization, demonstrate her antisocial attitude. Additionally, Mary’s attempts to avoid physical and sexual contact with her husband are related to the disconnection she is experiencing in relation to her body; similar to sexual abuse victims, she is unable to experience sexual attraction towards others. Furthermore, the results also demonstrated depressive symptoms, as Mary clearly expressed feelings of sadness and a desire to remain isolated. Through the results of the Experiences in Close Relationships-Revised (ECR-R) Questionnaire during the first phase we noticed Mary’s anxiety in regards to abandonment through her avoidance behavior. In addition, we obtained a very high score regarding the intimacy avoidance dimension which allowed us to target the cognitive representations that Mary has of her romantic partner and her levels of self-sufficiency, discomfort regarding intimacy and love interdependence. Mary’s results in these areas are in line with the results obtained in the Dyadic Adjustment Scale. Besides this, through the Thematic Apperception Test we observed Mary’s mental representations and the link between her marital difficulties and the sexual abused experienced during childhood. Mary referred to her family and the sexual abuse she has endured from her father and she identified herself with the woman who feels violated by an older man (card 6GF). Through this projective test once again Mary communicated the way she feels about her body which is that she sees it as tired, exhausted and forced to do things she doesn’t want it to. She made a clear statement about her wish to differentiate from her family, and the feeling of pain she endures when she is with them. The words beg, cry, and painful used by Mary (card 2) demonstrate a person who is deeply traumatized from her relationship with her family. Additionally, her feelings of despair and her inability to cope efficiently with situations that seem to cause her negative feelings are also manifested and are linked to her experience of sexual abuse and her actual marital situation. Mary’s mental representations, insecure attachment style and marital situation shifted throughout therapy as it was observed in the tests that took place after three years of psychodynamic psychotherapy. The results of the Dyadic Adjustment Scale that was completed during the second phase showed Mary’s feelings of satisfaction regarding her relationship with her partner. She was more able to demonstrate affection and she was spending more time with her partner. Her tendency to isolate herself was less present, as she declared that she spent more time with her husband and with her friends. She explained that she confides more often to her husband and has sexual contact more often with him. She also described her relationship as happy.

These results are in line with those obtained in the Experiences in Close Relationships Questionnaire in which the scores of the abandonment related anxiety and intimacy avoidance dimensions were significantly lower than in the first phase. Mary’s discomfort regarding her partner and her mental representations has changed. She declared being much closer to him and feeling more comfortable sharing her private thoughts and feelings with him. Furthermore, she revealed that it is easier than before for her to depend on her husband, that she is more comfortable being close to him and that she is more affectionate. Finally, the Thematic Apperception Test showed that she feels more empowered and less dependent on her parental figures. The wish to differentiate from her family was obvious, but she presented herself as more determined and empowered, and she seemed ready to realize her dreams. We observed less intensity of negative feelings. Mary still experienced the male presence as aggressive and unpleasant (card 6GF), but her feelings appeared to be less strong than last time. Moreover, Mary’s description of the woman in the card 6GF indicated that the woman has a more active attitude towards the man she finds threatening instead of being paralyzed by fear like in the previous testing. The positive feelings Mary attributed to the sexual act in this second phase showed a clear improvement in the way she experiences her own sexuality; it is the first time she referred to anything sexual as a source of pleasure and joy, which is clearly emotional progress compared to her last test when sexuality was intertwined with violence. Furthermore, she no longer expressed suicidal thoughts and feelings.

In the present article we examined the case of a young woman who had experienced sexual abuse as child by her father, who molested her for two years. The client visited our practice to receive psychological support as her marriage was falling apart and she was not able to handle the situation on her own. Through psychodynamic psychotherapy it was revealed that the abuse had shaped her attachment patterns and altered the way she connects to others. We used a variety of methods to allow her to restore her attachment style and reform her behavioral patterns, which allowed her to improve her relationship with her husband. To record this change, we present three tests she took at the beginning and the end of the therapeutic process, namely the Dyadic Adjustment Scale (DAS), the Experiences in Close Relationships Questionnaire – Revised (ECR -R), and the Thematic Apperception Test (TAT). The above tests allowed us to examine closely her attachment patterns and her personal account as a victim of abuse, and the results of both phases are discussed in regards to her marital relationship.

None.

The author declares that there is no conflict of interest.

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