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To report and discuss the use of psychoanalytic treatment for children victims of sexual abuse.
We report the psychoanalytic therapy of a seven year-old boy, sexually abused, discussing the “play technique” developed by Melanie Klein.
The boy does not speak to the analyst about the abuse. He has serious changes in his behavior and attempted suicide after that. In the first session with play materials, he draws a heart and partially paints it black, writing his name in it. He is very uncomfortable with the stains caused by black pencil on the white paper sheet. With scissors he cuts the heart and places it on the stretcher. He throws away the stained paper in the waste paper basket. Then he plays the game of catch-rods. At the end of the session, he puts all the toys in the box, and gives to the analyst the “cut up heart” that was on the stretcher, saying that it should be kept under the analyst's care.
With the use of the toy, Klein was able to extend the psychoanalytic concepts proposed by Freud from the analysis of adults, allowing children to be analyzed. By playing, children symbolically represent their fantasies, anxieties and defenses, expressing their models of relationship with the world. In the session of “play therapy”, children can communicate their anxieties and also find resources for the overcoming of their traumas. With his “cut up heart”, the child communicates his suffering, requiring care from the analyst.
To discuss the use of the psychoanalytic method in clinical research and treatment in cases of child sexual abuse, through the account of assistance to a 9 year old female victim of incest.
Session-report of the child.
The girl, abused by her father, shows up in her introspective first hour of play, refusing to address the abuse. Draws three hearts by writing down their names. In the first, writes her name inside the heart and the name of the mother. Under the second, she writes the name of her stepfather whom she calls “father”. Under the third “mother” and writes her name. Delivers to the design analyst and cries, saying she wants her father, calling the name of her stepfather. Later assembles a puzzle of Noah's Ark. She says that God sent Noah to build the ark to bring an animal of each species. The analyst wonders whether it would be a couple of animals. She curtly replied no.
Through the session hour, we observed the injuries produced by emotional abuse, and the child's need to seek a trusted father figure, represented in the drawing of her stepfather. Because of the loss of confidence, the analyst is an element of persecution for the child, and the “analytic couple” still cannot be formed. Note the importance of understanding the symbolic communication expressed in the play, which highlighted situations of psychic damage and the need to repair the damaged parts of the self.
To review the literature on child sexual abuse with emphasis on psychosocial/psychodynamic aspects.
Systematic literature review from the articles indexed in Medline, PSYinfo, Pepsic, Lilacs and Scielo in the last ten years. Terms researched were: child sexual abuse, psychosocial, psychodynamic and psychoanalysis.
Child sexual abuse can have devastating consequences for the psychological functioning of children, possibly interfering with their proper process of development. It can contribute to violent behavior, acts of delinquency and mental disorders in adolescence and adulthood, as well as the development of comorbid post-traumatic stress and self-aggressive behaviors, risk behaviors and teenage pregnancy. Gravity of psychic consequences increase in relation to the frequency of abuse. Aspects of power, seduction and coercion are involved. Inequalities of age and gender are highlighted. Often practiced without the use of physical force, it may be difficult to be proven. A frequent abuser of familiarity with the child creates conditions that foster abuse. The revelation of the abuse may not occur, perpetuating the suffering and helplessness of the child. Sexually abused children may develop identification with the abuser and even become sexual offenders in adulthood. There are difficulties in the conceptual definition of abuse, the establishment of protocols for investigative and therapeutic management of cases and in predicting the immediate consequences along with the medium and long-term consequences.
Studies on the therapeutic practices used for the treatment of abused children and their families can help to construct therapeutic models, minimizing suffering in this terrible situation of violence.
To investigate socio-demographic and clinical trials of 19 sexually abused children.
Statistical analysis with SPSS of data on psychiatric and pediatric care of sexually abused children, aged 2-12 years old, treated at the Pediatric Service of University of Campinas-Brazil Clinical Hospital in 2007.
From a total of 19 children, 2 (10.5%) were boys and 17 (89.5%) girls. The average age group was 7.4 years. Eleven (57.9%) attended regular school, one (5.3%) attended special school, one (5.3%) pre-school and six (31.5%) did not attend any school. Regarding ethnicity, 11 (57.9%) children were white and eight (42.1%) non-white. The abuse was committed with physical threats in nine (47.4%) cases, without threats in two (10.5%). Eight children were unable to define physical threat. The abuse occurred only once in 10 (52.6%) cases and several times in nine (47.4%). Prior psychiatric treatment occurred in two (5.3%) children and psychological treatment in six (31.6%). Twelve (63.2%) children had never attended psychological or psychiatric consultations. Eleven (57.9%) children received a psychiatric diagnosis and referral for treatment. In 13 (68.4%) attendance was diagnosed in the Z-code of the International Classification of Diseases-10. Family and people close to children appear as abusers in 15 cases (78.9%).
Despite the small sample, this study supports the literature in which child sexual abuse appears as a phenomenon more frequent in girls, dysfunctional families, and practiced mainly by family members or close friends of children. The relationship with psychiatric disorders was also highlighted.
To discuss the paradigm of melancholy in hysteria.
case report of M., a 45 year-old woman, who is under psychotherapy and psychiatric treatment at the General Hospital of the University of Campinas (HC Unicamp).
K. is a 45 year-old divorced mother and former teacher, who started psychotherapy and psychiatric treatment at HC Unicamp in 2007, two years after the death of her father.Since such loss,K. made several violent suicide attempts: she jumped from the balcony of her apartment, took an overdose of medications, and set fire to her body in front of the mirror, which caused permanent scars. During both the psychotherapy sessions and the psychiatric consultations, K. frequently expressed how her life had lost its meaning after the death of her father. She mentioned she was no longer able to love and had no reason to continue living. She also complained about her ex-husband, from whom she was divorced after being betrayed, and about her children, who did not give her, according to her point of view, enough attention and care.
The patient is inside a typical hysterical scene, a “spectacle” composed by dramatic acts against her life. However, it is undeniable her identification with the lost object, her father. By setting fire to her own body in front of the mirror, she shows a melancholic kind of satisfaction with the pain, caused by a massive and destructive narcissism turned against herself.
To analyze the qualitative answers profile of an anonymous standardized survey, with qualitative and quantitative questions, about the Brazilian psychiatrists' perceptions on their use of the multiaxial diagnostic systems ICD 10 and DSM-IV and on their expectations about future revisions of these classifications (ICD-11 and DSM-V).
the questionnaire, elaborated by Graham Mellsop (New Zealand), was translated into Portuguese and sent through mail to 1050 psychiatrists affiliated to the Brazilian Psychiatry Association. The quantitative analysis is presented elsewhere.
One hundred and sixty questionaries returned (15,2%). From these, 71,1% of the open questions where answered. The most needed and/or desirable qualities in a psychiatric classification were found to be: simplicity, criteria clarity, objectivity, comprehensibility, reliability and ease to use. The axis I of the ICD-10 was reported to be the most used due to its instrumental character in addition to being the official classification, including for legal and bureaucratic purposes. The DSM-IV was also used in the everyday practice, mostly for education and research purposes, by psychiatrists with academic affiliations. The less frequent use of the multiaxial systems was justified by the lack of training and familiarity, the overload of information and by the fact they are not mandatory. It was evaluated that some diagnostic categories must be reviewed, like: mental retardation, eating disorders, personality disorders, sleeping disorders, child and adolescence disorders, affective and schizoaffective disorders.
This material offers a systematic panorama about the psychiatrists' opinions and expectations concerning the diagnostic instruments used in the daily practice.
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