Practicing Psychoanalytic Theory in the field of Child Sexual Abuse

By Katrine Zeuthen, Associate Professor and PhD, MSc in clinical child psychology and Marie
Hagelskjær, MSc in Psychology and PhD scholar, Department of Psychology, University of
Copenhagen, Denmark. Candidate in the Danish Psychoanalytic Society.

Being a psychoanalyst at the university today is quite challenging. Psychoanalysis doesn’t live up to
the increasingly powerful demands og being a positivistic hard core science, a science that defines
itself through evidence based truths describing the world rather than trying to understand it. At the
same time it is difficult being a psychoanalyst practicing psychoanalysis outside the psychoanalytic
community and far away from the couch – with all the compromises and translations it can and
often does require disseminating psychoanalytic thinking to a field that has very little if any
experience with psychoanalysis. It this real psychoanalysis, one asks one self, and the answer to this
is yes. It is psychoanalysis, it is very real and it is a necessary duty of ours to communicate it as
such.

Introduction to the work of Center of Psychoanalysis

In the field of child sexual abuse psychoanalysis doesn’t seem to have a say. The focus on what has
happened in reality and a search for the objective truth overlooks a psychoanalytic approach.
Psychoanalysis acknowledges that sexuality is founded in the unconscious and that sexual abuse
comes to expression in ways that escape a neo-positivistic paradigm where observation leads the
way in terms of methodology. We argue that the aim of uncovering the actual event behind
suspicions of child sexual abuse should be supplemented with a praxis oriented psychoanalytic
theory of infantile sexuality and sexual trauma, thus emphasizing that we must listen to and with
our unconscious in order to capture (and quoting Freud): ‘the nature of the subject’ (Freud & Breuer
1893-1895).

The Field of Child Sexual Abuse: The Background of the Project

Our research has confirmed our assumption that child sexual abuse very often expresses itself in a
special way characterized by being absent. This opposes practitioners’ as well as laymen’s
expectations of it being expressed in evident and sexualized ways. Bluntly put, one can say that
sexual abuse is expressed by means of not expressing itself clearly, just as signs and symptoms that
readily can be understood as related to sexual abuse can have many other causes (Zeuthen 2009,
Zeuthen 2012a, 2012b; Zeuthen & Gammelgaard 2010; Zeuthen & Hagelskjær 2013). Although
empirical research indicates that sexual behavior problems as well as deviant, unrealistic and age-
inappropriate sexual knowledge can be related to child sexual abuse, these are not unambiguous
symptoms (Friedrich et al 2001; Brilleslijper-Kater et al 2004; Brilleslijper-Kater 2004; Dalenberg
et al 2002; Farmer 2004).
In spite of the uncertainties inherent in the understanding of child sexual abuse,
researchers have tried to determine its actual magnitude, and findings indicate that it is a widespread
global problem (Pereda et al 1994; Finkelhor et al 2005; Helweg-Larsen et al 2009). Sexual abuse
of children occurs in all demographic groupings and research has associated it with a variety of
pervasive symptomatic and pathological effects and sequelae, such as depression, substance abuse,
and post-traumatic stress disorder, to mention only a few (Kendall-Tackett et al 1993). There seems
to be little doubt that child sexual abuse represents a problem of considerable proportions. The most
substantial risk exists inside the family and though numbers vary, it is widely acknowledged that in
75 to 95% of cases the child and the offender live together, are related or at least know each other
well (Saunders et al 1999; Smallbone et al. 2008). Obviously, it is difficult for these children to seek
help, and due to the absence of clear cut evidence the practitioners involved find it extremely
challenging to assess these cases. They feel disillusioned and powerless, being bound by a natural
but seemingly confining centre of attention concerning ’what really happened’. It seems to prevent
them from acknowledging the presence of the unconscious in our listening and observing as well as
in the way sexual abuse comes into expression.
These cases more often than not give rise to a diffuse concern (Kuehnle & Connell
2008). And in our teaching and supervision we point to the importance of using doubt as a
necessary catalyst for the unfolding of an understanding of what the child is expressing – what does
it mean for the child – how does the child understand its life and the relations that defines it. In
psychoanalysis we do not take what is said at face value. By analyzing the field with psychoanalytic
theory and through the practitioners’ experience with it we legitimize its complexity and found it in
praxis. Thus we have succeeded in offering an integral and practice-oriented understanding of why
cases of suspicions of child sexual abuse are so difficult to understand, relate to and act on, and how
this could be better addressed by the various professional groups. Our work has consisted of the
teaching and supervision of psychoanalytical theory to many different groups of practitioners within
the field (i.e. social workers, school teachers, psychologists, psychiatrists, nurses, police
investigators), clinical work with children with sexual trauma and exemplary case studies derived
from this work, and finally, the development and implementation of Play Room, a projective
imagery originally aimed at prevention and currently being tested and developed for assessment of
cases with suspicions of child sexual abuse.

The Psychoanalytic Grounding of Play Room – The Theory

Present societal as well as academic discussions of child sexual abuse seem to hold on to Freud’s
original ambition of finding a causality between an event and its expression: Its symptom or its
representation. A causality that can free us from analyzing and thus free ourselves from
participating personally in what we see, hear, feel. However, sexual abuse challenges us and
demands that we make use of discernment and interpretation. In short that we analyze. It is
therefore essential to have a theoretical model describing how infantile sexuality develops within
the relationship between child and the adult, and what this means for the child's development – both
when development is handled with care, and when the child is subjected to sexual abuse. Without it
our ability to assess and make judgments remains in a private and diffuse sphere, making reference
to our own unconscious without us being aware of it.
With his theory of generalized seduction and the sexual the French psychoanalyst Jean
Laplanche focuses on how the sexual emerges through the manner in which the adult not only meets
but also initiates the child's wishes and fantasies (Laplanche 2011a). His theory can sustain us in our
view that it is not a question of whether a child has or has not been seduced, but rather of how and
on whose premises the seduction took place. In his introduction to the concept of the enigmatic
message Laplanche takes up seduction as the foundation of child development in relation to the
adult (Laplanche 1997, 1999a). The adult approaches the child with a special kind of care that is
characteristic of that particular adult, which the child can sense. With the care comes a message –
the adult shares something with the child, the meaning of which the child does not understand. The
message is enigmatic because it contains the adult’s sexuality. For Laplanche seduction is a
universal phenomenon based on the asymmetrical relation between adult and the child – it is a
fundamental anthropological situation created by the fact that the adult has a sexual unconscious
and the infant has not. Thus, Laplanche reintroduces Freud's seduction theory by saying that the
child always gets seduced by a specific adult and that the child registers the adult's sexuality and
tries to understand its meaning (Laplanche 1987; Gammelgaard 2010).
Laplanche’s theory of generalized seduction expresses a continuum of seduction, from the seductive
and enigmatic yet humanizing communication that takes place between every caregiver and infant
to the pathological perverse situations where communication is solely on the adult’s premises.
Following this line of thought Laplanche divides the adult unconscious into a repressed part and an
enclaved part, an inner foreign body. The enclaved part of the unconscious is an encapsulated place
where no psychic elaboration and representation can take place. According to Laplanche (2011b)
the message given from the adult to the child through the sexual abuse is stemming from this
enclaved part of the adult’s unconscious and it effects the child’s psyche in a specific way.
Laplanche describes sexual abuse as an intromission of messages that the child receives passively
and cannot translate, because for translation to take place the adult unconscious needs to be working
at a level where the child can take part in the relation. The violent process of intromission creates a
rupture in the child’s development, as the sexual abuse cannot be subjected to psychic
representations, and gaps of something un-representable is placed as a foreign body in the child’s
psyche. This stands in contrast to the generalized seduction where the child can participate in a
meaning-giving process (Laplanche 1999b). How these encapsulated messages effect the
development of infantile sexuality is of great interest to us and thus a central part of our
theoretically driven clinical research.

The Complexity of Preventing Child Sexual Abuse.

We set out developing a prevention program as the funding we received from The Ministry of
Social Affairs was directed at prevention, and the target group was children between 3 and 14 years
old, specifically children in high risk of being exposed to sexual abuse, i.e. children in care and
children with physical or psychological handicaps. Included in these groups where children that had
been victims of sexual abuse. As a starting point we reviewed all the literature we could find on
prevention (Zeuthen & Hagelskjær 2013), and this revealed that the prevention programs rarely
define what child sexual abuse is let alone what sexuality is, including what infantile sexuality is
and how it develops. Also these programs seldom take into account the relational factor of child
sexual abuse. They simply lack a clear definition or theoretical understanding of what it is they are
preventing and where the prevention is directed.
Thus we asked ourselves: How can we work preventively with children when they do
not understand the meaning of sexuality and when they have the right to discover this in their own
time? And how can we work preventively with children in an ethical manner knowing that abuse
most often takes place in close relations with caregivers? And how can we create and support a
developmental process in the relation between a child and a professional adult? Our aim with Play
Room was to develop, test and finally produce a projective imagery supporting children's learning
about relations with a focus on boundaries, emotions, and also psychosexuality. Thus the preventive
scope is integrated into a developmental perspective based on psychoanalytic theory of infantile
sexuality and dealing with the child's overall development, in this way integrating our belief that
children and young people should be able to discover sexuality in due time without it being
articulated as something potentially threatening.
Play Room is dialogue based, and the conversation unfolding between the child and a
practitioner well known to the child (mainly pedagogues, social workers, and teachers) is structured
around four gradually more complex questions that unfold around different illustrations
thematically distributed within five dualities, these being pleasure/unpleasure, activity/passivity,
voluntariness/force, fantasy/reality and care/abuse. The illustrations convey many different
everyday situations between children and adults. With the material comes the manual “Play Rules”
introducing psychoanalytic theory and concepts and describing how to use Play Room in
accordance with the different age- and target groups. Practitioners acquire Play Room by attending
a 3-day course called “Playing Together”, where they are introduced to psychoanalytic theory and
concepts, and where they through supervision learn to develop and structure a psychoanalytic
dialogue around the images with the child, not only listening to what the child says but especially
listening to their own listening, thus encircling the gaps of the un-representable, that which isn’t
directly approachable and yet so present in clinical practice.

The Research Process, Findings, and Hypotheses.

Play Room has been developed and tested in two pilot versions through qualitative and quantitative
studies in which various forms of use have been implemented, observed, recorded, analyzed, and
evaluated, and in collaboration with almost 200 children from various institutions in Denmark and
their practitioners. This was supplemented with interviews of the participating children and adults,
as well as a completed questionnaire with background information of the child. The process
resulted in a final version, a first edition was produced in 2011, the second edition in 2013 and a
digital and extended version Play Room and My Own Room - The App, has been developed in
2014 (Zeuthen 2011, 2013, 2014).
 Currently we are working on developing the preventive scope of Play Room into an
assessment tool for psychologists in Marie Hagelskjær PhD-project “Play Room as assessment”.
The study compares three groups of children using Play Room in collaboration with a psychologist:
A group of children that have been exposed to sexual abuse, a group, where the children have been
exposed to psychosocial neglect but not sexual abuse and a control group. Our preliminary findings
indicate the ability through Play Room to discriminate between different groups of traumatized
children and a norm sample. Thereby the material might have the potential of being useful as a part
of a psychological assessment battery in cases with vulnerable children and in cases of suspicions of
child sexual abuse.
The division into the two experimental groups has been difficult or even impossible to
accomplish. We have met many borderline cases where the structure and relations within a given
family can be severely pathological sexually speaking but where no factual sexual abuse seems to
be taking place. These cases are often excluded from studies, as they do not possess the simplicity
to fit into clear empirically defined categories, and in this way the diffuse pathology of sexual
trauma and thus the nature of the subject is neglected. Our hypothesis is that children who haven’t
been exposed to sexual abuse in the factual sense of the concept are looking for answers to an
encapsulated sexual message, and it is displayed through sexualized behaviors, coming into
expression through i.e. excessive use of pornography, sexualized chatting on the internet, or
excessive masturbation. These children are often mistaken of having been exposed to factual sexual
abuse (and certainly their behaviors expose them to high risk) in contrast to children who in fact
have been exposed to sexual abuse and express it through a variety of different and very diffuse
symptoms, not necessarily with a sexual content.
One of these borderline cases we are working with is Hanna. She is living with her
mother who originates from a poor European country. Hanna’s mother has been abused by her
father throughout childhood and into adulthood. She became pregnant with him, fled her country
and has no contact with him or the rest of her family today. Hanna is not aware that the man that she
knows as her father is also her grandfather. She has no regular contact with him but has tracked him
down and visited him a few times without her mother’s knowing. Hanna is referred for
psychological treatment at 10 years of age when it is discovered that she has visited her father, and
also that she has a massive daily use of internet pornography, an activity that she has included other
children in. The psychological assessment of Hanna shows no indications that she has been
subjected to factual sexual abuse. She is included in the empirical project in the non-abused group,
and so far in our analysis she doesn’t explicit the same diffuse symptoms and deviant answers as the
children in the sexual abuse group.
Something that is most interesting to us is that Hanna uses the whole Play Room trial
for one thing only - namely to try to figure out how the relations between the illustrated children
and adults are: “Is it a brother, a mother, a father? Sometimes you can tell by looking at the color of
the hair. Are they lovers?” she asks the psychologist. When seeing the picture of a woman kissing a
child Hanna says that only once and by coincidence, her mother has kissed her on the mouth.
“Should mothers do that more often? Or is once too much?” she wonders.
In the light of the theory of Laplanche you could say that Hanna has received an
enigmatic message from her mother about her complicated heritage that she hasn’t been given help
to translate. The general seduction has been saturated with the unspoken encapsulated trauma of her
mother, a mother that has been unable to show her daughter natural signs of affection. Hanna’s
beginning biological maturation and dawning ability to understand adult sexuality makes her seek
out genital pornography in order to figure out how tenderness, closeness, and romantic relations can
be understood outside and inside the family. She is looking for the genital counterpart of her sexual
trauma in order to give it meaning.
Other preliminary results from our study implicate that children to whom there are
strong indications or even proof of factual sexual abuse have great difficulty in trying to give
meaning to the illustrations in Play Room. This comes to expression as an over-representation of
rejections of the dialogue with the psychologist, “I don’t know, I don’t want to answer”, or only
superficial, vague and dismissive answers within the group. The sexual abuse seems to express
itself as an absence of creation of meaning, or in the words of the French analysts Botella and
Botella, as a negativity (Botella & Botella 2005). It isn’t there or it has no place to be, and genital
maturation has not yet set in in the child’s development, withholding the child’s attempts to
understand nachträglich what happened. When confronted with illustrations that seem to have the
most provocative content (i.e. bathing children and a male adult), the children within the sexual
abuse-group have remarkable more deviant answers with little or no relation to the specific content
of the illustration. The situations where the children in the sexual-abuse group where most affected
where often followed by them having an urgent need to eat something or drink the small juice box
that was served, calming themselves with what seemed as instant oral pleasure in order to minimize
the tension from the enclaved message coming from the outside but acting as a foreign body
encapsulated from within.
Encircling the Absence of Meaning by listening
It seems that these children convey an absence of ability to symbolize and to create psychic
representations when it comes to meaningful translations of the content of the illustrations (Botella
& Botella 2005; Brilleslijper-Kater 2004; Dalenberg 2000; Dalenberg, Hyland & Cuevas 2002;
Dalenberg & Palesh 2010), as if something is blocking the way of creating the appropriate meaning
or at least trying to do so in cooperation with their psychologist. We find that our psychoanalytical
approach can offer the field of child sexual abuse and trauma a new way of uncovering that which
isn’t identifiable through mere observation and registration of a child’s behaviour and symptoms.
By encircling the absence of meaning in sexual abuse or the negativity of sexual trauma we find an
alternative way of examining and supporting not only the child’s capacities of creating meaning and
psychic representation but also how the psychologist can support the child in doing this, thereby
giving room for the development of the encapsulated unconscious parts of the child psyche in due
time and in balance with the child’s overall development, and always in a relation to a caring and
listening adult.

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