A PSYCHOLOGICAL

THEORY

OF CHILD

ABUSE

Bruce Smoller, M.D. Alf~ed B. Lewis, Jr., M.D.

This paper presents a detailed study of two patients hospitalized in a closed psychiatric unit on which the treatment program emphasized dynamically oriented individual psychotherapy and family therapy. The first patient was hospitalized following physical abuse of her four-year-old daughter, while the second was hospitalized for a postpartum depression eight weeks following the birth of her first child, a girl. Although the presenting pictures in these two patients were markedly different, the psychodynamic patterns were so similar that a detailed comparison of the two cases seems to offer useful insight into some of the psychological causes of child abuse. CASE No. 1 Patient No. 1 was a 27-year-old white Catholic m a r r i e d female admitted for the first time to a psychiatric hospital with complaints o f depression and increasing irritability leading to outbursts o f a n g e r and physical abuse o f h e r four-year-old d a u g h t e r . F o u r years p r i o r to admission, the patient b e g a n taking p h e n m e t r a z i n e for weight reduction, a n d c o n t i n u e d to use it at increasing doses o f between 50-100 m g per day until admission. She first sought psychiatric help two years b e f o r e admission because she f o u n d herself hitting h e r child with little provocation. T h e s e episodes increased in f r e q u e n c y and intensity until she beat the child severely a b o u t the face a n d extremities two m o n t h s b e f o r e admission. At this time, care o f the patient's two daughters, aged 4 years and 18 m o n t h s was t a k e n over by h e r parents. Because the patient c o m p l a i n e d o f depression, she was treated with tranylcypromine. O t h e r problems included an extramarital affair k n o w n to h e r husband, taking f o u r T u i n a l capsules as a suicidal gesture after a fight with h e r husband, and firing his pistol at the wall d u r i n g one o f their arguments. Because o f h e r attacks o n h e r child, and h e r u n c o n t r o l l e d behavior, h e r psychiatrist reco m m e n d e d admission. Bruce Smoller is a Clinical Instructor in Psychiatry at George Washington School of Medicine. He was fellow in Psychiatry at Cornell at the time of writing this article. All reprint queries should-be addressed to Dr. Lewis at the Payne Whitney Clinic, New York Hospital, 525 E. 68TH St. New York, N. Y. 10021. 38

~ Y C H I A T R I C QUARTERLY, VOL. 49(1), 1977

39 Bruce Smoller and Alfred B. Lewis,.jr.

The patient was born the first of five children and only girl to an upper middle-class family. She remembers her father, a physician, as a remote and distant individual who was seldom at home and whose expectations for the patient were much lower than for her brothers. She remembers her mother as obsessive and "a bit scatterbrained." She always competed with her brothers and remembered having to throw tantrums to get attention from her parents. She attended several colleges, experiencing considerable academic difficulty, and during her senior year, she became pregnant, d r o p p e d out, and married a police officer of different religion and social class. At that time she had been in individual psychotherapy for about a year, because she "didn't know where I was going," but terminated therapy when she married. For the first two years of marriage, she felt depressed and anxious but was not aware of aggressive impulses toward her child.

Hospital Course During several days following admission, the patient was noted to be intellectualizing, superficial, demanding, and manipulative. No evidence of psychosis was observed. She was taken o f f all medication and by the third day became overtly depressed. She was initially permitted visitors and telephone calls. When the patient could not reach her husband at home by phone, she became fearful and depressed, feeling that he did not care and had deserted her. She asserted that her husband, her father, and her therapist had hospitalized her and 'lust left me." This sense of desertion reminded her of feelings about being sent away to camp as a child and to college in her teens, and was to be dramatically expressed later in the course of therapy. Exploration of her relationship to her children and husband revealed several points. Her abuse of her daughter was related to the feeling that she received no "gratification" from her, and that her children did not respond to her as if they loved her. She related this to a feeling of "not being loved or wanted" as a child. In addition, her husband was a parent figure to her, and his occupation as a police officer seemed to fit in with her sense of" needing to be controlled. When he left the house for work, she felt helpless and unable to deal with the very real frustrations o f raising a child. She quite literally felt "abandoned." At this point in therapy, the patient was allowed to leave the hospital on passes. She overstayed each of them, saying she had not taken her husband's work schedule into account, and since the purpose of the pass was to spend time with him, she waited for him to come home from work. This was interpreted by us as an attempt to ward off feelings of depression and desertion by clinging to her husband. It became clear that therapy could not progress until passes, visiting, and telephone calls were stopped. With this change in approach, the patient became intensely depressed. When she saw her husband leaving the hospital after what was to be his last visit for several weeks, she wept and felt "deserted, abandoned, and left to

40 A Theory of Child Abuse

die." Separation from him gave her a feeling of impending death, even though she realized the absurdity of the idea. It became clear that this fear was operating prior to hospitalization and that the patient had tried to deal with it and the underlying depression through provocative and attentiongetting behavior, such as the extramarital affair known to her husband and suicidal gestures. This pattern continued in the hospital in relation to the therapist. The patient became abusive to him for restricting her, and at one point burst into his office while a session with another patient was in progress. She became aware that she saw her husband as a parent-substitute, and that she saw her children as siblings who competed with her for her husband's attention and prevented her from gratifying her own infantile needs. She seemed to be replaying her role as an unwanted, unloved child with her own children and husband. After several weeks, visiting with the husband was resumed, followed by passes outside the hospital of increasing duration until the patient was discharged improved after five months in the hospital.

CASE NO. 2 A 31-year-old white, married, Protestant woman was admitted for the first time to a psychiatric hospital with complaints of depression and frightening fantasies of harming her eight-week-old infant. T h e patient's illness began at approximately five weeks postpartum when, while speaking on the telephone to her younger sister, she felt "hot, flushed, dizzy, and thought I would lose my mind." She began having fantasies of throwing the baby out the window or down the incinerator, or of knifing him. She became frightened that she would not be able to prevent these fears from materializing. Two days after their onset, she began to feel sad, with early waking and insomnia. She was afraid to hold or care for the baby. At this point her husband took over most of its care. Two weeks after the onset of the fantasies, the care of the baby was taken over by her parents. Despite supportive psychotherapy and antidepressant medication, the fears and depression continued. The patient requested hospitalization on the advice of her psychiatrist. T h e patient was born the first of two girls to a middle-class family. She attended a college 25 miles from her home, where she felt lonely and homesick throughout the first two years, and returned home every weekend. She vaguely remembers one episode during her first year in college when she felt "nervous and afraid," would not go to class because of a phobia of large lecture halls, and lost 28 lbs. After graduation she moved to New Jersey and taught for three years in the public school system. She then moved to New York and began working at private schools, teaching the third and fourth grades. She met her husband two years before their marriage. Several weeks after the marriage she discovered that she was pregnant and was distressed that it had happened so soon. Pregnancy was

41 Bruce Smoller and Alfred B. Lewis,Jr.

marked by vomiting throughout the three trimesters. Delivery was without complication. The child was full-term and normal in all respects. The first five weeks of the postpartum period were unremarkable.

Hospital Course On admission, the patient was observed to be depressed, anxious, and tearful. She showed no significant disorder of thinking and j u d g e m e n t was unimpaired. She was treated with amitryptiline 125 mg per day which w-as rapidly increased to 200 mg per day. As therapy progressed, it became apparent that the marriage relationship and the way the patient viewed her husband played an important part in her illness. Twice weekly conjoint sessions were instituted. As in the first case, the patient saw her husband as an authority figure, and found it very difficult to express any anger towards him. She tried to curry favor with him by doing things that he liked and suppressing her own wishes. This pattern seemed to recapitulate the mother-daughter relationship, in which the patient was constantly concerned with pleasing her mother and was extremely tentative about asserting her own wishes. Again, as in the first case, the patient seemed to view herself in competition with her child for her husband's attention. She became jealous when she saw the two of them together. In conjoint therapy, it became clear that the husband fostered this feeling with such comments as, "When you get visiting privileges, I won't know whom to be with, you or the baby." She felt secure at home with the child as long as her husband was there, but if he stepped out of the house, even to go to the store, she would be terrified to the point of immobility. When the husband was not allowed to visit, this patient, like the first patient, became extremely frightened and depressed and felt abandoned. She recognized these feelings of abandonment as being similar to her experience before hospitalization when her husband left the home. The patient's current family situation, in which she felt in competition with her child for her husband's attention, seemed to reenact her own childhood, during which she competed with her sister for her parents' attention. This pattern continued into adult life when the sister, who was younger, married and had children first. The patient remembered that soon after her baby was born, one of her first thoughts was, "If my baby gets sick, will my mother take care of her like she did my sister's baby?" The theme of sibling rivalry was also replayed in the therapist's office. Unsure of which patient was scheduled first, the therapist was checking the posted list of times when the patient ran up to him and said "I am first, I am first!" as if she were a young child. She revealed fears that her infantile needs would not be met by her husband if he had to devote attention to their' child. The fact that pregnancy occurred immediately after marriage upset the patient greatly; she felt that she deserved some time alone with her husband. As therapy progressed, she began to understand and accept her feelings towards her husband. She still, however, found it difficult to ex-

42 A Theor~ of Child Abuse

press any anger toward him. After an argument during a home visit, the patient kicked a closet door o f f its hinges rather than express her hostility directly to her husband. Asked what she thought the worst thing he might do to her was, she first said, "kill me," and then said, "leave me." As the patient acquired more understanding of her behavior, her fears decreased and the depression lifted. However, she was still frightened to be alone with her child, and she had to be encouraged to spend much time alone with the baby, first in the hospital and then at home. After two months of hospitalization, the patient was discharged much improved to outpatient care.

DISCUSSION: Two patients with strikingly similar psychodynamic patterns, but with very different symptom pictures, have been described and compared. Both patients' childhoods were characterized by difficulty in separating from their mothers, and by the memory of conscious fears of being left alone. Both women married passive-aggressive men who then became cast in mothering roles. Both appeared to be looking for dependent gratification from their husbands, and also for some form of external control. In one case the arrival of a child and in the other case the child's reaching the age of beginning independence upset the already pathological marital equilibrium. Perceiving the child as an intruder in the relationship between patient and husband led to the realization that the husband would never provide the kind of mothering, protection, and guidance that the patients desired. Both patients then saw themselves in competition with their children for the attention and love of their husbands. This produced an upsurge of rage at the children. The principal difference was in the way that this rage was handled. Patient No. 1 expressed it in direct physical abuse of her older child, while patient No. 2 contained it in infanticidal fantasies which were associated with a postpartum depression. Comparison of these two patients suggests certain possible psychodynamic factors in child abuse that deserve further exploration. Studies of child-abusing parents, such as those of Steele and Pollock (1968) and Green (1974) have emphasized the importance of "role reversal" as a recurrent finding in the distorted mother--child relationship. The concept of role reversal implies that the mother is seeking love and nurture from the child because she unconsciously or even consciously feels that her own parents did not provide these. The child is unable to provide enough affection to satisfy the mother's needs and this in turn leads to rage directed at the child. In other words, the child is "parentified" by the mother. What we found in both our patients, however, was an attempt by the mothers to "siblify" the child rather than to "parentify" it. There was a tendency to view their husbands as parental figures and their children as intrusive siblings in competition for the surrogate patent's love and affec-

43 Bruce Smoller and Alfred B. Lewis,.Jr.

tion. Rage and resentment were then directed at the child for two reasons: First, the child is viewed as a threat insofar as it competes for the husband's love and affection. Second, the rage directed at the husband fbr not gratifying the mother's dependency needs cannot be directly expressed for fear of provoking rejection and withdrawal of love. The rage is therefore displaced onto the helpless child. This concept finds support in Rinsley's (1971) work with adolescents and their parents in Topeka. Rinsley identified several characteristic distortions in the parents' perception of the child which led them to "depersonify" their children, i.e., to view them not as separate human beings but as some kind of projection or extension of their own needs or fears, a reflection of the mother's own lack of differentiation. Several different categories of "depersonification" were delineated, including "child as sibling." Rinsley (1971) pointed out that the depersonifying parent establishes the child as a spouse's favorite, "Thereby revealing that the need to parentify the spouse is at the heart of the problem." In particular, when a child is depersonified as a younger sibling, intense competitive, retaliatory and punitive wishes emerge which come from the parents' early rivalry with their siblings for their parents' love. These comments are strikingly applicable to our two patients, both of whom seemed to view their children as younger siblings with whom they were in competition for the affection of their husbands, who in turn had been cast in mothering roles. A second point of similarity between the two patients was the intense feelings of abandonment and depression they felt when deprived of their husband's nurture and love. Both patients experienced profound depression in the hospital when their husbands were not allowed to visit. The core dynamic problem therefore would appear to be fear of abandonment. In fact, Masterson's (1972) finding of an "abandonment depression", coupled with an ego-development arrest, underlying several psychopathologic syndromes of adolescence, seems to apply to these patients. Certainly fear of abandonment emerged as a paramount issue in the psychotherapy of both patients. Much of their behavior in relation to their husbands before hospitalization seemed to be dictated by the need to deny, forestall, or repair a sense of abandonment. Both patients equated abandonment with death and both showed substantial depression when cut off from their husbands during the hospitalization. It was, in fact, the emergence of this depression related to fear of abandonment in two patients with very different presenting pictures that led us to see the importance of the marital relationship in child abuse and, in turn, helped us to understand the mother's misperception of the child as a younger sibling. TREATMENT IMPLICATIONS On the basis of the above formulations, the major issue in therapy seems to be to help the patient clarify her preconscious perception of her child, and to verbalize it explicitly so that it becomes amenable to modifica-

44 A Theory of Child Abuse

tion. However, our experience suggests that before this goal can be achieved, the patient must be separated from her husband, and the husband-wife relationship explored in detail. To accomplish this, hospitalization in a dynamically oriented and therapeutically active hospital is necessary. It is the most effective way to accomplish the separation and also, through the structure and support of the hospital milieu, the patient can be helped to work through the depression that occurs tollowing separation from her spouse. Once the separation is effected, a relatively severe depression can be expected to emerge and the patient can be expected to resist the separation in any way possible. However, the patient can be supported through this difficult period if she is helped to see that the depression is an essential phase in the treatment, and if she can he warned in advance what to expect. When the depression does emerge, conjoint therapy with the husband should be instituted, focusing on the nature of the marital relationship and directed equally to helping the husband to modify his own tendency to infantilize the patient and to helping the patient understand her own infantile needs in relation to the husband. CONCLUSION: Two patients are presented, one who physically abused her child and another who abused her child in fantasy. Developmental and family dynamics were remarkably similar in these two cases. Both women had pronounced problems with sibling rivalry. Both tended to parentify their husbands and to view their children as intruders into the marital relationship. Both tended to depersonify their children, preconsciousty viewing them as younger siblings with whom they competed for their husband's love. Experience with these two cases suggests that insight into the psychological causes of child abuse might be furthered by a detailed study of the relationship between the spouses and by an alertness to the possibility that the abusive mother views the child as an intrusive younger sibling. Our experience further suggests that successful psychotherapy must include marital therapy, and that at some point in the course of therapy hospitalization may be necessary, not so much to separate the patient from her child as to separate her from her husband. REFERENCES Green, A., Gaines, R. W., & Sandbrund, A. (1974). Child abuse: pathologicalsyndrome of familyinteraction.Am. J. Psychiatry, 131: 882-886. Masterson, J. F. (1972). Treatment of the Borderline Adolescent: A Developmental Approach. New York: John Wiley& Sons. Rinstey, D. B. (1971). The adolescent inpatient: patterns of depersonification.Psychiatr. Q. 45:1-20. Steele, B. F. & Pollock, C. B. (1968). A psychiatric study of parents who abuse infants and small children, In The Battered Child, R. E. Helfer, and C. H. Kempe, eds. Chicago: Universityof Chicago Press, pp. 103-147.

A psychological theory of child abuse.

A PSYCHOLOGICAL THEORY OF CHILD ABUSE Bruce Smoller, M.D. Alf~ed B. Lewis, Jr., M.D. This paper presents a detailed study of two patients hospita...
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