Sexual abuse: a perversion of attachment?

Introduction

Group analysis and other schools of psychotherapy have been historically influenced by core aspects of psychoanalytic theory, including Freud’s reversal of his seduction theory and the failure among the majority of his colleagues to challenge such reversal; which contributed to the extended denial of child sexual abuse and of professional sexual abuse, for many decades. In the latter part of the 20th-century, the public emergence of evidence of widespread sexual abuse challenged longstanding assumptions held by generations of individual and group analytic practitioners.

Most psychotherapy institutes (not excluding group analysis), and other institutions in society, have seen the ravages of sexual boundary violations. It is important for healthcare professionals, including psychiatrists, social workers, psychologists, psychotherapists, psychoanalysts and group analysts, to be aware of this in their thinking and clinical practice.

Furthermore, institutional collusion has been present at all levels (in individual and group psychotherapy bodies, as well as in society by and large). Thus, the subject is particularly relevant to those of us who are group analysts wanting to understand the collusive group element of this problem with a view to enhancing prevention and sensitivity with the victims.

While discussing specifically the various individual and group psychotherapy treatment options for survivors is beyond the scope of this article, I would like to refer to the pioneering work of Estela Welldon (2011), a distinguished group analyst who offered, with good results, treatment for survivors and perpetrators of sexual abuse in the same therapy group, at the Portman Clinic, in London.

Child sexual abuse: is it all in the mind?

In the last six years of his life (1984–1990), Bowlby was my supervisor and my mentor at the Tavistock Clinic (Ezquerro, 2015). During that period, I only saw him angry once. That happened when I asked him about child sexual abuse. He raised his eyebrows and said with a sense of regret that Freud’s change of heart on this matter, in 1897, was a disaster!

Psychoanalysis’ early history is indeed linked to sexuality, particularly to the concealed existence of child sexual abuse which, in late 19th-century Europe, particularly in the most conservative elements of society, was hidden behind a wall of respectability, modesty and collusive silence—if not outright lies. In 1885, the 29 year-old Freud obtained a grant to study with Charcot, a leading neurologist at the Salpêtrière, in Paris. Freud was haunted by Charcot’s clinical presentations of patients with ‘hysteria’—at the time, the neurotic condition par excellence.

Hysteria is a Greek word for uterus. In ancient times physicians believed that the disease was caused by ‘body wandering’ of the uterus. It was Charcot’s co-worker, Pierre Janet, who first described the traumatic origin of hysterical symptoms and laid the foundation for a new understanding of the impact that traumatic events have on mind and body.

Freud’s first attempt to explain hysterical symptoms appeared in the book Studies on Hysteria (Freud and Breuer, 1895) that he co-authored with his mentor Josef Breuer (http://en.wikipedia.org/wiki/Josef_Breuer), in 1895. The book was based on their clinical observations about a number of patients with a diagnosis of hysteria. Breuer saw the symptoms as reactions to emotional trauma. Freud went further than that and considered that repressed memories of sexual-related trauma may play a part in the formation of the hysterical symptoms.

Breuer struggled with the treatment of one of his patients, who has been well known in the psychoanalytic literature under the pseudonym of Anna O. She, at one point, imagined that she was pregnant and called him to assist her with labour, as an emergency. Fortunately, Breuer managed to disentangle himself from the treatment before disaster occurred and referred her to Freud. Incidentally, Anna O became the ‘mother’ of the term ‘talking cure’, which has been widely used to describe the method of psychotherapy.

Freud continued gathering information from Anna O and from other patients reporting to him incidents of sexual molestations during their childhood. On 21 April 1896, he presented his controversial paper The Aetiology of Hysteria to the Society for Psychiatry and Neurology of Vienna. He detailed the stories of 18 patients, 12 women and six men (Partridge, 2014). He made more direct links than in the Hysteria book between the patient’s symptoms and childhood sexual trauma, perpetrated mainly by fathers but also by other close relatives, older siblings and carers.

Freud’s so-called seduction theory was born; but it would be short-lived. Most of his colleagues rejected the paper; they did not accept that childhood sexual abuse in the family could have actually occurred. Some even accused him of putting these ideas into his patients’ minds. And Krafft-Ebing, who chaired the meeting, commented that the presentation sounded as a scientific fairy-tale (Ezquerro, 2017). On 4 May 1896, Freud wrote to his loyal friend Wilhelm Fliess expressing his sense of rejection and isolation . . .

And this after one has demonstrated to them a solution to a more than thousand-year-old problem, a ‘source of the Nile’! (in Zulueta, 1993: 139)

What Freud postulated was that the abusive experience had been repressed and remained latent for years, before the hysterical symptoms erupted with the emergence of strong sexual urges in adolescence and young adulthood. A latency period was consistent with medical conditions such as syphilis:

Our view then is that infantile sexual experiences are the fundamental precondition for hysteria . . . they do not do so immediately, but . . . only exercise a pathogenic action later, when they have been aroused after puberty in the form of unconscious memories. (Freud, 1896: 212)

As symptoms of hysteria were so widespread, not even sparing his siblings or himself, Freud had to infer that maybe his own father was guilty too. But he then appeared to exclude the fathers as main perpetrators, and concentrated more on relatives, carers and older siblings—although in the latter case, Freud implied, the older child had been seduced previously by an adult.

We may say that Freud surrendered to external pressure from his peers and from the bourgeois society of the Austro-Hungarian Empire, as well as to the internal pressure of his own doubts. He repudiated his initial belief and affirmed instead that his patients’ frequent reports of childhood sexual abuse were illusions or fantasies.

In September 1897, Freud wrote to Flies again to let him know about the difficulties he was experiencing in the treatment of incest victims and about the rationale behind his retreat from his seduction theory:

The continual disappointment in my efforts to bring any analysis to a real conclusion . . . Then the surprise that in all cases the father, not excluding my own, had to be accused of being perverse . . . Then, third, the certain insight that there are no indications of reality in the unconscious, so that one cannot distinguish between truth and fiction . . . Accordingly, there would remain the solution that sexual fantasy invariably seizes upon the theme of the parents . . . (in Zulueta, 1993: 157)

Freud felt forced to postulate that his patients’ emotional problems were caused by ‘phantasies’ or delusions of seduction that had not actually occurred. Bowlby considered that Freud’s disbelief or denial of childhood sexual abuse contributed to a dreadfully ignorant and unhelpful clinical practice with the victims. The denial also held back a much needed social awareness of the problem for more than half a century (Ezquerro, 2017).

In the final interview given by Bowlby on 15 February 1990, conducted by Virginia Hunter at the Tavistock Clinic, he stated:

I have to say as a student I was almost forbidden to give attention to real life events. Well, I’m talking about the 1930s . . . and there’s still, I think, excessive emphasis on fantasy. (in Hunter, 2015: 139)

Bowlby then explained that, only four years previously, he had been at a case conference in a well-known clinic in the USA. A psychoanalyst presented the case of a woman who reported that she had been sexually abused by her elder brother. However, the analyst was convinced that this was a fantasy.

Bowlby had no doubt that the woman was reporting a true story, as her problems were typical of what you might expect as an outcome of child sexual abuse. He then asked the analyst whether he had read the literature on sexual abuse in childhood and its consequences. And he was rather horrified that the analyst was totally unfamiliar with any literature on the subject, to which Bowlby added:

Well I mentioned this, you see, because this was only four years ago. So this reluctance to believe that what a patient tells you is true is still around and I think it’s not only un-therapeutic, it’s anti-therapeutic. (in Hunter, 2015: 140)

Besides psychoanalysis, the majority of mental health professionals and social institutions also maintained a dignified silence. Denial at all levels is a powerful force, as masterfully expressed by Nietzsche:

‘I did that’, says my memory. ‘I could not have done that’, says my pride, and remains inexorable. Eventually, the memory yields. (Nietzsche, 2000: 270)

In the 1970s and 1980s, the feminist movement contributed to bringing the problem of child sexual abuse into the open, along with other taboo issues such as rape and gender violence. The publication of the Cleveland Report, in the summer of 1987, had a powerful shaking effect in all the social strata in the UK.

In the spring of that year, 121 children from the (then) county of Cleveland were taken into temporary local authority care on suspicion of having been sexually abused. The majority of the children had been abused and some were re-abused by an unprepared child protection system. Cleveland was one the first known cases of child sexual abuse in Britain that involved multiple victims and multiple perpetrators.

Unfortunately, the criminal justice process itself added much to the victims’ trauma. Children were summoned unnecessarily, given little information, kept waiting, and subjected to tough cross-examinations. The UK media reported the suicide of Frances Andrade after giving evidence in the criminal trial of her abuser, in February 2013. This tragic event highlighted the re-traumatizing nature of the legal process.

New fires have continued erupting until the present day. On 7 July 2014, Theresa May (Home Secretary at the time) started a national enquiry into child sexual abuse. This followed the revelation that 114 Home Office’s files on alleged abusers, during the period 1979 to 1999, had been lost or destroyed. This implies that the evidence must have been suppressed by people in positions of power.

This ongoing inquiry includes public bodies, the private sector and wider civil society with a duty of care to protect children in England and Wales, from 1970 to the present. The enquiry has had many setbacks, but may eventually help address the wider social and political context in all its complexity.

The number of sexually abused children in England and Wales could be as high as 600,000 or more. The estimation comes from the National Household Survey of Adverse Childhood Experiences (Bellis et al., 2014). The concern of the police is that it is not gangs that are the biggest problem but home: 90% of such abuse is perpetrated by people children already know.

Childhood sexual abuse is far too often a hidden crime; it is shockingly pervasive and occurs throughout all layers of society. It is in fact a social illness and we need to approach it as such. Being a bystander and remaining silent is a way of colluding with the abuse. Unfortunately, prevailing power structures often overwhelm witnesses who then feel paralysed.

The general response has often been one of denial, minimization or rationalization. Fundamental changes are required to fight this social illness and enable survivors to be open about their experience. And still be able to participate in society as equals—without being ashamed, judged, rejected, discriminated against and stigmatized.

I think it is necessary to go beyond the consulting room, and to address the problem effectively in the social, cultural and political arenas.

In the 1970s and 1980s, Bowlby joined the voices who were alarmed by the high incidence of incest and its damaging effects on children. He clearly (Bowlby, 1979) named this as sexual exploitation of the children and considered that, in the most severe cases, the abuse can lead to psychosis and to problems of multiple personality or ‘dissociative identity disorder’ (DID). He remarked that the experiences that give rise to such disorders have probably been repeated over several years of childhood:

perhaps starting during the first two or three but usually continuing during the fourth, fifth, sixth and seventh years, and no doubt often for longer still. (Bowlby, 1988: 113)

In supervision, Bowlby told me that, during most of his career, child sexual abuse was rarely referred to by anyone and that, on those rare occasions, the abuse was considered to be produced by fantasies and not a real event. He strongly advised me to believe my patients when they reported stories of abuse.

Valerie Sinason (2011) stated that, until quite recently, most major psychotherapy and psychiatric training schools in the UK did not accept the existence of child sexual abuse and the long-term harm that it causes. In reference to this institutional collusion or denial, she added that Bowlby had left a powerful reflection: ‘We cannot know what we cannot bear to know’ (in Sinason, 2011:10).

Professional sexual abuse: a cure through love?

The media has been paying increasing attention to the fact that sexual abuse is often perpetrated by professionals, including art, politics, sport, education, social work, healthcare and other institutions. The field is huge and I shall concentrate on sexual abuse perpetrated on their patients by mental health professionals, particularly psychotherapists.

There are several features which are common to the latter category of abuse: first, not acting in the patient’s best interests; second, failing to keep professional boundaries; third, taking advantage of the patient’s trust; fourth, exploiting their vulnerability. I postulate that there is a parallel between child sexual abuse and professional sexual abuse. In these two forms of abuse, there is sexual exploitation of a vulnerable person by someone who is in a position of power.

Bowlby was concerned about the unethical behaviour of some of his colleagues and referred to this problem as a ‘hot potato’ (in Hunter, 2015: 154). He was not totally against the occasional use of touch in psychotherapy as a caring gesture, because in certain circumstances it can have therapeutic value. However, he was mindful that it can turn sexual and at one point said that in the therapeutic encounter between a middle-aged man and a young attractive girl, touch ‘could so much easily mean sex than anything else’ (ibid.: 154).

Bowlby emphasized that therapists have a special duty to protect vulnerable patients, for which it is crucial to understand the difficulties in their attachment history. Many victims of professional abuse have a background of child abuse. Some therapists are unable or unwilling to understand that the patient’s proximity-seeking can be an expression of an anxious longing for a secure attachment. And this can lead to the patient being re-traumatized in the consulting room.

Patients do not seek therapy to have sex with the therapist, but to feel wanted, accepted and understood. More often than not, they seek a reliable attachment figure and secure base. Not grasping the nature of the unmet attachment needs that these patients bring to therapy may increase the risk of sexual boundary violations (Ezquerro, 2017).

In the first volume of his trilogy on Attachment and Loss, Bowlby (1969) suggested that Freud seemed to have been unable to grasp the true nature of attachment, both, in childhood and in therapy. Indeed, in his Three Essays on the Theory of Sexuality, Freud (1905) had mentioned the presence of a grasping instinct (an extension of the grasp reflex), linked to catching hold of some part of another person. He also noted that an infant of 18 months disliked being left alone.

Originally, Freud postulated that attachment was a secondary consequence of the mother providing satisfaction of physiological or erotic needs and that fear of losing her was a growing tension of non-satisfaction—which needed to be discharged. In 1922, he wrote:

In the first instance the oral component instinct finds satisfaction by attaching itself to the sating of the desire for nourishment; and its object is the mother’s breast. It then detaches itself, becomes independent and at the same time auto-erotic, that is, it finds an object in the child’s own body. (in Klein, 1952: 435)

Here, Freud was talking about a libidinal attachment to an object, the mother’s breast, which occurs prior to auto-eroticism and narcissism. But he gradually realized that his theorizing was insufficient to explain the complexities of our instinctual life. And he was honest enough to write the following statement in 1925:

There is no more urgent need in psychology than for a securely founded theory of the instincts on which it might then be possible to build further. Nothing of the sort exists. (in Bowlby, 1969: 37)

Towards the end of his life, Freud recognized that understanding the true nature of this powerful, early bond was beyond his grasp. In 1931, he wrote: ‘Everything in the sphere of this first attachment to the mother seemed to me so difficult to grasp in analysis’ (in Bowlby, 1969: 177).

Freud was alarmed when he realized that the therapeutic encounters between many of his followers and their patients involved sex. What today is documented as professional sexual abuse was not an uncommon occurrence in the early days of psychoanalysis. Even nowadays, according to Tschan’s (2014) research, 10% of male and 3% of female psychotherapists violate sexual boundaries with their patients.

Gabbard (1995) suggested that the sexual transgressions perpetrated by the psychoanalytic pioneers contributed to a legacy inherited by several generations of psychotherapy practitioners. Moreover, Gabbard indicated that institutional resistance to addressing these difficulties in contemporary psychotherapy practice may partly relate to the ambiguities surrounding boundaries.

For a long time, it has been argued that there was no clear understanding of professional boundaries—or was it? In a personal communication, Jonathan Coe (CEO of the Clinic for Boundaries Studies) told me that a common element in professional sexual abuse (past and present) is that, before the actual physical involvement, the intra-psychic boundary is the first to disintegrate.

Boundary violations are more often than not preceded by boundary-crossing incidents. For example, extending sessions beyond the agreed contractual limit, disclosing inappropriate personal material to patients, moving them to isolated consulting rooms or changing their appointments to late evening times.

Freud abstained from sexual liaisons with his patients. Many times, he stated that analysts have to continually work on abstinence from sexual relations in their clinical practice (Tschan, 2014). However, in a letter to Carl Jung in 1906, quoted in Bettelheim (1984), Freud made a double-edged remark that psychoanalysis is in essence a cure through love. Unfortunately, Jung misinterpreted this and ended having an infamous and abusive sexual relationship with one of his patients, Sabina Spielrein.

Freud himself struggled with sexual boundaries and wanted to keep the problem secret within the profession. In his letter to Jung, on New Year’s Eve of 1911, Freud commented:

We must never let our poor neurotics drive us crazy. I believe that an article on ‘countertransference’ is sorely needed; of course we could not publish it, we should have to circulate copies among ourselves. (McGuire, 1974: 475–476)

In a further letter to Jung about sexual experiences with patients, Freud stated:

Such experiences, though painful, are necessary and hard to avoid. Without them we cannot really know life and what we are dealing with. I myself have never been taken in quite so badly, but I have come very close to it a number of times and had a ‘narrow scape’ . . . weighing on my work and the fact that I was ten years older than yourself . . . have saved me from similar experiences. (McGuire, 1974: 230)

Simon Partridge (2014) collected evidence that before his third birthday Freud was sexually stimulated by his nanny, one of his attachment figures, in a completely inappropriate way. Tschan (2014) pointed out that there are good grounds to believe that a number of leading early psychoanalysts (including Melanie Klein, Carl Jung, Otto Rank, Wilhelm Reich and Sandor Ferenczi) were sexually abused as children to different degrees.

Within this elite group, Ferenczi was the one who talked more directly about his childhood trauma, to the point that entries in his diary show ‘his confusion of his own need to be healed with that of his patients’ (Gabbard, 1995: 1125). Ferenczi wanted to give to his patients the secure attachment and love they had not experienced in the relationship with their parents. He developed a technique in which he attempted to repair his patients’ childhood damage. His technique included kissing and hugging the patient as an affectionate mother who . . .

gives up all consideration of one’s own convenience, and indulges the patient’s wishes and impulses as far as in any way possible. (in Gabbard, 1995: 1125–1126)

It seems that, as a victim of mistreatment, Ferenczi over-identified with his patients. This dynamic was not foreign to other analysts.

While Freud kept mainly quiet about child sexual abuse, Ferenczi became more able to talk about it openly—as he had no doubts that many of his patients had been sexually abused as children. Ferenczi decided to exhume the seduction theory that Freud had buried and presented its re-discovery to a large audience of psychoanalytic colleagues in Wiesbaden, in 1932.

That was an honest and disturbing article: Confusion of Tongues between the Adults and the Child (Ferenczi, 1932). One example of the confusion of tongues is when the child yearns for closeness and affection with a parent who, from a disturbed perspective, misinterprets the child’s need in terms of an adult sexual tongue (a language the child does not know) and then forces the child to conform to it.

For instance, a father touches his daughter in a sexually inappropriate manner, while she speaks her innocent child tongue. Additionally, the father tries to persuade the daughter that lust on his part is really the love for which she yearns. Let us be clear: this is not ‘infantile sexuality’. This is plainly child sexual abuse—something that can be understood as a perversion of the attachment relationship (Ezquerro, 2017).

Ferenczi’s article was strongly rejected by his colleagues, particularly by Freud—who 36 years previously had been subjected to a comparable rejection when he presented his cases of child sexual abuse in Vienna. Is it not paradoxical that Freud appeared to have lost any sense of empathy towards Ferenczi in spite of his own experience of rejection? In fact, Ferenczi was excommunicated from the psychoanalytic community; which, according to Partridge (2014), might have contributed to his early death the following year—aged 59.

The Confusion of Tongues article was not allowed to be translated into English for nearly two decades. The article contains criticisms of the professional hypocrisy that is hidden and never revealed. It also draws attention to scenarios in which the professionals (including himself) create a situation that is unbearable as it imposes on their patients ‘the further burden of reproducing the original trauma’ (Ferenczi, 1949: 227).

Personal and professional lives were intertwined in almost every conceivable way during the early developmental stages of the psychoanalytic movement. Gabbard suggested that psychoanalytic technique, like other learning processes, had to develop via trial an error, and added that one way of understanding these historical boundary violations is ‘to see them as the inevitable labour pains accompanying the birth of a new field’ (Gabbard,1995: 1131).

But hang on a minute! Are we missing or denying something here? More than two thousand years ago, the Hippocratic Oath had left no room for ambiguity. Any physician was expected to promise to treat patients keeping them from harm and injustice, remaining free of sexual relations with both female and male persons, be they free or slaves.

The reality is that every psychotherapy institute and society has seen the ravages of severe boundary violations (Gabbard, 1996). And it can be quite tempting to attribute these abuses to a small handful of corrupt colleagues. But this way of thinking would mislead us to defensively disavow our vulnerability to boundary transgressions, and to see them as the province of a few who have nothing in common with the rest of us.

The facts are otherwise: when professionals who commit professional sexual abuse are compared with professionals who do not commit boundary violations there are not so many differences as expected, which was outlined in Lessons to be learned from the study of boundary violations by Gabbard (1996), following his research and his work with perpetrators. Believing that this would never happen to me, assuming that the offender belongs to a different species can be dangerous. Awarded and well-regarded professionals have committed professional sexual abuse. Any of us could be an offender and supervision of our clinical practice should be mandatory, no matter how experienced we might be.

Psychotherapy and other institutions have often been paralysed in their efforts to take action when such cases surface, particularly when the analyst charged is a well-respected practitioner in the field. The therapeutic needs of the victims, which should be paramount, are often neglected. So, protecting children and patients from sexual victimization and from re-traumatizing should be at the core of any support or therapy programme, including the treatment of perpetrators (Gabbard, 1994; Gabbard and Lester, 1996; Welldon, 2011; Tschan, 2014).

Fear of the legal implications has also contributed to institutional paralysis. Psychotherapy and other institutions must be less reluctant to giving an institutional apology. Defensive attitudes (though understandable) perpetuate the suffering of survivors. Saying sorry is a way of expressing regret about the damage caused—as well as sympathy and reassurance for the survivors that it was not their fault.

In the Madrid Declaration on Ethical Standards of Psychiatric Practice, the World Psychiatric Association (1996) left no room for doubt:

Under no circumstances should a psychiatrist get involved with a patient in any form of sexual behaviour—irrespective of whether this behaviour is initiated by the patient or the therapist.

Conclusion

Attachment theory is crucial for understanding the suffering of the survivors of both childhood and professional sexual abuse, which are a relational crime. Due to their caring role, psychotherapists, group analysts and other mental health professionals must be considered to be significant attachment figures with a substantial power differential over their patients.

Equally to child sexual abuse, professional sexual exploitation is a complex traumatic experience, which includes a breakdown of trust in the person who is meant to provide a safe haven. Far too often, survivors are not believed or respected. Their pain can be trivialized and sometimes not even acknowledged. It is not unusual for the abuse to take place in front of the eyes, noses and ears of people who do not want to know, as if these witnesses were neutral observers.

Historically, professional bodies have exhibited greater concern for the protection of the transgressing therapist than for that of the patient. Fortunately, this attitude has been gradually changing. However, there is still a long way to go. More institutional apologies and reparative gestures are needed to help survivors in their struggle to overcome the trauma.

The needs of the survivors are paramount and turning a blind eye should be an option no longer.