Scott Stewart, M., 2002. The Internalisation of the Perpetrator. Reformulation, Spring, p.14.
When reading a book on working with childhood physical and sexual abuse numerous questions arise in the hope they will be addressed. How to find ways to help patients who have suffered in this way articulate their dreadful experiences? How to work with feelings of being cast as another penetrative abusive other through being part of a verbal intercourse? How to work with intense transference and counter-transference, fierce attachment, or enraged or cold contempt and distance, when these states are part of the most traumatic horrifying histories that are the background to the work? How to manage the sexual material? Will there be guidance as to what is possible, and define the limits of what can be achieved, with the people most damaged by these experiences?
Pollock does manage to describe the complexity of what is brought to therapy. He explains that there is no linear connection between children being abused and fragmented mental health. Each history is multifaceted and has to have a model of understanding which can encompass this diversity. A sizeable proportion of children who are sexually abused do not present or develop mental illness or suffer from personality disorders. But the number of those in need of the mental health services who have been abused is statistically disproportional. He defines the range of difficulties faced by children who are abused. There are the sexual acts themselves, the age at which this happened, whether it was sustained, the relationship with other carers and members of the family. But most important is the relationship to the perpetrator, how he/she constructed this relationship, and the response of the child to this construction. The internalisation of the perpetrator’s world has a profound and lasting impact on the sense of self and other. Pollock tells us that a model of working with this complexity must be able to deal with disturbances of the self, the effect of the experiences on emotional life and the effect on intrapersonal and interpersonal relationships, and he and the other contributors demonstrate how this is done using CAT.
Pollock has a clear straightforward prose style. This may be the outcome perhaps of being so familiar with the details of his subjects’ lives and having a clear reformulation of their experiences. He shows how the CAT scaffolding can give the explanatory framework and resulting powerful encompassing narrative strength to the work. This power is seated in the relational aspects that permeate CAT. It can thereby explain how the past affects the present. The relationships of the past are explored in RRPs (Reciprocal Role Procedures) but also in a two-person process. There is also emphasis on learning about relating from the therapist and the need to learn from the patient, particularly about what is tolerable. Pollock emphasises the need to pay attention to what is bearable to speak about. Talking about the trauma can be seen dogmatically as a working through but it can easily become re-traumatising.
The central learnt reciprocal roles means that the patient takes on cruelty in some form towards themselves and others. The realisation of this can make it feel as if the perpetrator lives on in the individual, which can be terrifying in its implications for the patient. Pollock’s writing is helpful in being able to give feedback about the model and the need to pace understandings drawn from the relational reciprocal role understandings where the roles have been so monstrous. One description of the RRs is of the carer as monster, and in these descriptions the words take on the full force of their meanings.
Pollock gives a good account of the components of CAT. But its concise, intelligent exposition also highlights the difficulty with these accounts. The elements of CAT, TPs (Target Problems), TPPS (Target Problem Procedures), RRPs(Reciprocal Role Procedures)and the MSSM(Multiple Self States Model) give a dry sense of the work and can seem dulled away from the material they link heuristically. Also the difficulty of linking differences between the parts, particularly TPPS and RRPs, is confusing. Pollock says he is giving a brief account and guides the reader to the relevant literature. This is not necessarily an easy place to tease it out either.
But once the model is linked to the case histories the linking and lucidity it creates is impressive. He also uses other techniques with CAT. Reperatory grids are used in the development of the relationship descriptions. In trying to relocate responsibility he describes the use of guided fantasy. The difficulty in the need to experience being a deserving person is helped greatly by power mapping. The Victim State can be helped by IRR(Imagery Rescripting and Reprocessing) and EMDR(Eye Movement and Desensitisation and Reprocessing). The work he is doing with CAT is based on a model of trauma and he gives good descriptions of the theory of Type I and Type II trauma and the theory linking CSA(Child Sexual Abuse) to PTSD(Post Traumatic Stress Disorder). He has clear descriptions of the levels one, two and three in CAT and how using this can help to assess levels of damage. There is a good chapter on comparative approaches.
The answers to my own specific question were most directly answered in the case histories described by Sue Llewelyn and Sue Clarke. Perhaps because they were describing people similar to those I had worked with and not the more florid forensic cases. What was most helpful here were the detailed accounts of moments of transference in the sessions connected to perpetrator and seducer and details of how the therapist responded to these difficult Reciprocal Roles. They tell us how they fearlessly keep the boundaries of therapy and keep their patients safe. One account describes how a female therapist deals with the role of Seducing/Seduced when a male patient tries to gain control through sexual behaviour. Another account will be familiar to those working in units with highly disturbed patients with severe personality problems. The patient rings the unit the day after the session and asks to speak to the therapist. The call is not returned and the patient in fury breaks her arm with a hammer and presents herself to A&E. The therapist stays in the boundary and talks to the patient in the session about the swing between idealisation and abandonment. The possibility that the therapy will rescue and be ineffective because of idealisation is averted and the patient is able to work in a real place with the limits of human relating. It perfectly illustrates how frightening the work is and the bravery of both the patient and the therapist in the undertaking of therapy.
Mog Scott Stewart
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