The psychological examination of alleged child sexual abuse. Projection and body image

INTRODUCTION
The psychological assessment of sexual abuse in children remains a difficult diagnostic endeavour, in the context of the child’s age, of the organisation of family life and parental care, as well as of antecedents related to the child’s neuropsychological development and the defence mechanisms the child develops in such a situation, involving fear, shame and guilt. Research
in this field has presented contradictory results [3]. A theoretical debate began as early as the first part of the 20th century, in the field of psychoanalysis, between FREUD [6] and FERENCZI [7], regarding the real or fantastic nature of sexual trauma, and their conclusions remain contradictory.
The issue of diagnosis with regard to the reality of abuse has sparked serious debates related to the danger of blindly trusting a child’s confession, or the confession of a parent or tutor, for that matter [1]. French clinical psychologists [2,10] promote and defend the idea of resorting to projective techniques when the victim of a supposed sexual abused is examined, for the purpose of also performing psychotherapeutic intervention. The major argument in favour of using projective techniques as diagnostic instruments resides in the fact that they reduce the subject’s conscious defences and stimulate a labour of symbolising the event by means of projection. In such clinical situations, working with stories, drawing tests, the Rorschach and T.A.T. tests are recognised as projective techniques.
MATERIALS AND METHODS
This study used “The ant’s tale” – created by ROYER [10] and later validated by DE TYCHEY [2,4] – as part of a clinical examination performed in an alleged sexual abuse case, in order to assess the effects of physical suffering by projecting the child’s body image. The text of the story explores several important aspects of body image. This tale (see annex) forms the object of subsequent validation [9].
Question 1 refers to the place where the ant goes on the child’s body and allows the clinician to notice whether the subject clearly differentiates body image at the cognitive level, in the sense given by SCHILDER [11] or whether this is a regressive investment: (a) the evolved level resorts to predominantly cognitive activity – the ant ends up on a body extremity (head, face, hand, leg, arm); (b) the regressive level is represented by the ant walking on the navel, mouth, buttocks, stomach or sexual organs.
Question 2 involves rich sensory references, if the child is able to evoke at least two such references during the ant’s journey. Criteria regarding sensory references are: SIGHT (the ant walks on one’s eyes, eyelids, glasses); TOUCH (the ant walks on fingernails, hair, skin); SMELL (the ant walks on one’s nose); TASTE (the ant walks on one’s mouth, lips, tongue); HEARING (the ant walks on the subject’s ears). Normative answers for the ant’s entering and exiting are the three natural openings: mouth, nose, ear. Regressive answers refer to openings with a sexual charge: navel, buttocks, sexual organs.
Questions 4 and 5 refer to the bodily casing and the child’s ability to integrate ambivalence relating to his/her body and experiences related to pleasure/ displeasure. The questions refer to the evolution of the body’s unconscious image, conceived by DOLTO [5] i.e. “the erogenous image”, “the place where erotic pleasure or displeasure is focused in relation to the other”. Normative answers are related to the child’s ability to evoke both pleasant and less pleasant things.
Question 6 is related to the conclusion of the story. A normative answer is given by the child’s ability to imagine a positive ending, where the two protagonists – the child and the ant –separate. A problematic answer will be expressed by a negative conclusion, e.g. the death of one of the protagonists, or by the impossibility to imagine the separation of the two.
CLINICAL CASE, SUBJECT: MARIA, 4 YEARS OLD.
Presentation and behaviour
The girl came to the psychological practice accompanied by her mother and grandmother. The mother assisted in the child’s psychological examination and took part in the clinical interview which took place before the actual psychological examination.
The little girl has a pleasant appearance and relatively well cared for attire. She is shy upon first contact, but quickly adapts to the atmosphere of the office and accepts the work and play tasks given by the examinant. She answers questions somewhat reluctantly, the tone of voice is sometimes whispered, but she gets involved in playing with the two dolls which she has brought from home and is very communicative in non-verbal expression (gestures, mimic, actions). She maintains eye contact with the examinant and collaborates, asking for help in certain play sequences.
Data resulted from the clinical interview with the mother
The clinical interview took place separately with the girl’s mother, who stated that her request for psychological examination is due to her suspicions related to the father’s behaviour towards the girl; the mother accuses the father of having sexually abused the minor. She describes several of the girl’s behaviours which indicate a preoccupation for the genital area, such as: the desire to introduce toys into the genital area, touching the area with her hand, imitating sexual gestures. The mother had noticed these preoccupations three weeks before; the girl had been left several times with her father, who bathed her and slept in the same bed with her.
The mother states that she had the baby prematurely, at 36 weeks. The baby experienced normal psychomotor development during the first year of life, after which the development rate slowed for a few months. The mother blames this developmental delay on her own accumulated exhaustion, as she had to care for the baby alone, stating that the father had no involvement in child care or housework. Even at the time of the examination, the mother continues to breastfeed the girl during the night. The girl is not enrolled in kindergarten, as the mother uses educational tasks from the Montessori program at home. The mother takes responsibility for certain irritable behaviours towards the child, also blaming them on excessive housework strain. She is currently in the process of divorcing the father, who initiated the process himself.
At the end of the interview, the mother describes recent symptoms in the girl’s behaviour: enuresis and agitated sleep with frequent rousing. The mother is now the one who sleeps with the child.
With regard to alleged touches or sexual abuse, the child does not describe such situations in words, and the mother states that the girl has not told her of such situations either, but she did exhibit gestures and preoccupations with sexual connotations.
Intelligence assessment
Taking into account the subject’s chronological age, simple tasks were applied related to attention focus, naming object and situations, meant to clarify the development of intelligence. The following were observed: global intellectual level is not deficient and is in accordance with age; the child exhibits skills of understanding simple situations.
The child shows adequate functional language skills, using the appropriate words for the situations she describes during examinations. She correctly associates the names of objects or situations according to the items that are presented.
It is important to note that the subject solves game or story tasks without being anxious or inattentive; only towards the end of the examination can one notice a certain impatience and need to move, as if to explore the environment in the office, which emotionally and behaviourally corresponds to the subject’s age.
Psychological functioning
The following psychological tests were applied: C.A.T. (Children Apperception Test), The tale of the ant: Royer [10], De Tychey [4], role play.
The C.A.T. test reveals the following results decoded in the following cards:
Card 9 – “The bunny is sitting on his bed. His mother went home. They left him alone. His mother pulled his hair and ear, so he stayed with his father” reveals feelings and ideas related to abandonment, in the context of an aggressive maternal figure.
Card 5 – “The little bears are alone. Their parents went to Sinaia” reveals the same representations related to abandonment associated with the parental figures.
Card 1 – “The chickens are waiting for their mother” reveals unsatisfied oral position