Wednesday, June 20, 2012

The inexorable Repetition Compulsion from childhood sexual abuse

A woman, now in her fifties, whose psychopathology revolves around the consequences of having been subjected to sexual abuse by her father when she entered puberty, and who is now very sick, riddled with self punishing impulses which at times have turned into frank suicide attempts, reported  two dreams that were virtually identical but for one minor detail. Both dreams occurred on the same night.

I am at Stuart's house. I climb up the steps which are covered with green old fashioned shag carpet. I have grocery bags which I place upon the kitchen counter and start making the dinner.  I cut the potatoes and cheese for I am making perogies. All of Stuart's family is there, sitting at the dinner table, his sisters, his father and his brother Jerome who is sitting at the end. His mother comes to help me finish making the dinner. 

The second dream was exact repetition of the first except instead of perogies it was meatloaf that she was cooking and Stuart's mother does not come and she finishes the cooking all by herself.    

The dream occurred after the patient was taken off from Trileptal and Prozac, which had been started when she was hospitalized for a suicide attempt. She was still left on 300 mg. of Lithium and 2 mg. of Risperdal. Antidepressants make her tremulous and agitated and the anti-seizure mood stabilizers make her feel weird. She nevertheless always gets put upon these medications whenever she goes to the hospital. These hospital admissions occur for suicide attempts and because of that the psychiatrists who as a rule know very little about it other than as an excellent justification to hospitalize and make some money automatically put her on anti-depressants and mood stabilizers.

When she is heavily medicated she does not dream but nevertheless wakes up with severe anxiety and overwhelming sense of having done something wrong, an affect which she is unable to shake off for rest of the day. Only by evenings her mood improves, she feels  near normal and finds energy to do a little house work and occasionally to override her agoraphobia and go out for shopping with her boyfriend.

"Why does the dream take place at Stuart's house?"

"Because when I ran away from  home, I was 15 then, I lived at Stuart's for a while. He was my first boyfriend, it was a welcome relief to have normal boy-girl relationship, and his family was nice to me."

"So is the dream showing that you are running away from your father?"

"I don't know. Maybe the dream is showing what we actually did at Stuarts, which included sitting around the dinner table and eat.  His brother Jerome always sat at the end of the table so the dream shows it that way. The dream is simply replaying what took place in my life during that period."

"No, the dream does not have time to waste upon simply replaying the past. Some wish fulfillment must be taking place which requires the recreation of the scene for its fulfillment."

"Well we always ate at 5 pm on the dot. Things were so organized at their house. The Stuarts were nice people, so it was a welcome relief from the abuse and harshness that existed at our house. At my father's, children had to work very hard and everything was oriented towards pleasing the adults. It was just the opposite at the Stuart's."

"You mentioned Jerome specifically by name while you did not name the sisters and also made sure to mention the exact position where he sat. Any associations to Jerome?"

"Jerome was my brother's friend. My brother also lived at Stuarts for a while after running away from home like me."

"Didn't you tell me your brother was sexually abused as well?"

"Yes, he was. Our step-grandfather who lived upstairs with our grandmother abused him."

"So the dream is showing you two escaping from abuse. Jerome appears in the dream with so much prominence because he serves as a link to your brother in the dream . The dream is certainly about the wish to escape from the terrible conditions of your home. And while you were not that much close to your two sisters you were close to your brother. In the dream Stuart's sisters are ignored perhaps to show your indifference towards your sisters but your solidarity with your brother."

"Yes, I was very close to my brother, who was just two while I was four, when our mother abruptly left us.  It was very heavy load for my father, taking care of the four of us and being on the road for he was a truck driver. Though his mother who lived upstairs helped him to take care of us."

"Why is the color of the carpet green?"

The patient could not come to any reasonable associations to it except that Stuart's family did have a shaggy carpet that was so characteristic of the 70s though it was inside the house not at the entrance steps.

On theoretical grounds the color green was interpreted as a symbol of jealousy and the patient confirmed that she was kind of jealous of Stuart's family because everybody lived happily and did not have to worry about getting abused or exploited.

Patient could come up with no associations as to why the dream showed her climbing up the steps, why she was cutting potatoes and cheese making perogies, and then meatloaf and why the dream had occurred twice.

When , on theoretical grounds,  interpretation was made that climbing the steps must be depiction of sexual intercourse, the patient started to laugh and said, "There is nothing sexual about this dream and I know you will tell me somehow it is connected with my redreaming the sexual abuse in hands of my father."

But I was not willing to give up that conjecture which the patient herself brought up so spontaneously and which was grounds for assuming that perhaps it was the central theme of the dream. Now many of her previous dreams on analysis had shown themselves to be repetition of the furtive sexual activity that had taken place between her father and herself in the wee hours of the night, fearful that the grandmother will hear something unusual and which were always initiated by her father and always resented by her for they would leave her feeling dirty and morally wrong. It was this knowledge about her, from years of treating her, which emboldened me to pursue this line of inquiry.

I said to her, "I will not be surprised that behind Stuart's house perhaps lies your own house. And your relationship with Stuart emerges so readily and repeatedly because behind it lies hidden memory of your relationship with your father."

"No, the dream has nothing to do with my father. He was not there, and I dreamt of Stuart because I loved him. We had wonderful times together and I would have married him if he had not left for service and his parents had not objected on grounds that we were too young to get married. And the dream is about Stuart's family and that is all to it."

But from previous sessions I knew the girl dreams of her relationship with her father almost every night and then wakes up in the morning feeling dreadful, tremulous and guilty, quivering and shaking and unable to leave the house afraid that if she goes driving, out of nervousness she may run into some other vehicle and kill the other driver. This dread of meeting a vehicular accident on the road, which was the basis of her agoraphobia, had two contrary wishes fueling it. One to encounter her father on the road by chance in the garb of a stranger and to make violent love to him and second to kill him for doing such a wrong thing. I also knew from the analysis of her previous dreams that dreams of being with Stuart and his family were invariably a cover up for being with her father and their family. They were two parallel families one which she loathed being part of and one which she desired so much to blend in with.

"Did you cook at Stuart's family?"

"No. Their mother did it.. I was treated like one of the children. May be I helped her here and there. But no I only cooked at my house."

"Did you make perogies at Stuart's family?"

"No. They were not Polish. But I cooked perogies at my house. And coming to think of it it was much harder to make them than meatloafs, which I had to cook for my father quite often, for he loved them, and in the dream it is not Stuart's mother who is helping me with the cooking but behind her lies the memory of my grandmother. For those suckers are hard to make and can take your entire day and she would come at the tail end and help me finish doing them. But I could cook those meatloafs for my father all by myself. In fact I loved cooking. We had assigned  chores like cleaning the dishes, vacuuming etc. I always exchanged my chores with my sisters so I could cook."

The patient would not accept the interpretation but her father's placing her in the position of his wife rather than his daughter had aroused the fantasy of being his wife and acting the mother of his children and it was this fantasy that she dreamt of nightly and woke up from it tremulous and guilty ready to commit suicide because of its morally unacceptable nature.

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