What are the specific themes in treatment?
In addition to the aforementioned interventions aimed at trauma-related problems, promoting the attachment relationship and improving the position in the community, the topics listed below deserve special attention. These topics are specifically relevant to the problems of mothers and their children born of sexual violence, whether it concerns the attitude of the therapist or the parent-child relationship.
Specific themes that play a part in the treatment of mothers and their children born of sexual violence are: attitude of the therapist/(health)care professional, mental representations, ambivalence, differentiation, disclosure, acceptance and social isolation. Since these specific problems often interfere with sensitive parenting and the parent-child relationship, the interventions can be integrated into the ongoing attachment-oriented treatment.
Attitude of the (health)care professional
It is crucial for the effectiveness of the intervention that mothers feel fully accepted. They will be better able to discuss their experience of themselves, their child and the connection with their child. Any ambivalent feelings, doubts, hopes and worries are also easier to discuss. As a (health)care professional, it is not always easy to endure feelings of ambivalence or even hatred towards a child. It is not uncommon for these mothers to express their wish that the child had not been born. However, in the interest of both mother and child, it is important for mother to be given the opportunity to express these feelings so that they can be part of the therapeutic conversation.
At the same time, the (health)care professional has the task of focusing on resilience in addition to any problems. Parenthood can also strengthen the resilience of mothers (1). It is the challenge for the (health)care professional to find a balance between the impact of the trauma, the strength and hope of the mother, and the vitality and attachment needs of the child. It is important that sufficient attention is paid to the positive commitment of the mother and to strengthening it. Supporting the mother as the person responsible in the relationship with her child, instead of seeing her exclusively as a victim of sexual violence, helps to focus on any parent-child relationship problems that may be present (2, 3).
An essential part of the treatment is to explore how the mother experiences parenthood and how she experiences her child and their relationship. Sometimes the child is a trigger for flashbacks for the mother, through a sound, a physical resemblance, or a gesture. Seeing the perpetrator in the child can lead to aversion or rejection of the child, avoiding affection and physical contact and can even provoke hostile reactions. For other mothers, the child has a different meaning: ‘to have family again’. This applies in particular to isolated mothers and to mothers who have lost their families, for example as a result of war, fleeing their country or migration. If an isolated mother sees the child as the only thing she has left, it is possible this will lead to a symbiotic relationship or role reversal. It is expected that the child will meet the needs of the mother instead of the other way around. It's good to be alert to this.
When mothers see themselves as unworthy due to their traumatic experiences, and therefore also as an unworthy mother, this can be an obstacle in the contact with her child. Looking at how the mother experiences herself as a parent will help her gain insight into the influence of sexual violence on parenthood. For example, does the mother see herself as the guilty one or as a victim? Is she unsure about whether mixed feelings for her child will ever make her a good mother to her child? Understanding the thoughts and feelings that benefit or undermine parenthood is often a first step for mothers in understanding that they have choices in how they view their child and themselves. This insight opens a door to new options.
A child born of sexual violence can evoke conflicting feelings in mothers. This can certainly be the case when mothers have not had the opportunity to make a decision about whether or not to keep the child. The child can be seen as a perpetrator and a victim at the same time. Tenderness and hostility, acceptance and rejection can be present in varying ways and can lead to inconsistent parenting, with risks of unsafe or disorganised attachment. When the therapist understands, accepts the mother's conflicting feelings and emphasises that this is quite understandable and often occurs, this creates a safe space for further exploration of the mother's ambivalence. What are the fun moments with the child and when does she experience negative feelings towards the child? What does she do when that happens? How does the child experience the changed attitude of the mother? In this safe space, the mother can share her fears and doubts about parenting and her concerns about her child's future. At the same time, the mother's self-confidence is strengthened by validating her commitment and the positive moments of interaction between her and her child.
Video: a mother reports PTSD complaints
A mother reports PTSD complaints. How do you ask further questions about the challenges in motherhood and security?
When the child evokes painful memories in the mother and she continues to see the perpetrator in the child, this often leads to negative feelings for the child. One of the goals of treatment is to separate the images of the father projected onto the child from the mother's representation of the child. This can be part of an individual trauma treatment and also of parent-child-oriented interventions. Recognising the child's characteristics or behaviours as triggers, reminiscent of sexual violence and the perpetrator, help the mother gain better control over her thoughts and feelings. The better the mother is able to manage to observe her child calmly, to play with the child, and to discover the characteristics of the child, the better she will get to know the child and differentiate it from the father and to accept.
Mothers with a child born of sexual violence are confronted with the child's questions as to who or where their father is. This sometimes starts at a very young age, around 3 to 4 years old, and comes back at different ages. The child has the right to know who the father is and sometimes mothers understand that. But a lot of mothers don't know what their answer should be. They are ashamed to talk about what happened, afraid that their child will reject them, or want to protect the child from the harsh truth. That is why the subject is often avoided or, for example, children may be forbidden to ask any questions about it. Children may also stop asking questions when they see their mother's emotional or dismissive response. The fact that the questions are no longer being asked does not mean that they are not there. Sometimes mothers make up a story: the father is travelling in a distant country, he disappeared during the war or something similar.
The treatment focuses on a shared understanding of the reasons that prevent the mother from telling her child about the father. And to explore how the mother sees the advantages and disadvantages of disclosure. This makes it possible to elaborate what choices are appropriate to the age of the child, which are at the same time culturally and contextually acceptable. The (health)care professionals can offer support in the construction of a narrative for the child, for example, creating a little book for the child (3). In a group treatment of mothers with children born of sexual violence, mothers can help each other find the best balance between revealing and concealing (4). The first requirement is for the mother to feel comfortable with the story being told. In addition, support when reading the book to the child can be very valuable. The (health)care professional can support the mother in assessing what a good time is to tell the child about their origin. Sometimes a completing a first trauma treatment is important for the mother before she is able to talk to her child about this topic calmly. The revelation can raise a lot of questions in the child. (5). Attention and support for the child and young person, mother and child together, is part of treatment.
Acceptance or adoption
Some mothers manage to accept the child from pregnancy or shortly after birth. Others say that in the first days after the child was born, they were unable to look at or touch the child. They were able to build a good relationship with the child later on. Sometimes mothers continue to doubt whether they can give their child enough so that they can develop properly. They continue to consider giving the child up, or opting for ‘part-time’ parenting in order to give the child better opportunities for development.
During treatment, it is important to take sufficient time to consider all possibilities for a mother to make a decision that is in the best interests of her and her child. When the therapist is willing to listen to all of the mother's thoughts without judgement, it creates a safe space where mothers can take time to consider their choices. Focusing too one-sidedly on motherhood when the mother does not really want to do this can result in too little attention to the child's developmental needs. Thinking about what the child needs and who else can offer this, or perhaps instead of the mother, is also a good way to consider parenthood.
Although this process takes time, the safety of the child must not be a priority. If there are concerns about the safety of the child, it is necessary to follow the ‘reporting code for domestic violence and child abuse’.
In addition to the relationship between mother and child, it is essential to explore whether there isolation, stigmatisation and/or exclusion by the environment. For mothers who have had a child as a result of sexual violence, several aspects can come together that can lead to social isolation. On the one hand, traumatisation reduces trust in others, which can lead to withdrawal from social interaction. On the other hand, motherhood or the child can cause feelings of shame, which means that mothers avoid contact, often also to avoid questions from others about their child. Finally, single parenthood limits the possibilities of making contact. What they did before to see people is no longer possible, or much less often.
Because social support plays an important role in the recovery of trauma-related problems, it is important to look at this. Mapping the social network can be a start for further interventions. This involves mapping what support the mother needs and the help and support she is already receiving. It may also be desirable to do part of the treatment in a group, or to look for a group in which the mother can participate in addition to the treatment.
After all, practical help, which will actually take some of the burden off for the mother, is of great value.