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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.48 no.spe2 São Paulo Dec. 2014

http://dx.doi.org/10.1590/S0080-623420140000800009 

Artigo Original

Cumulative Vulnerability: A Case Study on intrafamilial violence, Drug Addiction and Adolescent Pregnancy

Vulnerabilidad acumulada: Estudio de un caso de violencia doméstica, drogadicción y el embarazo en la adolescencia

Paula Orchiucci Miura1 

Gislaine Martins Ricardo Passarini2 

Loraine Seixas Ferreira3 

Rui Alexandre Paquete Paixão4 

Leila Salomão de La Plata Cury Tardivo5 

Dora Mariela Salcedo Barrientos6 

1Paula Orchiucci Miura, PhD student in Clinical Psychology at the Institute of Psychology, University of São Paulo (Universidade de São Paulo - USP)

2Gislaine Martins Ricardo Passarini, Master’s degree in Clinical Psychology from the Institute of Psychology, USP

3Loraine Seixas Ferreira, Master’s student in Clinical Psychology at the Institute of Psychology, USP

4Rui Alexandre Paquete Paixão, Associate Professor at the School of Psychology and Educational Sciences, University of Coimbra, and Researcher at the Center for Social Studies, University of Coimbra

5Leila Salomão de La Plata Cury Tardivo, Associate Professor at the Institute of Psychology, USP

6Dora Mariela Salcedo Barrientos, Professor in the undergraduate program in Obstetrics at the School of Arts, Sciences and Humanities, USP

ABSTRACT

A pregnant adolescent’s vulnerability increases when she is a victim of intrafamilial violence and drug addiction, which cause physical and biopsychosocial damage to the mother and her baby.

Objective

Present and analyze the case of an adolescent who is addicted to drugs, pregnant and the victim of lifelong intrafamilial violence.

Method

A case study based on a semi-structured interview conducted in the Obstetrics Emergency Unit at the Teaching Hospital of the University of São Paulo. The data were interpreted and analyzed using Content Analysis.

Results

intrafamilial violence experienced at the beginning of the adolescent’s early relationships seriously affected her emotional maturity, triggering the development of psychopathologies and leaving her more susceptible to the use and abuse of alcohol and other drugs. The adolescent is repeating her history with her daughter, reproducing the cycle of violence.

Conclusion

Adolescent pregnancy combined with intrafamilial violence and drug addiction and multiplies the adolescent’s psychosocial vulnerability increased the adolescent’s vulnerability.

Key words: adolescent pregnancy; Domestic violence; drug addiction

RESUMEN

La vulnerabilidad de la adolescente embarazada se acentúa mucho más cuando la misma es víctima de la violencia doméstica y es adicta a las drogas, provocando daño físico y biopsicosocial para ella y su bebé.

Objetivo

presentar y analizar el caso de una adolescente adicta a las drogas, embarazada y víctima de violencia doméstica durante el transcurso de su vida.

Método

Se trata de un estudio de caso, basado en una entrevista semi-estructurada, realizada en el Servicio de Emergencia de Obstetricia de un Hospital Universitario en la ciudad de Sao Paulo. Los datos fueron recolectados, procesados y analizados mediante el Análisis de Contenido.

Resultados

la violencia doméstica vivida al inicio de las primeras relaciones afectivas comprometió seriamente la madurez emocional de la adolescente, lo que provocó el desarrollo de psicopatologías dejándola más vulnerable al uso y abuso de alcohol y otras drogas. Fue constatado también que la adolescente repitió su historia con su propia hija, reproduciendo el ciclo de la violencia.

Conclusión

El embarazo durante la adolescencia, las experiencias de violencia doméstica y adicción a las drogas han potencializado la vulnerabilidad psicosocial de la adolescente.

Palabras-clave: embarazo en la adolescencia; violencia doméstica; adicción a las drogas

Introduction

With the goal of obtaining in-depth research data, this article analyzes the case of a pregnant adolescent who is a victim of intrafamilial violence and addicted to drugs(1).

ADOLESCENT PREGNANCY

Adolescent pregnancy is a high-risk pregnancy that has multiple possible repercussions in terms of psychosocial damage and maternal-fetal health. From the biological perspective, the most obvious risks are as follows: hemorrhage, prolonged labor, long-term complications, prematurity, intrapartum injury, perinatal death and low birth weight. From the psychosocial perspective, risks include dropping out of school, early entry into working life, imbalanced psychosocial integration and little preparation for the development of a satisfactory relationship with one’s children(2).

One study found that the population of adolescent mothers in Brazil decreased from 2001 to 2008. However, this percentage has increased considerably in families earning up to the minimum wage, which indicates a correlation between adolescent pregnancy and family income. This study also demonstrated that adolescent pregnancy affects the education level, particularly for those adolescent mothers who belong to the lowest social class (less than 30%), and concluded that dropping out of school and a lack of participation in the labor market are associated with both adolescent motherhood and the prior socioeconomic condition(3).

Regarding the psychodynamic aspects of adolescent pregnancy, adolescent pregnancy and motherhood can be understood as difficulties in a girl’s psychosexual development that resulting from unresolved childhood conflicts that impede the mourning of the losses of adolescence(4,5).

Early pregnancy originates in an pre-Oedipal fixation, more specifically to the pre-Oedipal mother, as a result of deprivation and overstimulation. Adolescent pregnancy may be understood as an acting related to a girl’s desire to take revenge on her mother because she feels rejected. In this sense, many adolescents become pregnant because they identify with the phallic mother (thus, the showing a pseudo-heterosexuality)(4).

The relationship of adolescents with their parental figures may affect their object-choice. This study demonstrates how the mother’s absence may hinder the establishment of new relationships. The emotional needs caused by this absence, which are expressed by high expectations and over-idealization, prevent the establishment of a relationship based on reality. Thus, frustrations with the real object are unavoidable, and the relationship becomes unsustainable(4).

Thus, early pregnancy would be an acting related to an oral and pre-Oedipal fixation to the mother. When this girl is confronted with the demands of maturation uses the pregnancy as a way of to revive the mother-daughter bonding. In this context, at the level of fantasy fulfillment, the girl’s sexual partner would correspond to the mother’s place in the early relationship, and the sexual act and the subsequent fertilization would correspond to the reestablishment of an idealized mother-daughter bonding(4,5).

In addition, the impulse to become pregnant does not originate in an O edipal desire to have a child or a model of assistant motherhood (as an assistant to the mother to care for the child), much less from a woman’s desire to be a mother. It is more like a compulsive behavior, which may persist and tend to repeat itself. In this sense, there would be no use in controlling this phenomenon through instruction or birth control pills because of the nature of the acting(5).

intrafamilial violence

intrafamilial violence is a problem that reaches far beyond Brazil. Several studies have revealed that violence against children and adolescents occurs worldwide in developed and developing countries(6-8).

Research on the sex lives of adolescents who were maltreated before the age of 12 years found correlations between the experience of childhood maltreatment and early sexual initiation, sexual relationships established with multiple partners, the non-use of contraception and methods to prevent sexually transmitted diseases and adolescent pregnancy(9).

Thus, child abuse (physical, sexual and emotional) becomes a risk factor for victims throughout life. Within the scope of physical health, those who were victimized tend to develop self-injurious behaviors, such as smoking, drinking, drug use and overeating, in addition to having greater difficulty with changing and maintaining healthier habits(10).

Studies have also demonstrated the relationship between trauma (physical or sexual violence) and borderline personality disorder. In a study on 41 patients with borderline personality disorder, 76% of the patients reported being victims of sexual violence in childhood and 50% said that they had suffered continuous abuse(11). Another study found that borderline patients significantly reported failures in maternal and paternal care during childhood, which indicates the importance of psychodynamic theories regarding the childhood of borderline patients and the theory of biparental failure in the development of this psychopathology(12).

In Brazil, one study demonstrated that females are the primary victims of domestic and sexual violence: in 69.83% of the cases, intrafamilial violence, sexual violence and other types of violence was directed against women(13).

intrafamilial violence causes suffering because the abusive experience to which the child or adolescent was subjected causes a psychic imbalance, which cannot be represented or symbolized by the victim(14). Another study also found that intrafamilial violence is a risk factor for child and adolescent development, affecting identity, personality disorders and social adjustment(15).

ADOLESCENT DRUG ADDITION AND PREGNANCY

Young people, who long to establish an identity and face the anguish of not knowing “who they are”, may identify with negative figures (e.g., criminals and drug addicts) or initiate a sexual life early as a manic defense organized to force the onset of an existential feeling and the sense or identify in order to control the strong feeling of “not being”(16). A study conducted with women dependent on crack cocaine demonstrated that users exposed to trauma during childhood or adolescence start using drugs at earlier ages than those whose trauma occurred in adulthood(17).

Studies have indicated that factors such as dysfunctional families, truancy, unemployment and low professional training contribute to the maintenance of an unfavorable socioeconomic situation and to the high prevalence of cocaine and marijuana use by pregnant adolescents and those with psychiatric disorders(18,19). Another study that corroborates these results found that the use of chemical substances, such as marijuana and alcohol, is correlated with the phenomenon of adolescent pregnancy because in many cases experience with drugs precedes adolescent pregnancy. Thus, these substances were used more frequently among adolescents who became pregnant than adolescents who did not become pregnant(20).

Therefore, this article’s purpose is to present and analyze the case of a pregnant adolescent who is a victim of intrafamilial violence and addicted to drugs.

Method

This is a case study, which is an approach that should be used when “a) the questions ‘how’ and ‘why’ are proposed; b) the researcher has little control over events; c) the focus is on a contemporary phenomenon in the context of real life”(21). This same researcher states that this type of empirical research applies when the intent is to thoroughly understand a phenomenon that is currently occurring in real life, and whose understanding is linked to “important contextual conditions”(21). Thus, the case study serves to explain, describe, illustrate and examine highly complex situations that cannot be explained by simple cause-and-effect reasoning.

This study was conducted on a pregnant adolescent who sought treatment in the Obstetrics Emergency Unit (Pronto Atendimento - PA) at the Teaching Hospital of the University of São Paulo (Hospital Universitário da Universidade de São Paulo - HUUSP), which is located on the University of São Paulo (Universidade de São Paulo - USP) campus(1). The instrument used was a semi-structured interview, which was recorded and transcribed, ensuring anonymity and confidentiality. The study respected the participant’s privacy and intimacy and ensured her the freedom to participate in this process or to decline at any time, following the recommendations of the National Health Council according to resolution no. 466/2012.

The adolescent participant’s legal guardian signed the consent form and the adolescent signed the assent form. All ethical precepts were followed, and the study was approved by the HUUSP Ethics Committee (Opinion no. 1214/12 and Record SISNEP-CAAE: 0043.0.196.198-11).

The data obtained in the semi-structured interview were interpreted and analyzed according to Content Analysis(22).

Results And Discussion

Taís1 is 18 years old and pregnant. As a child, she was abandoned by her mother and father. Her mother is a drug user (crack cocaine) and lives on the streets. Taís was raised by her maternal grandmother, who is an alcoholic. The grandmother physically abused and was negligent with her granddaughter. The adolescent describes her life as one of suffering. She would prefer to live on the streets than in her grandmother’s house because of the maltreatment she experiences at the hands of her grandmother.

Taís says that she married when she was 12 years old and separated from her husband when she was 16. Soon after the separation, she met her current partner, Wagner (30 years old), who is the father of her unborn child. When Wagner was 24, he suffered a spinal cord injury as a result of taking a “shot the wrong way”, and he became a paraplegic. He was once a drug user. However, by the time Taís met him, he no longer used illicit drugs and only consumed alcohol. Taís thinks he is very “smart” and considers him to be a person who helps her when he can, talking with her and being welcoming to her.

Taís began to smoke marijuana when she was 15 years old, influenced by her ex-husband. At approximately 16, she began to use cocaine after being encouraged by a friend. Although she is unable to stop using drugs, she denies being addicted to them. For her, a drug addict is someone who begins to steal inside and outside the home to buy drugs, and because she does not have this attitude, she does not view herself as a drug addict.

Regarding her socioeconomic condition, Taís is a pregnant adolescent from a low social class. She dropped out of school during the 8th grade and is not employed. She lives with her partner at his mother’s house, where there are four adults (Taís, Wagner, the mother-in-law and a brother-in-law) living in three rooms. Only her mother-in-law is employed. Her partner receives disability retirement payments.

Discussion

Based on its psychodynamic aspects, Taís’s life story demonstrates that she had no opportunity to experience her spontaneity, i.e., her process of continuity of being(23). That is, the development of the process of continuity of being was interrupted. Already in the first moments of her life, she could not act according to her needs. Instead, she had to react to defend herself from a threatening environment. The result seems to have been the development of a pathological false self, which was created to defend and protect the true self.

The process of ego maturation moves naturally toward the creation of an integrated self. However, this maturation depends on whether the children felt that their ego was protected in their relationship with their mother. When environmental failures are continuous, numerous unthinkable agonies are felt, thus constituting a pattern of the self’s discontinuity and fragmentation. In psychopathological terms, the ego development is overwhelmed, which can frequently occur in cases of intrafamilial violence. The lack of protection felt since the beginning of life prevents ego maturation and hinders the ability to establish a healthy relationship(24).

All individuals create a true and a false self. However, each person’s process of creating and organizing the self occurs in a different way. The true self relates to spontaneity. If a baby had the chance to experience his or her impulses spontaneously, the baby will create a true self with the capacity to continue maturing and a false self that would only have the function of constructing a bridge between the true self and external reality. However, this process is only possible when the mother satisfies the baby’s needs, i.e., enables the baby to experience the illusion of omnipotence. Nourishing this illusion is key to strengthening the baby’s fragile ego and enables babies to experience their own impulses and appropriate what is theirs. This entire process results in the capacity to imagine, play and create, thus establishing the foundations of symbolization(25).

However, if the mother cannot satisfy the baby’s needs, leaving the baby susceptible to maternal needs or the instability of the environment, a defensive and pathological false self is eventually created in response to the threatening and inhospitable environment. Thus, the false self is created to defend the true self. Individuals who have had a failure in their development of self, in which the true self is the only living, yet unexplored, may spend much of their lives mimicking the environment, while outwardly appearing to be healthy. However, the mask can fall at any time, or rather, at an emotionally demanding time.

The absence of a welcoming environment, of a “good enough mother”, sufficiently responsive to the child experiences, upset Taís’s emotional maturation. Immaturity is a characteristic of adolescence(26). However, in this case, the re-creation and re-signification of endogamous relationships are experienced in an even more turbulent and distressing manner because of the failures of her early relationships.

An analysis of a “borderline case” demonstrates that “her subjective condition seems immersed in the psychic death of distrust and despair, paradoxically expressed in agitation”(27). “She is suspicious, easily adapts to the environment (false self) and displays antisocial and predatory behavior (she robs a clothing store and exploits her closest friendships)”(27). This person is in a continuous process of object disinvestment “due to the essential failure of the primary object, which cannot be found, then any possible good objects are subjected to predatory action, indifference and denigration; they tend to turn to dust, to hardly anything at all, to nothing”(27). However, the person tries to counteract this movement and searches for object relationships, real relationships. However, in this case, what is objectualized is an unreliable object, i.e., the person’s primary object. Thus, the person ends up obsessively engaging in a romantic relationship with someone who used and abandoned her.

Comparing the person described above with Taís, it is clear that Taís ended up unconsciously choosing unreliable individuals, such as her mother. Thus, unable to symbolize her anguish and feelings, Taís continues to reproduce the injuries and failures of her history. The adolescent ends up establishing relationships with unreliable individuals. That is, she interacts with individuals who use and deal drugs, rob and murder. She feels that these “wrong people” are close to her, and she interacts with people in an environment similar to the one in which her mother lives: on the streets with individuals who use drugs. Thus, in an unconscious search to feel genuine in relationships, the adolescent interacts with unreliable objects, as her primary object was.

According to the analysis of another patient, the only genuine aspect of her relationships was “the lack or lacuna, that is, death, absence or amnesia”(28). In this case, the negative is the only thing that is felt to be genuine and therefore positive. Similarly, for Taís, only relationships similar to that of her early relationship are felt to be genuine.

Taís also adapts easily to her environment. For example, she states that she started using marijuana because her first husband used it. She started using cocaine in a similar way: after seeing her friend using it, she said she became curious. However, her first experience with cocaine was devastating. Taís states that she used cocaine for eight consecutive days, eventually losing 10 kilograms. Notably, these eight days were the same days during which Wagner was hospitalized because of an ulcer.

Here, it seems that Taís mimics her environment, an action that the pathological false self develops very well. That is, she becomes the environment that surrounds her. When she is with Wagner, she is in the world in which she lives with him. When she is with her friends, she enters the world of her friends.

Drugs assume an important function for Taís. They reduce her distress, fill her feeling of void and mask her emptiness. Temporarily, everything is perceived as beautiful, whole and good. The use of stimulants and anesthetics among borderline patients is common. “Stimulants are used in an attempt to recover a sense of life that opposes death from emptiness. Anesthetics protect the borders of narcissistic wounds and offer an artificial substitute for the satisfaction and calm of Nirvana. Both contribute to maintaining a state of almost symbiotic lack of differentiation between the self and its surroundings”(27).

From a psychoanalytic viewpoint, borderline patients would be those who construct a pathological false self in situations that are not conducive to maturation to protect the completely immature and fragile true self, as in the case of Taís(25). Similarly, from a psychodynamic perspective, the term “borderline” designates a singular personality structure, which is characterized by an extremely unstable, oscillating dynamic that is full of abrupt transitions as well as advances and retreats and that would reveal the two great anxieties present in one phase of the separation-individuation process. In these cases, the most commonly identified defense mechanisms are splitting and the low-level defenses: early idealization, projective identification, denial, omnipotence and devaluation. Drugs, primarily cocaine and heroin, trigger this idea of the primitive self (i.e., magical and omnipotent) who defends the self from the bad object and persecutory feelings(30).

From a psychiatric perspective, the essential characteristics of a person with borderline personality disorder are personality and functional (i.e., self and interpersonal) impairment and the presence of pathological personality traits. The criteria described in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders(29), include the following: impairments in ego functioning (i.e., markedly poor self-image, chronic feelings of emptiness, instability in goals and aspirations), impairments in interpersonal functioning (i.e., an impaired ability to recognize the feelings and needs of others with a tendency to feel underappreciated; intense, unstable and conflicted intimate relationships marked by mistrust, neediness; and an anxious concern with real or imagined abandonment) and pathological personality traits (i.e., negative affectivity (which consists of unstable emotional experiences and frequent mood swings), anxiety regarding the negative effects of unpleasant past experiences and negative future possibilities and low self-esteem. Disinhibition refers to actions in the heat of the moment, difficulty establishing or following plans, engaging in dangerous, potentially self-damaging situations, a lack of concern for one’s limitations and a denial of the reality of personal danger)(29).

Taís’s projective identification can be perceived at different moments. Because there was no integration of the self in this case, good and bad objects are split off from one another in the internal world. The psychodynamic of borderline patients is grounded in divisions, unlike that of the neurotic, which is marked by conflict(27).

The boundaries of the internal and external worlds of these patients are not delimited. Rather, they are loose and porous, and the inner world extends into the outer world. Projective identification is one of the defense mechanisms that demonstrating this lack of delimitation. These patients are confused with their environment or feel persecuted. Taís thinks that she is not a good person because of her history, in which she did not have enough good experiences to enable the internalization of good objects. She says, “everyone speaks badly about me, they always did”. When she was a student, she also believed she was the “terror of the school” because everyone (i.e., her grandmother and those in her school environment) could only perceive her in this role. The absence of magically introjected good objects(28) can be observed in the following statement by Taís: “My daughter is going to make me very happy! She definitely won’t be like I was; she’ll be a responsible woman, a responsible person, caring, with the necessary education to be different”. For Taís, her daughter and Wagner seem to represent the good objects of her inner split world, whereas she represents the bad object. The external world appears to be an extension of her internal world. This condition may be defined as split fields of mental experience. Typically, these experiences can (or should) dominate the psychic world through more usual patterns. However, they may be reversed, passing from good to bad and bad to good, which occurs because the experiences are fragmented into representations (some good and others bad).

With respect to pregnancy, Taís actually acts and displays primitive defenses when referring to her daughter, which typically occurs in cases in which the mother was absent during early infancy(4,5). For example, the adolescent idealizes family situations that she never experienced. She imagines a wonderful relationship of motherhood that she wishes to provide her daughter. However, she exhibits insecurity and low self-esteem about establishing this relationship, likely because she never had a “good enough mother.” For Taís, the good object that she projects is her daughter, whereas the bad object is herself. In these cases, early pregnancy does not contribute to the development of true motherhood. Rather, it provokes “an even greater inhibitory effect”(5).

Idealization clashes with reality and creates an even greater frustration. Taís idealizes that her relationship with her daughter will be different from her relationship with her own mother. However, we observed attitudes contrary to what the adolescent states because even though she was pregnant, she continued to use licit and illicit drugs.

Regarding motherhood, developing the ability to be a mother only occurs because a woman has experienced the care of a sufficiently good mother when she was a baby. This experience of comfort and safety is psychically and bodily recorded(23). Although Taís states that she wants to be different from her own mother, given the long record of violence experienced throughout her life, she ends up repeating her own experience of maltreatment and neglect, now with her daughter, through the use of drugs.

In the case of Taís, one can also observe the lack of perception that the adolescent has regarding her body. Taís seems oblivious to the daughter inside her. Here, it is worthwhile to review the concept of depersonalization: a loss of connection between ego and body, including the id’s impulses and satisfactions. This dynamic occurs in patients with a pathological false self(24). In the case of Taís, because there was no such integration, the psyche and soma have also not been unified. Thus, her impulses cannot be felt to be her own, which results in the depersonalization witnessed in this adolescent.

In addition, two paradoxical characteristics of borderline patients can be observed in this case: “they are both impulsive and excellent observers of others and themselves”(27). In intensely schizoid moments, borderline patients are capable of reporting impressive self-observation. However, in expansive moments, they completely ignore certain aspects of external reality.

At one moment, Taís can perceive herself as a sad person who is suffering. “I’m thinking about things. Suffering, crying, thinking about everything. A lot of bad things. Criticisms, people saying bad things... Former classmates, former friends, family…”. At another moment, she can spend eight days using drugs. The only task for borderline patients is to exist, “exist painfully”(27), and Taís describes her life as a one of suffering: “It’s suffering, because I didn’t live with my mom, I didn’t live with my dad, my grandma always drank. I lived more on the street than at home, I didn’t have a family, I didn’t have anyone. I suffered. She (Grandma) hit me a lot and I’d rather be on the street than at home; at least on the street she couldn’t hit me. So every time she drank, I went to the street, stayed on the street”.

Conclusion

This article demonstrates how the intrafamilial violence experienced in early relationships eventually undermined the process of Taís’s emotional development. She ended up developing severe psychopathological problems.

Adolescence is an intense and turbulent time and entirely depends on how each person experienced this process. In the case presented, Taís revives and resignifies her affective relationships based on previous experiences, i.e., based on mistrust, instability and maltreatment, which culminated in the abuse of licit and illicit drugs and adolescent pregnancy.

This recognition contributes nothing to the process of Taís’s maturation. On the contrary, the adolescent is already displaying signs that she will repeat her own history with her daughter. Although she consciously does not want this repetition, her attitudes signal that it will occur.

Thus, intrafamilial violence, drug abuse and early pregnancy act cumulatively as risk and vulnerability factors for the adolescent. They are a strong impediment to the healthy maturation of the adolescent and her baby and should be a key focus of research and preventive and interventive actions.

ACKNOWLEDGMENTS

The authors thank the São Paulo Research Foundation (Fundação de Amparo à Pesquisa do Estado de São Paulo - FAPESP) for granting a post-doctorate scholarship to conduct this research and the Brazilian Federal Agency for Support and Evaluation of Graduate Education (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) for granting a master’s scholarship.

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1Fictitious name, interviewed with consent.

Received: April 30, 2014; Accepted: July 16, 2014

Correspondence Paula Orchiucci Miura, Endereço: Av. Prof. Mello Moraes, 1721 Bairro: Cidade Universitária CEP: 05508-030 São Paulo/SP - Brasil Telefone: (11) 3091-4173 paulamiura@hotmail.com

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