Self Psychology and Male Child Sexual Abuse: Healing Relational Betrayal

Clin Soc Work J DOI 10.1007/s10615-013-0453-2 ORIGINAL PAPER Self Psychology and Male Child Sexual Abuse: Healing Relational Betrayal Ramona Alaggia...
5 downloads 2 Views 185KB Size
Clin Soc Work J DOI 10.1007/s10615-013-0453-2

ORIGINAL PAPER

Self Psychology and Male Child Sexual Abuse: Healing Relational Betrayal Ramona Alaggia • Faye Mishna

Ó Springer Science+Business Media New York 2013

Abstract The prevalence of male child sexual abuse (MCSA) is higher than initially thought with up to 26 % of men in community samples reporting sexual abuse in childhood, and up to 36 % of men in clinical samples reporting childhood sexual abuse. Disclosure of MCSA is complex because of men’s difficulties in viewing themselves as victims, especially of sexual violence. This difficulty is exacerbated by societal attitudes that sexual abuse rarely occurs with boys, and is further complicated with the taboo of victimization by same sex perpetrators. Too often, the response to disclosure is disbelief and minimization. For these reasons disclosure is often delayed or withheld thus prolonging the abuse. The negative effects of child sexual abuse are well documented and far reaching with depression, anxiety, post-traumatic stress disorder, addictions, sexual dysfunction and impaired interpersonal relations as common presenting issues in therapy. Treatment is indicated for significant numbers of male survivors. This paper identifies aspects of interpersonal relational difficulties commonly experienced by male sexual abuse survivors, and describes self psychology as guiding a clinical approach to address these interpersonal difficulties. The application of self psychology with male sexual abuse

R. Alaggia (&) Factor-Inwentash Chair in Children’s Mental Health, FactorInwentash Faculty of Social Work, University of Toronto, Toronto, Canada e-mail: [email protected] F. Mishna Margaret and Wallace McCain Chair in Child and Family, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada e-mail: [email protected]

survivors is traced and discussed through the use of a clinical case study with Adam. Keywords Male child sexual abuse  Self psychology  Relational therapy  Disclosure  Empathy  Clinical case study

Introduction The recent exposure of several high profile cases involving historic long term abuse of boys has brought to light the issues of sexual violence against boys, a longstanding phenomenon which has been denied, obscured and covered up (Finkelhor et al. 2008; Globe and Mail 2012; Gartner 1999). The criminal conviction of football coach Jerry Sandusky, and sanctions levied against Penn State University for Head Coach Joseph Paterno’s role in helping to conceal these sexual crimes, is but one of many examples that have been surfacing across North America (New York Times 2012). In Canada Graham James, a hockey coach in the minor hockey league was convicted of sexually abusing young players when two of his victims came forward and disclosed to authorities (Globe and Mail 2012). Most notably famed hockey player Theron Fleury in his book ‘‘Playing with Fire’’ wrote about the sexual abuse he was subjected to at the hands of James (Fleury 2009). Martin Kruze, an aspiring young hockey player in Toronto, disclosed the sexual abuse he and other boys endured for decades, by Toronto Maple Leaf Gardens staff, that led many of the victims to come forward and seek justice before he took his life in 1997 (Vine and Challen 2002). These particular occurrences are not to the exclusion of other emerging cases, such as those involving clergy, and cumulatively they represent large scale organizational/

123

Clin Soc Work J

institutional abuse. As well, incidences of offences committed against boys within families, and in their communities by trusted people in family-like roles have also been clearly documented (Finkelhor et al. 2008). The prevalence of male child sexual abuse (MCSA) is higher than initially thought with as high as 26 % of men in community samples reporting having experienced sexual abuse in their childhood (CSA), and up to 36 % of men in clinical samples reporting MCSA (Cawson et al. 2000; Fergusson et al. 1996; Finkelhor et al. 1990, 2008; Putnam 2003). In one meta-analysis on the prevalence of MCSA in North America the authors found rates of 13–16 % in the general population and 13–23 % in clinical samples (Polusney and Follette 1995). In another review, investigators found the rate of CSA for men to be between 3 and 13 % (Bolen and Scannapieco 1999). An international review of large population-based studies in 19 countries found a range of MCSA prevalence rates from 22 to 26 % (Finkelhor 1994), and one US study found that 6.7 % of the boys interviewed in their sample of 2000 reported some kind of CSA in the past year (Finklehor et al. 2005). While these studies represent best scientific efforts to uncover the rates of MCSA, these statistics are likely an under-representation since disclosure and reporting is generally low (Alaggia 2005; Arata 1998; Staller and Nelson-Gardell 2005; WHO 2004). Studies of the long-term psychological impact of MCSA show that victims are at greater risk for a host of negative effects including major depression, suicide, addictions, post-traumatic stress disorder, anxiety disorders, personality disorders, sexual identity issues and sexual dysfunction (Chen et al. 2010; Cutajar et al. 2010; Dube et al. 2005; Putnam 2003; Walrath et al. 2006). The sum effects of these mental health consequences are the toll they take on the survivor’s ability to experience fulfilling intimate relationships, healthy social relationships, achieve work life satisfaction, or attain a general state of well-being (see Putnam 2003 for a full review of CSA effects by gender). While these symptoms, or combinations of symptoms, will be unique to each individual, survivors often experience profound interpersonal relationship difficulties as a result (Dube et al. 2005; Nelson 2009; Putnam 2003). The effects of child sexual abuse are often exacerbated by the length of time it typically takes for disclosure to occur (DeBellis et al. 2011; Nelson 2009). Disclosure of MCSA specifically is complex because of men’s difficulties in viewing themselves as victims, especially of sexual violence, which reflects societal attitudes that sexual abuse of boys rarely occurs. Further complicating the difficulty of disclosure is the taboo of victimization by same sex perpetrators since the majority of sexual offenders of children are male and the questions this raises about sexual identity (McCloskey and Raphael 2005). Male victims’ sense of

123

responsibility in the sexual abuse can be distorted because of any associated physiological responses. For example, a boy experiencing an erection with the offender observing and/or commenting on it, or suggestions that arousal implies willingness, are likely to confuse the child about his role and participation in the sexual abuse act. Lacking the cognitive and reasoning ability to understand their response as no more than a physiological response and not a sign of willingness, can create persistent cognitive distortions about their complicity in the abuse -this is clearly a deterrent to disclosure. Some research suggests that victims of MCSA fear being viewed as having the potential to sexually offend, subscribing to common beliefs that female victims are at risk for becoming adult victims and that male victims are destined to become adult offenders (Alaggia 2005; Gartner 1999). Preserving their family when the offender is a relative is another motive for withholding disclosure (Paine and Hansen 2002). Finally, repression and intentional forgetting may be defense mechanisms at play when disclosure is significantly delayed (Alaggia and Millington 2008). Often compounded by delayed disclosure, and/or disclosure that was minimized or denied by others, the impact on interpersonal relationships can be major, difficulties that can be profound and run deep. The literature cites numerous problems in the ability to trust, ambivalence in intimacy, distancing and clinging behaviors, control issues, and feeling isolated and feeling different from others (Alaggia and Millington 2008; Holmes and Slap 1998; Lisak 1994; Nelson 2009; Putnam 2003). To address the interpersonal relationship difficulties faced by a number of MCSA survivors this paper applies self psychology as one therapeutic approach. This therapy is not recommended to the exclusion of other treatments which may be deemed necessary in order to address various issues such as post-traumatic stress disorder (PTSD) and anxiety (e.g., cognitive behavioral therapy) or addictions (e.g., harm reduction and 12 step programs). Trauma focused cognitive behavioral therapy has been heralded as one such evidence based treatment for adult survivors of sexual assault and should be kept in mind for treating PTSD symptoms (Feeny et al. 2004), along with psychotherapy approaches being recognized as effective interventions (Taylor and Harvey 2009). However, it is beyond the scope of this paper to review all treatments for the effects of sexual abuse. Rather, the intent of this paper is to offer the application of selfpsychology as an approach to complement other treatments or to be the used as a long-term intervention. Self Psychology Self psychology is a psychoanalytic therapeutic framework and a relational therapy that grew out of classical

Clin Soc Work J

psychoanalysis, departing from classical thinking in specific ways (Ornstein and Kay 1990). Heinz Kohut developed an analysis that focusses on clients’ subjectivity and sense of self rather than objective functioning (Kohut 1971, 1977), with an emphasis ‘‘on the person’s subjective sense of cohesion and well-being rather than on the supposedly objective functioning of various aspects or parts of the self’’ (Flanagan 1996, p. 173–174). The theoretical premise is that a combination of repeated empathic parental failures and the child’s responses ranging from adaptive to maladaptive, results in the development of or the lack of internal psychic structures. These internal structures are needed for a person to regulate affect, have good selfesteem and to calm oneself (Baker and Baker 1987). Kohut (1984) conceptualized selfobject experience as ‘‘that dimension of our experience of another person that relates to the person’s functions in shoring up our self’’ (pp. 49–50). He further elaborated on this to mean that early experiences may at times carry forward into the present in problematic ways (Kohut 1984). Selfobjects are those people or activities that complete the self, which in the early years are usually the primary caregivers. Based on past and present attainment of selfobject needs, a healthy person will develop a sense of cohesion and well-being of the ‘‘self.’’ If these selfobject needs are not attained overall however, problems in the self occur with varying degrees of psychopathology (Ornstein and Kay 1990). Kohut first described two selfobject needs: (1) mirroring, which consists of loving admiration and validation; and (2) idealizing, which comprises reassurance, calming and strength of another person on whom to rely. In his later work he identified a third need: (3) alter-ego or twinship, which involves a sense of essential likeness with others (Baker and Baker 1987). Kohut’s original list has been expanded by others who have added, for instance, adversarial and efficacy selfobject needs (Lichtenberg 1989; Wolf 1988). During early development children are dependent primarily on parents/caregivers to meet their selfobject needs. In the middle years selfobject needs may also be met by teachers, extended family and friends. Later, in adolescence, peers increasingly become a source of selfobject experiences. The theory is rooted in the foundational idea that child development is inter-connected with their environment, and that people cannot be viewed in isolation from their environment, a notion that is highly compatible with ecological developmental theory (Baker and Baker 1987; Rasmussen and Mishna 2003). Empathic responses are intrinsically linked with attaining selfobject needs, and persistent or significant failures in empathic responses can result in a person becoming highly vulnerable and dependent on others in order to have their needs met, or who becomes detached and isolated as a result of anticipating that their selfobject needs will not be

met (Baker and Baker 1987). In Kohut’s work human behaviour is understood to be motivated by the need for connection and a cohesive sense of self (Rasmussen and Mishna 2003). Maturity requires sufficient empathic responses and it is stressed that selfobject needs can be sought and attained at any stage of development well into the life cycle (Kohut 1984). Kohut’s original conception of empathy was referred to as ‘‘vicarious introspection’’ which later evolved into a broader term of empathy (Kohut 2010). Empathy is central to therapy informed by self psychology, with the premise that the therapist must address the client’s subjective meaning of self (Roughton and Dunn 2003). The therapist is required to immerse herself in understanding the world of the client and participate with the client in interpreting the client’s psychological processes through selfobject transferences (Kohut 1984). Emotionally corrective experiences lie at the heart of self psychology, as do exploration of disruptions in the therapy. Mirroring, validating and twinship transferences become therapeutic vehicles to strengthen the client’s self, wherein vulnerabilities and disruptions in the therapeutic work are identified and worked through (Ornstein and Kay 1990). Working through the transferences, and opportunities to experience mirroring and validating in the therapy are considered core elements of the therapeutic work (Baker and Baker 1987). The client’s experience of being understood and accepted in the therapeutic relationship, however, serves to strengthen one’s sense of self. It should be noted that by immersion into the client’s subjective world, because a deep level of understanding is required for empathy, the therapist is undeniably affected by the material especially if it is traumatic in nature. Kohut (1984) argued that therapy should be more involved with the patient than with analytical theories. To that end the focus of this paper is to follow the case study of Adam, a survivor of CSA, in order to illustrate the concepts of empathy and two examples of selfobject needs, as they operate in the therapeutic work. The next section of this paper will illustrate the application of self psychology, highlighting examples of empathy, and selfobject transferences of mirroring and idealization as these manifested and were worked through in the therapy. As well, impact of the client’s therapy material on the therapist will be addressed.

Case Study In observing the ethics of confidentiality, identifying features of the case presented, that of Adam, have been changed to protect his privacy. A composite of the case has been developed to illustrate common factors associated

123

Clin Soc Work J

with MCSA. Aspects of his case are highlighted to exemplify how self psychology concepts are used in the therapeutic work. Adam, a 39 year old trades worker, was sexually abused between 11 and 14 years, by a man who was a friend of his family. He told his mother when he was 13, who then told his father. Their reactions were mixed. His father could not believe this initially but eventually came around. His mother believed Adam but took no concrete action to have the abuser confronted or to have his father take action. His parents told Adam to stay away from the man and severed their friendship with him. Adam was disappointed with their reaction but didn’t know what else he expected them to do. Later in life Adam (39) sought counseling after spending 90 days in an alcohol treatment rehabilitation center. He entered the facility after a crisis -‘‘his wake-up call’’. He was in a motor vehicle accident in which the driver of the other car was seriously hurt. He was not under the influence of drugs or alcohol at the time of the accident but was hung over from a weekend binge. His wife, Celia (38), took a stand at that time suspecting the accident was related to substance abuse, and together with their family physician met with Adam to tell him he needed to seek inpatient treatment for his addictions. Adam was employed at a community college as an electrician and his workplace supported him through an employee assistance program granting him a disability leave. During in-patient treatment Adam disclosed the sexual abuse. This was the first time it was fully acknowledged—by the counselors and members in his therapy group. Many feelings surfaced for Adam during treatment and since he was not using substances to medicate these feelings away he became symptomatic and had problems sleeping and eating, and experienced anxiety attacks and intrusive thoughts. He received a course of cognitive behavior therapy (CBT) to help alleviate his symptoms of anxiety and depression. Adam was clean and sober for 9 months when he decided to seek intensive therapy for the underlying issues, -many which were related to the abuse, his parents’ response and his feelings of low self-worth. Although CBT helped manage his symptoms he continued to experience interpersonal problems in his relationships, which is common in the aftermath of sexual abuse. While abusing substances Adam he was extroverted, the life of the party, whereas at home and

123

work, he acted out his rage in his relationships; he was critical of people and short-tempered; he drove recklessly; and he was financially irresponsible. Celia over functioned in the relationship cleaning up his messes with friends and family and keeping him on an allowance. She cared deeply about him and wanted to make the marriage work. She was aware of the abuse but not of the depth of it, although she knew Adam did not want children as a result of his childhood experiences. Their sexual life was affected by the drinking and history of sexual abuses marked by Adam’s need to be in control (e.g., initiating) and often he could not ejaculate. Adam began seeing a female therapist, weekly. He sought a female therapist specifically because his abuser was male and he could not see himself working with a male therapist. After a month of sessions Adam felt he was not up for the work and wanted to decrease the sessions. He found it intense and was flooded with feelings that took him days from which to recover. He wondered if she really understood what men go through when they have been sexually abused and especially by a man. Adam’s abuser had been his father’s friend since high school. He frequently had boys over to his house which was a playground for them—video games, satellite television, state of the art electronics, pizza parties and eventually beer.

Empathy In the therapeutic work with Adam, according to self psychology theory, empathy is considered integral to both human development and to the therapeutic process (Kohut 1984). The therapist must be acutely attuned to Adam’s subjective story and try to understand Adam’s world and experiences from his perspective. It is to be expected however, that the client’s previously frustrated selfobject needs will be reactivated in the context of an empathic connection with the therapist (Kohut 1984). The reactivation of these longstanding needs may produce the fear of re-experiencing the trauma that reverberates from previous selfobject failures and from not having the needs met (Rasmussen and Mishna 2003). Not surprisingly Adam began to question whether his therapist could understand or relate to his traumatic experiences. These anticipated fears and/or actual empathic failures on the part of the therapist trigger defenses and/or ‘resistance,’ which are best understood as the client’s attempt to protect the self from further hurt and trauma (Kohut 1984; Ornstein 1978). Adam’s overtures to slow down the sessions were a signal to his therapist that she was

Clin Soc Work J

possibly not ‘‘getting’’ him. It was important that she did not interpret this as simple resistance to be understood and addressed but rather it was critical to view Adam’s suggestion to slow down as his need to have her understand him and his hesitancy to cross the next threshold of disclosure, which involved his self-perceived complicity in the abuse. He was fraught with confusion about his conflicted feelings of pleasure and shame during the sexual abuse; affection and sex; arousal and revulsion. He enjoyed the attention, games, and the permissive atmosphere and returned despite the abuse. Adam understandably believed this adult to be a trustworthy person in his life, who over time committed a profound betrayal of Adam’s trust. Developmentally Adam was entering puberty, a critical time for sexual development. Thus his comment regarding being abused by a man was a reference to the complex questions raised about his sexual preferences and orientation. Although he identified as heterosexual as an adult he was abused by a male in non-consensual sex relations during the formative years of his sexual development. Empathic failures are considered inevitable, caused by a range of situations such as the therapist disappointing and/ or misunderstanding the client. When such disruptions occur it is important to examine and understand the rupture from the subjective perspective of the client, which may differ from that of the therapist (Lachmann and Beebe 1995; Wolf 1988), which can in turn lead to shared understanding and change (Wolf 1988). In Adam’s situation his full disclosure to his therapist would activate for him his previous disappointments/trauma because his parents had been at a loss to take appropriate action in response to his disclosure of having been sexually abused by his father’s old friend. In fact, his parents put the onus on Adam to protect himself from the perpetrator by instructing him to have no further contact with the man. The abuse had started slowly and insidiously with Adam and the ‘‘grooming’’ process included subtle ‘bribes’. Adam felt guilt for going over so often but he wanted to have fun with the toys and each time thought it wouldn’t happen again. Eventually he was coaxed by his abuser to bring friends over and Adam sensed that they were on the ‘hit list’ as well. Adam initially could not tell her about his desires to keep going back and for what he perceived as his recruitment of other boys. He felt deep shame. His therapist encouraged Adam to continue therapy at the same pace believing that he was making headway, as painful as it was. She was unaware of his deeper shame because of what he believed was his participation in the abuse. Clearly issues of trust were beginning to come into play. He wondered if she would continue to have positive regard for him if he confessed his conflicted feelings, or

whether he would be judged, or whether like his parents she would take no action. It was important to sustain a measured pace of treatment so that empathy could be strengthened and to allow a ‘‘holding environment’’-a secure, safe therapeutic space to process strong affect (Winnicott 1965). It was important that Adam eventually felt safe enough to speak of his guilt because of having involved other boys with the perpetrator. Although he was not certain, he thought these boys have may have been eventually abused as well. The therapist temporarily shifted the focus of the sessions to spend time getting to know Adam as a person, in the present, apart from the abuse and prompted him to discuss relational issues especially with Celia. This was an important shift as he was then able to deal with his most intimate relationship. He was able to speak of his feelings about letting Celia down because he did not want to have children. He also described feeling distant from people in a generalized way even though on the surface this wasn’t evident. He often felt like an outsider looking in. He revealed that he regularly became remorseful for all he had put Celia through and would beg her to not leave him. At other times he was aloof and unresponsive to her needs. According to Adam he did not understand what motivated these actions. Selfobject Needs Mirroring Eventually Adam disclosed to the therapist his feelings of shame and guilt, and his entrenched belief system that he had somehow participated in the abuse. Once he acknowledged these feelings Adam wept in session after session, and sometimes was unable to speak for most of the session. His therapist was now turning her attention to the intense transference issues of validation and mirroring that were emerging. She listened and waited, reminding Adam that he was a child at the time and that despite how he felt he was not responsible for an adult’s actions to manipulate him. She validated his feelings, and talked about the trickery used by the abuser to box Adam into a corner. At other times the therapist simply let him cry and mourn the losses he had experienced as a result of the abuse, hearing and bearing his intense pain and shame. At this point therapeutic mirroring played a vital role in the therapy wherein his therapist provided a holding environment for the expression of a wide range of emotions. Many of the emotions with which Adam was dealing, such as rage, were ones he was not able to process during or after the period of sexual victimization. The intense painful feelings also related to Adam’s traumatic disappointment in his parents when he disclosed. This build-up of intense emotions

123

Clin Soc Work J

needed to be recognized, acknowledged and validated— mirroring that was not provided at the time of the trauma. Idealization The therapist began asking Adam, looking back, to consider how he would have wanted his parents to have responded when he disclosed the sexual abuse to them. She was aware that Adam had expectations of her as well, to react in certain ways thus setting the stage for an emotionally corrective experience. This ongoing conversation continued the process of Adam being able to have his selfobject needs met in the present through the idealization transference which comprises reassurance, calming and strength of another on whom to rely. These needs surfaced in the next phase of therapy through his therapist’s probes about his parents’ response to his disclosure. Initially he brushed off these probes with comments such as ‘‘what could they have done?’’ The therapist persisted over a few sessions however, and one time Adam said to her that it came to him suddenly that he would have wanted his parents to involve the police. She pursued this further and asked if that was something he wanted to do now, for example to press charges or at least explore the idea. This line of inquiry created an emotional crisis for Adam over the next several months, one which his therapist had not anticipated. He was angry in some sessions, cancelled other sessions, and overall began to experience noticeable swings. Eventually Adam began to articulate and explore the idea of bringing the abuser to justice along with all of the associated ambivalence, including his desire to contact the other boys, now grown men, who might have also been abused. Ultimately he had to come to terms with an aspect of the abuse he had wished to avoid but no longer could, that is, his involving other boys. In examining the question of pursuing criminal charges, Adam and his therapist carefully explored what he hoped would be the outcome of involving the police, trying to account for both positive and negative implications. For example, historic sexual abuse allegations are difficult to prosecute. How would he feel if little came of an investigation? Or how would he react if his case went to court and the perpetrator was acquitted or received a minimal sentence? Before he could proceed, Adam realized that he had to dialogue with Celia and his parents, and that he had to confront how they might react to him bringing up the painful past by pursuing criminal charges. Celia felt reluctant as she worried that Adam might be setting himself up for disappointment if things did not go his way. She felt the odds of retribution were low. When he eventually spoke to his parents they were able to respond more supportively than when he was a child. Time had passed and they had reflected on and regretted their meager response. They truly

123

had not known what to do. In the end Adam decided not to pursue legal action. However, with his consent, his therapist contacted local child protection services, who determined that they were not able to locate the alleged perpetrator in question. Yet, the process of considering legal avenues and having conversations with his wife and parents, left him with a greater sense of calm. Throughout this process Adam experienced his therapist as someone on whom he could rely, who remained calm and reassuring as he sorted through the myriad of feelings with which he was grappling. Celia then joined in some of the sessions in which they were able to discuss their relationship, which was slowly improving. Adam had also returned to work. At this point Adam joined a sexual abuse survivors’ support group for men and Celia took part in a conjoint group for partners of male survivors of sexual abuse. This organization also ran retreats for couples affected by CSA with a very specialized focus on dealing with intimacy issues. Adam ultimately reconsidered and decided to contact the police and ask for an investigation, and for charges to be laid. This was a turbulent process partly because his offender had moved out of the jurisdiction necessitating the involvement of two police forces, and also because of the historic nature of the offences. Charges were laid however, and after an almost 3 year process the perpetrator was convicted of two counts of sexual assault on a minor. The court hearing was protracted due to several adjournments and a request for a plea bargain which was denied. The convicted perpetrator was put on the local child abuse Registry which meant that he could have no contact with minors including his under-age grandchildren. No other boys came forward as victims. The entire process was emotionally taxing for Adam, and his therapist and parents were called to testify. The clinical notes kept by his therapist became central corroborating evidence. His disclosure to his parents also became important testimony. The unwavering support of his wife, parents and therapist were vital to this grueling process. Impact on the Therapist Undoubtedly, the traumatic material brought forward by Adam would have an impact on his therapist. Her attempts to enter into his subjectivity to truly attain understanding of his world would expose her to the abuse and betrayal he experienced. In the course of attaining this level of empathic understanding, she at times would naturally feel the intensity of his traumatic experiences. Her own worldview could become altered whereby questions regarding safety and the integrity of people are raised. She consequently made use of regular supervision with an experienced therapist to identify these feelings and process

Clin Soc Work J

them. Supervision helped her to feel validated in her experiences of the therapy and assist her in addressing the intense selfobject transferences which emerged. One unfortunate reaction might have been to defensively (for self-protection) withdraw from the client’s traumatic material, which could have led to the client not feeling heard or understood and thus experiencing empathic failure in the therapy -perhaps therefore a form of re-traumatization. In the process of clinical supervision the therapist was acutely aware that it was essential that she not withdraw. For example, at one time when Adam thought he might stop the therapy or reduce the frequency of the sessions as he was questioning her ability to be effective with him, the therapist needed to be exquisitely aware of any ambivalence on her part to deal with and address his trauma together with him. Any form of withdrawing would have conveyed empathic failure, for which the therapist would require the help of an experienced supervisor to label and address this occurrence.

Discussion and Conclusion Self psychology as a therapeutic framework in counselling male survivors of child sexual abuse has merit for the healing process in a number of ways. Primarily, through an emotionally corrective experience, previous selfobject failures can be worked through and opportunities can allow these needs to be met in the present. Mirroring and idealization in the case of Adam are illustrated as transformative moments in the therapy. Within the parameters of the therapeutic relationship the therapist acted as a safe holding environment for intense emotions that were expressed and worked through. For Adam these emotions ranged from rage, to grief and profound feelings of loss. His therapist maintained a calm and stable stance, someone who sat with him through painful sessions of emotional expression validating his feelings -maintaining stability and demonstrating the ability to handle his strong feelings. And although twinship selfobject needs were not met directly through the therapy Adam became open to the idea of joining a male survivors therapy group. Twinship is the need for essential likeness with others. The group experience with other survivors was a means of being with others who had experienced similar abuse reducing his sense of isolation and stigma. Second, opportunities to repair relationships and improve interpersonal relations grew out of this course of therapy guided by self psychology. Adam was able to revisit with his parents their response to his initial disclosure and although he was the one to initiate discussion of this issue, they nonetheless reacted to him in a much more emotionally adequate way. With reflection and hindsight

they had transmuted their response. Adam started to become more available and emotionally accessible to Celia because he was no longer consumed with overwhelming feelings of rage, guilt and loss, and was thus no longer submerging his feelings through abusing substances. His family and therapist’s unremitting support throughout the investigation and trial gave Adam the opportunity to explore unresolved issues of betrayal. Their unconditional support and belief in him allowed him to trust again. This process was especially vital because Adam ultimately felt let down by the legal system during sentencing which resulted in minimal time for the perpetrator. As well Adam was advised by his legal counsel not to contact others who he felt might have been victimized as this would potentially contaminate any future allegations and investigations they might have decided to pursue. Therapeutic work with Adam as a survivor of child sexual abuse illustrates the complexities of responding to a deep betrayal of a child, now an adult, whose relationships had been profoundly affected by this early trauma of sexual victimization. His relationship with his therapist offered an emotionally corrective experience in which empathic failures could be worked through and new opportunities for self object needs could be met, throughout the therapy and significantly in his relationships with his wife and parents.

References Alaggia, R. (2005). Disclosing the trauma of child sexual abuse: A gender analysis. Journal of Loss and Trauma, 10(5), 453–470. Alaggia, R., & Millington, G. (2008). Male child sexual abuse: A phenomenology of betrayal. Clinical Journal of Social Work, 36(3), 265–275. Arata, C. M. (1998). To tell or not to tell: Current functioning of child sexual abuse survivors who disclosed their victimization. Child Maltreatment, 3(1), 63–71. Baker, H., & Baker, M. N. (1987). Heinz Kohut’s self psychology: An overview. American Journal of Psychiatry, 144(1), 1–9. Bolen, R. M., & Scannapieco, M. (1999). Prevalence of child sexual abuse: A corrective- metaanalysis. Social Service Reviews, 73(3), 281–313. Cawson, P., Wattam, C., Brooker, S., & Kelly, G. (2000). Child maltreatment in the United Kingdom: A study of the prevalence of child abuse and neglect. London: NSPCC (The National Society for the Prevention of Cruelty to Children). Chen, L. P., Murad, H. M., Para, M. L., Cobenson, K. M., Sattler, A. L., Goranson, E. N., et al. (2010). Sexual abuse and lifetime diagnoses of psychiatric disorder: Systemic review and metaanalysis. Mayo Clinic Proceedings, 85(7), 618–629. Cutajar, M. J., Mullen, P., Ogloff, J., Thomas, S. D., Wells, D. L., & Spataro, J. (2010). Psychopathology in a large cohort of sexually abused children followed up to 43-years. Child Abuse and Neglect, 34, 813–822. De Bellis, M. D., Spratt, E. G., & Hooper, S. R. (2011). Neurodevelopmental biology associated with childhood sexual abuse. Journal of Child Sexual Abuse, 20, 548–587.

123

Clin Soc Work J Dube, S. R., Anda, R. F., Whitfield, C. L., Brown, D. W., Felitti, V. J., Dong, M., et al. (2005). Long-term consequences of childhood sexual abuse by gender of victim. American Journal of Preventive Medicine, 28(5), 430–438. Feeny, N. C., Foa, E. B., Treadwell, R. H., & March, J. (2004). Posttraumatic stress disorder in youth: A critical review of the cognitive and behavioral treatment outcome literature. Professional Psychology: Research and Practice, 35(5), 466–476. Fergusson, D., Lynsky, M., & Horwood, I. (1996). Childhood sexual abuse and psychiatric disorder in young adulthood: I prevalence of sexual abuse and factors associated with sexual abuse. Journal of the American Academy of Adolescent Psychiatry, 35, 1355–1364. Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse and Neglect, 18, 409–417. Finkelhor, D., Hammer, H., & Sedlak, A. (2008). Sexually assaulted children: National estimates and characteristics. Office of Justice Programs, US Department of Justice; Washington, USA. Finkelhor, D., Hotaling, G., Lewis, I. A., & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse and Neglect, 14, 19–28. Finkelhor, D., Ormrod, R., Turner, H., & Hamby, S. (2005). The victimization or children and youth: A comprehensive, national survey. Child Maltreatment, 10(5), 5–25. doi:10.1177/ 1077559504271287. Flanagan, L. M. (1996). The theory of self psychology. In J. Berzoff, L. M. Flanagan, & P. Hertz (Eds.), Inside out and outside in: Psychodynamic clinical theory and practice in contemporary multicultural contexts (pp. 173–198). Northvale: Jason Aronson Inc. Fleury, T. (2009). Playing with Fire. Toronto: Harper Collins Publisher. Gartner, R. B. (1999). Betrayed as boys: The psychodynamic treatment of sexually abused men. New York: Guilford Press. Globe & Mail. (2012). The tragedy of doing nothing: Ken Dryden on how sexual predators corrupt hockey. February 24, 2012. Holmes, W. C., & Slap, G. B. (1998). Sexual abuse of boys: Definition, prevalence, correlates, sequelae, and management. Journal of the American Medical Association (JAMA), 280(21), 1855–1862. Kohut, H. (1971). The analysis of the self. New York: International University Press. Kohut, H. (1977). The restoration of the self. New York: International Universities Press, Inc. Kohut, H. (1984). How does analysis cure?. Chicago & London: The University of Chicago Press. Kohut, H. (2010). On empathy (Reprint from 1981). International Journal of Psychoanalytic Self Psychology, 5, 122–131. doi:10. 1080/15551021003610026. Lachmann, F. M., & Beebe, B. (1995). Self psychology: Today. Psychoanalytic Dialogues, 5(3), 375–384. Lichtenberg, J. (1989). Psychoanalysis and motivation. Hillsdale, NJ: The Analytic Press. Lisak, D. (1994). The psychological impact of sexual abuse: Content analysis of interviews with male survivors. Journal of Traumatic Stress, 7(4), 525–548. McCloskey, K., & Raphael, D. (2005). Adult perpetrator gender asymmetries in child sexual assault victim selection: Results from the 2000 national incident-based reporting system. Journal of Child Sexual Abuse, 14(4), 1–24. Nelson, S. (2009). Care and support needs of male survivors of childhood sexual abuse. Centre for Research on Families and Relationships, Briefing 44. Scotland: University of Edinburgh. Retrieved from http://www.crfr.ac.uk/reports/rb%2044%20web.pdf.

123

New York Times. (2012). Juror says panel had little doubt on Sandusky’s guilt. June 24, 2012. Ornstein, P. H. (1978). Introduction: The evolution of Heinz Kohut’s psychoanalytic psychology of the self. In P.H. Ornstein (Ed), The search for the self (Vol. 1, pp. 1–106). New York: International Universities Press. Ornstein, P. H., & Kay, J. (1990). Development of psychoanalytic self psychology: A historical-conceptual overview. In A. Tasman, S. M. Goldfinger, & C. A. Kaufmann (Eds.), Review of psychiatry (pp. 303–322). Washington, DC: American Psychiatric Press. Paine, M. L., & Hansen, D. (2002). Factors influencing children to self-disclose sexual abuse. Clinical Psychology Review, 22, 271–295. Polusney, M., & Follette, V. (1995). Long-term correlates of child sexual abuse: Theory and review of the empirical literature. Applied Preventive Psychology, 4, 143–166. Putnam, F. W. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 269–278. Rasmussen, B., & Mishna, F. (2003). The relevance of contemporary psychodynamic theories to teaching social work. Smith College Studies in Social Work, 74(1), 31–47. Roughton, R., & Dunn, J. (2003). Relational perspective, interpersonal psychoanalysis, social constructivism, and intersubjectivity. In A. Tasman, J. Kay, & J. Lieberman (Eds.), Psychiatry (2nd ed., pp. 482–485). West Sussex: Wiley. Staller, K. M., & Nelson-Gardell, D. (2005). ‘‘A burden in your heart’’: Lessons of disclosure from female pre-adolescent and adolescent survivor’s of sexual abuse. Child Abuse and Neglect, 29, 1415–1432. Taylor, J., & Harvey, S. (2009). Effects of psychotherapy with people who have been sexually assaulted: A meta-analysis. Aggression and Violent Behavior, 14, 273–285. Vine, C., & Challen, P. (2002). Gardens of shame: The tragedy of Martin Kruze and the sexual abuse at Maple Leaf Gardens. Vancouver: Greystone Books. Walrath, C. M., Ybarra, M. L., Sheenan, A. K., Holden, E. W., & Burns, B. J. (2006). Impact of maltreatment on children served in community mental health programs. Journal of Emotional and Behavioral Disorders, 14(3), 143–156. Winnicott, D. W. (1965). The maturational processes and the facilitating environment. Madison: International Universities Press. Wolf, E. S. (1988). Treating the self. New York: The Guilford Press. World Health Organization. (2004). Managing child abuse: A handbook for medical officers. World Health Organization, Regional office for South East Asia. (http://www.searo.who.int/ LinkFiles/Publications_SEA-Injuries-6.pdf).

Author Biographies Dr. Ramona Alaggia Ph.D. Associate Professor is the FactorInwentash Chair in Children’s Mental Health at the University of Toronto. She uses her considerable social work practice experience in the areas of child sexual abuse, intimate partner violence and child exposure to inform her teaching and research. Dr. Faye Mishna Dean and Professor at the Factor-Inwentash Faculty of Social Work, University of Toronto, is cross-appointed to the Department of Psychiatry and holds the McCain Family Chair in Child and Family. Faye has extensive practice in children’s mental health and conducts research on cyber bullying/cyber technology in counseling.