Goals, Process, and Themes in Treatment

From Betrayed As Boys

What can we hope will happen by the end of psychotherapy for an adult who was sexually abused in childhood? Price (1995) anticipates that “the patient will move from being an incest survivor to being a person with a history of incest”. Dimock (1988) looks forward to him becoming “an adult who can take care of himself in a better way than he was cared for as a child”.

A number of writers have addressed the steps and/or the process of therapy with sexually abused adults. In general, the recovery process described in these works involves:

Acknowledging that the victimization occurred;

Seeing its historical and familial contest;

Discharging the intense affect surrounding it (particularly grief, terror, and rage), having first buttressed the patient’s capacity to endure intense feelings and thus having created a greater sense of safety;

Recognizing its impact and separating out the child’s traumatic reaction from the adult’s greater capacity to withstand overwhelming experience;

Perceiving its dysfunctional influences on the adult’s current day-to-day functioning and relearning patterns of living; and

Consolidating learning and putting the abuse into perspective so it recedes in importance and no longer dominates how the patient lives.

In my experience, these stages of recovery are conceptually useful, but they certainly do not occur in the ordered way this description implies. Further, I believe therapeutic work is rarely over when abuse is accepted and integrated into a man’s self image. This may be true in some cases, but for most patients this point marks the beginning of the hardest part of their treatment. This is the long period when they struggle with the many ramifications, both subtle and overt, of their abuse experience. During this phase my interpersonal psychoanalytic training most obviously affects how I work. It leads me to focus with the patient on his relational world, both outside the therapy room and, most powerfully, within the live context of our therapeutic relationship.

It is, of course, essential to be able to help a man heal from the directly disabling effects of trauma. However, although this is necessary objective of treatment, it is an insufficient goal. In order to stop a sexual betrayal from being the engine that runs a man’s life, therapy must also deal with the spreading effects of sexual abuse. In particular, such relational aftermaths as interpersonal isolation, distrust, and the ability to live intimately in relation to a loved one must also be addressed. This takes a long time, and I believe that in the majority of cases long-term treatment is most effective for this task. At the same time, specific situations may require shorter-term interventions because of the constraints of time, finances, or the reluctance of a man to stay in treatment longer. Such shorter treatments can be very useful; indeed, for some men, they are all that is needed. Others may need a period of time out of therapy to see how they now fare in the world. Some of these may return for future treatment sequences when they feel ready to continue therapeutic work.