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/
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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.