Effective Group Therapy
With Male Survivors Of Sexual Abuse

March 1997
By Mikele Rauch & John W. Jones

BIO: Mikele Rauch, M.A., MFT, 54 Wilde, Waban, MA 02168. Mikele Rauch is a licensed Marriage, Family and Child Counselor in private practice. She co-lead a male incest survivor's group for almost 2 1/2 years, and has lead weekend workshops for adult survivors of both genders. She has presented at several colleges and universities on the PTSD/Borderline profiled client, and is available for consultation.

BIO: John W. Jones, M.A.,MFT, is a licensed Marriage, Family and Child Counselor, with a private practice in South Pasadena, CA. He received his Master's Degree in Counseling Psychology from Pepperdine University in 1990. He has been co-leading a male incest survivor's group for approximately 2 1/2 years, and has done weekend workshops for adult survivors of both genders. He has been a consultant for the Los Angeles County Department of Mental Health as well as Occidental College. He has presented at several colleges, universities and community mental health agencies, and is available for consultation. He can be reached by telephone, at (626) 524-7081, or by writing to 446 S. Marengo Ave. ,Suite B, Pasadena CA 91101.


To be an incest survivor suggests that there has been a mutation in the rite of sexual initiation. For a man, this aberrant initiation can incur tremendous losses: in the trust and safety with one's own caretakers, in body boundaries and image, in the modulation of feelings and the naming of them, and most profoundly, in the loss of self.

It is more difficult for men to acknowledge that they have been abused, usually because of societal, cultural and familial stereotypes. They often experience self-doubt and shame concerning their sexual identity and/or sexual orientation. Regardless of whether the perpetrator was male or female, it is terrifying and anxiety producing for a man to enter a group for sexual abuse survivors.

The work of individual therapy is both a journey of self restoration and griefwork. The work of skillful group therapy is to provide a context to reclaim oneself in connection with other survivors through the renewing transferential experiences both with facilitators and one another. What happens together is not just a rerun of the past. The experience with other group members who share a similar history and the reparative transference with the co-therapists can affect recovery emotionally, cognitively, relationally, and spiritually.

The writers are a male and female co-therapy team. We use a psychoanalytic systems model with the boundaries and rules appropriate for the work: Group members must be in individual therapy while attending the group. The patients sign a release so that the therapists can have ongoing communication with the client's individual therapist to ensure effective coordination of treatment. Each potential group member is interviewed for a history of abuse-reactive perpetration.

Because it is essential that these men feel safe, the therapists have chosen not to permit perpetrators into the group. In addition, each member signs a group contract which requires at least ten weeks participation, explains the rules of confidentiality, and states that although the group members can support one another there will be no dating or sexual contacts between them. The contract also includes a commitment from group members to put feelings into works, and to actively work on the issues that have brought them to therapy. There are basically three stages through which a group progresses: an early, a middle and a late phase. In the early phase, establishing safety and trust are the two most crucial tasks for the co-therapists. This can include education about healthy and abusive families, and the initial sharing by the group members of their history. The second phase, the longest in duration, usually includes more of a therapeutic re-enactment of the dynamics of the family of origin. The co-therapists' tasks here include providing containment and interpretation. The third phase of the group is where group members, after experiencing the modeling and holding environment they need from the therapists, begin to feel more empowered to work with each other, with less overt intervention by the clinicians.

The group is composed of five to six men: gay, bi-sexual and straight. We find that the meeting of this population from all areas of sexual orientation is the most restorative in each and every one's sense of their commonalties as men. This permits respectful exploration of the issues regarding sexual behaviors and sexual preference. Because these men were abused by a male or a female or both, the presence of a male and female co-therapist invites the rich and varied opportunities for transference. In any given situation, group members may experience the therapists or other group members as someone from the past: perpetrator, idealized rescuer, loving attachment figure, non-involved parent, sexual object, or sibling. The group provides a context like a family where the members can work through the disappointment, rage and grief about what has happened to them. It also provides an environment to mourn the losses of the past and to "reality test" the experiences of the present.

Sexual abuse is traumatic. It has been said that survivors of long term sexual abuse do not have either personality disorders or psychosis; they have chronic trauma disorder. These particularities present a dual consideration of a PTSD and borderline profile. Men with a history of long term abuse present a challenge in the group process both because of their fragile ego structures and their propensity to defensively lash out. Because they have been both abused and rewarded inconsistently, they can set double standards between what they expect of themselves and others. They may reenact doublebinds with one another characteristic of a pathological family. Splitting and projections, primitive idealizations and devaluations, omnipotence and diminishment, are all adaptive defenses to long term traumatic survival, and will often be acted out in group. This replicates the borderline process with members attempting to divide the group or collude with one another, making passive aggressive comments, or withdrawing.

It is up to the co-therapists to name these processes and to help members to empathically work through their projections and self-loathing without shaming or devaluing the others in group. These individuals can and do trigger each other. The therapist team must hold a firm boundary: they must not engage in the ongoing dance of abuser, victim and rescuer that, unnamed, can create chaos in the group process. Members may also try to reenact the family pathology with either one another or the "parent" figures of the therapists. Here the holding context of the group may make it more tolerable for the men to confront the situations before them and stay present with what is experienced. The co-therapist team has a better chance of catching all that is happening because they have one another to monitor the process.

In the arena of childhood molestation, dissociative defenses often have played a key role in the survival of the psyche. They can be manifested in the personality anywhere from numbed, cut off memories or feelings to separated ego states. It is crucial for co-therapists to be experienced in treatment of the dissociative process so as to most effectively assist members to manage their splitting. It can happen that as one man shuts down or "goes away" another will being him back.

Like women survivors, what may be most common among men who were abused as children is that they feel like they are unfit human beings:
"Filled with shame, they experience themselves as profoundly defective and horribly toxic. Often they have internalized the scourges hurled at them in childhood...Frequently told by abusers they provoked and wanted the sexual attacks, survivors see themselves as malevolently powerful." 1 These men may engage in violent enactments or manipulate destructive sexual encounters, masochistically picking up with themselves where their perpetrators left off. Together, the group can face this pain and move through these grim places with more compassion for themselves and one another than they could have done alone. This is a very potent experience because it is often felt at a primitive preverbal level.

In our culture, men are often expected to have words or solutions for everything. Otherwise they simply don't talk about the unspeakable and put it behind them. It is difficult for both client and therapist alike to tolerate the tension of "that which cannot be spoken" in the regressed ego state of the little boy who did not have words for his circumstances at the time. The empathic power of the group here can address the early feelings of shame and genuine abandonment that are the central themes of therapy.

The fruit of deep therapeutic work is not without a series of risks. Because one man's "material" may resonate and activate painful experiences within the other men, it is important for clinicians to be aware of signs of depression. Though this is a necessary component of the grief work involved in this process, depression, even suicidal depression, can be masked in behaviors which include sexually acting out, substance abuse, bodily violence toward others or oneself, angry displaced outbursts, missed sessions, or even sarcasm. While these behaviors often serve a self-soothing function, it is important to take the time necessary to explore and thoroughly understand what may have triggered them. For example, what is the client's perception of the behavior? Does he like it or not, or both? Hence, the survivor gains more of an understanding of his underlying feelings and needs. With this understanding, he doesn't feel so out of control and is empowered. Of course, timing is critical because premature exploration and interpretation can stunt the process. In other words, the client must be made ready to absorb the impact of his experiences on a gut level. Therapists must be watchful and attentive, for this is an important moment in the therapeutic process.

It is important at this point to emphasize the value of humor in the group. Good use of self-effacing (not-defacing) humor by the therapist models compassionate self-acceptance of imperfections, moving away from unrealistic expectations and false self-grandiosity. Humor can also be a defense to deflect pain. Nevertheless, laughing with, not at, one another may be a first for these men. They have experienced being the butt of derision or perpetrated cruel defensive attacks on others due to the need to ally with their abusers.

Countertransference is the hot potato of therapy. It can be the internal barometer of the group's process or one's Achille's heel which will thwart or even damage therapy.
The writers have found the following guidelines useful: Co-therapists need to be in close contact, brutally honest with each other so as to monitor transference and countertransference reactions, and to manage the splitting that patients often attempt in group. Consultation is crucial if for no other reason than to avoid the common pitfalls in working with survivors which include over or under identification with the patients, overintellectualization, avoiding the pain, lack of clear and safe boundaries, perpetration, and maintaining an omnipotent or victim stance.

Frawley and Davies describe these transference and countertransference positions, which can be interchanged between therapist and client: the unseeing, uninvolved parent and the neglected child; the idealized, omnipotent rescuer and the entitled victim; the sadistic abuser and the helpless, impotently enraged child; and the seducer and the seduced. 2 We have found these positions relevant in work with male incest survivors in monitoring both transference and countertransference reactions.

The clinically rich but equally tricky re-enactment of the family which occurs in group work, can create problems if the therapists withdraw, are intolerant of their own pain, or feel panicky or stupid as transferential material is directed toward them. In order not to reenact the crazy making situation for the client, therapists must be willing to name and listen to the horror because the abuse survivor was either ignored, discounted, or blamed. The therapist team must stay connected to the client, and to their own issues.

The revolving wheel of victim-perpetrator-rescuer is vital to name in group process. Clients have been victimized throughout life. Therapists want to fix. What could be a better trap than for clinicians to want to "save" the client with brilliant, dramatic interventions. When this trap backfires, both therapist and client may end up feeling entitled or heroic without taking responsibility for present reenactments. Therapists must carefully consider the delicate underbelly of grandiosity, shame. As they help group members negotiate their experiences with responsibility, therapists must also watch a major pitfall of therapist narcissism, burnout. The clinical team will be modeling self-care by setting boundaries, monitoring their over-involvement or overprotective actions which devalue the clients' abilities to take care of themselves.

The reworking of sexuality in the therapy process presents perhaps the most intimate and important restorative work of all. For men who have known the compromising position of pleasure and pain during childhood molestation, to be close often means being sexual; and to be vulnerable can mean being a potential victim or potential perpetrator.
The therapists carefully note erotic transference and/or their countertransferential responses. Once again, acute timing and skill is required with these sexual issues so that group members do not feel shamefully exposed or revictimized.
There are some special considerations for therapists who are abuse survivors themselves. Co-therapists must debrief together and assess their own overstimulation, overidentification with the survivors, body memories that arise during group, or, if the therapists are more zealous, angry or obsessive than their clients on a particular subject. The team must monitor one another if one fails to explore the material, if one protects perpetrators, if one dissociates, or neglects to get supervision on an issue. The most important guideline therapists can follow is that they do their personal work in individual therapy to understand their own issues.

Group therapy is going to be a series of frustrations, accommodations, and betrayals'; of disappointment, misses, and working through. The work of a male-survivors group will be to validate what it really means to be a man, to confront the truth about the old patterns and story lines. The task of the clinicians will be to provide a real presence which affirms and validates the true self. Even when the members blame, diminish, rage or fight with the process, or attempt to seduce, or re-enact the old abusive relationships, therapists will provide a continuous frame without regressive gratification or exploitation.

To do all of this will be no small task. To act together as co-therapists will require time, relentless and honest communication, a good sense of humor, self-vigilance, ongoing consultation, and humility. Co-therapists will be modeling, both in and out of the treatment room, a healthy relationship with all its warts, pimples, and beauty.
For the group, what does it mean to be "brothers" in this together? Can one feel so safe that one can say what he wants, can work out his fears and anger, tell his secrets, honor each man's privacy and his own, set limits, and yet be intimate enough that he can recognize the darker faces of familiarity without acting them out? If this is possible with other men in a safe therapeutic holding environment, men can venture together toward restoration and recovery.


BIBLIOGRAPHY

Cortois, Christin A., Ph.D., Healing the Incest Wound:
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Davies, Jody Messler Ph.D. and Mary Gail Frawley Ph.D.  Treating the
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Hunter, Mic.  Abused Boys:  TheNeglected Victims of Sexual Abuse.
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Kroll, Jerome. PTSD Borderlines in Therapy:  Finding the Balance. New 
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Miller, Alice,  Thou Shalt Not Be Aware:  Society's Betrayal of the Child.
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1 Frawley and Davies, p. 131
2 Frawley and Davies, p. 167

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