Ethical Boundaries & Treating Sexually Abused Boys

From the therapist's perspective, therapy with male survivors has four distinct phases. This four-phase model of therapy is helpful both as an analogous description of the recovery process for male survivors and as an analytical tool to assist in case management and treatment planning.
The four phases are:
1 - Breaking Silence
2 - The Victim Stage
3 - The Survivor Phase
4 - The Thriver Stage
(N.B. In following chapters, interventions are organized in relation to this four-phase model and they are presented according to the therapeutic phase in which they are most appropriately used.)

Individual clients will spend more or less time in any given phase of healing and some phases will overlap with one another. Some clients will stay in one phase for a long time, reaching a plateau in their growth; it may be advisable to take a planned break from therapy during these times. However, in general, each phase is associated with distinct issues and demands different skills from the therapist.

At all times, the therapeutic process for male survivors needs to be relevant to individual needs. Identifying a client's phase of healing can help a therapist to skillfully and strategically focus the therapy to meet this client's unique requirements.

Before beginning abuse-focused therapy, clients need information about the therapeutic process. Knowing ahead of time that recovery tends to be long-term rather than short-term and that the healing journey is not a linear one helps clients to make decisions about their investment in treatment. (The client engagement process is discussed in Chapter 9.) Each client will have to decide how to allocate his resources (e.g., time, money, etc.) to support his recovery. Relatively accurate and candid predictions about the therapeutic process, including the length of the journey, will help clients make these decisions.

Giving clients a cognitive map with which to understand the healing process can be a supportive intervention. Although the concept of a four-phase model of healing is somewhat abstract, being able to identify which phase he is currently in helps a client know where he is headed and what kind of process he can anticipate en route. Whether or not clients want such a map, it is essential that each therapist uses one to guide his interventions. The different phases of the four-phase model are described below:

Phase 1-Breaking Silence
Acknowledging to himself that he was sexually abused as a child is the first step a survivor must take to heal from this experience. Reaching out to others for support and validation of this experience, as well as breaking the silence that has surrounded the secret of the abuse, is an important step.

Survivors come indifferent ways to the realization that they were abused. For some men, their memories surface during therapy for issues that are not abuse-related, when they begin to realize that their patterns of behavior are the result of childhood sexual trauma. Other men have never forgotten being abused, but have discounted the impact of these events on their lives or have never labelled them as abuse. Yet others have a sudden realization while watching a TV show about sexual abuse, or while reading a book that refers to sexual abuse, that they have themselves been victimized.

Some therapists are reluctant to pursue questions about abuse if their client has no memory of having been abused. "False Memory Syndrome," in which therapists are thought to create their clients' memories of abuse by planting hypnotic suggestions, is currently a topic of much debate in therapeutic circles. I believe that concerns about creating false memories are secondary to giving a client feedback that his symptoms suggest a history of childhood trauma, which may include sexual abuse. Until such time as this possibility can be clearly eliminated, it bears examination.

Phase 2-The Victim Stage
The main focus of this phase of therapy is to validate the client's abuse history, to build a safe therapeutic process with the client, and to provide educational information about the effects of sexual abuse on its victims. Unless a client has intense flashbacks or other affectively demanding concerns, much of the work in this phase will be cognitively focused.

Men often need support in acknowledging their victimization. Even if they can recall the sexually intrusive events that have happened to them, many men don't call them "abusive." Educating clients about power differences, coercion, misrepresenting adult reality, the use of threats and lies to gain compliance, and so on can assist male victims to fully claim their experience.

To the extent that the client's memories permit, he will be asked to develop a "sexual abuse autobiography" during this phase of therapy. Remembering how he was groomed for the abuse, who offended against him, how often the abuse occurred, what explicitly happened, what his reactions were at the time, whether or not he told anyone and what, if anything, he liked about the experience are areas to investigate at this stage. Talking openly about the abuse and continuing to challenge any denial of the experience are primary tasks for this therapeutic phase.

The therapist needs to teach stress management and self-care skills during this phase, so that as the therapeutic focus becomes more affective, clients have functional ways of attending to their emotions. Ensuring that clients have active support systems in place or focusing on building these supports are therapeutic tasks in the Victim Phase.

In this phase, clients will generally feel some emotional relief at realizing that the problems they face in their lives are not the result of being crazy, but the outcome of being sexually abused as a child. As they gain information about dissociative processes and other coping strategies, they begin to feel more normal and hopeful about the future.

The transition between the Victim and Survivor Phases of therapy is marked by the client's ability to place full responsibility for the abuse on the offender. When the client recognizes that he was a victim in an abusive relationship and that the abuse was a reflection not of his worth as a person, but of his offender's unresolved problems, he moves into the next phase of therapy.

Phase 3-The Survivor Phase
The Survivor Phase of therapy describes the often arduous work of repairing clients' emotional, cognitive, and behaviorial dysfunctions. This is a push/pull stage of therapy. The client's maladaptive life patterns are slowly replaced by functional sequences as the client takes the risk of developing new coping strategies. Walking a fine line between containment and expression, as well as finding a workable balance of both, is the key to success during this phase of therapy.

Often, clients become discouraged in this phase. Because they are reclaiming their previously blocked affective processes, they are more aware of feelings of fear, pain, rage, or sadness. They feel unstable as they discard old methods of coping and substitute new ones that are still relatively untested and awkward to use. They feel as if therapy has made them worse rather than better. Many cases of premature termination occur in this phase as clients lose their faith in ever being able to make significant changes.

During the Survivor Phase, new skills need to be practised outside of therapy sessions. Throughout this therapeutic stage sessions may involve both spontaneous and planned abreactive processes. (Working with abreactions will be discussed in Chapter 6.) At times, clients may need to take a planned break from therapy and integrate their learning before continuing the process.

The transition between the Survivor Phase and the Thriver Phase is marked by the client's readiness to take back his own power; this will frequently be manifested by the client's readiness to confront his offender, either in reality or, more often, symbolically. This is not a reactive stand taken in defiance against the offender; instead, it represents an integrated change in which the client no longer feels that the offender has power over his life.

Phase 4-The Thriver Phase
When the client reaches the Thriver Phase, he begins to feel hopeful once again. From an empowered perspective of having changed previously dysfunctional coping patterns he can articulate the ways in which he was affected by having been abused. He realizes that the outcome of successful therapy is not "living happily ever after," but having the skills and resources that he needs to address the difficulties that occur in his life.

Thrivers feel responsible for their lives and they believe that they have many options to choose from in addressing their life problems, both past and present. The abuse is no longer seen as a central issue in the client's self-identification; his image of himself has shifted into the present and he trusts his adult self.

During the Thriver Phase, client and therapist must begin the process of termination. Termination needs to be managed so that the client can leave the therapeutic process at his own pace. In addition, clients should be given plenty of permission to return to therapy should they experience a resurgence of symptoms or should new abuse memories surface.

The therapist must be very careful not to compromise therapist/client boundaries by permitting double relationships to develop. Clients need their therapists to remain available to them for potential future consultation; any double relationship, such as when a therapist becomes a friend, lover, landlord, or business partner to a client, jeopardizes the safety of the therapeutic relationship. Risk of such double relationships might arise when the therapist is himself a survivor with needs for social support from relatively "recovered" fellow survivors or when a recovering client is seen as a professional ally who can assist in furthering desperately needed services for survivors.
- Crowder, Adrienne, Opening the Door: A Treatment Model for Therapy with Male Survivors of Sexual Abuse, Brunner/Mazel Publishers: New York, 1995.

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Personal Reflection Exercise #2
The preceding section contained information about a four-phase model of stages of therapy. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Charak, R., Eshelman, L. R., & Messman-Moore, T. L. (2019). Latent classes of childhood maltreatment, adult sexual assault, and revictimization in men: Differences in masculinity, anger, and substance use. Psychology of Men & Masculinities, 20(4), 503–514.

Peterson, Z. D., Beagley, M. C., McCallum, E. B., & Artime, T. M. (2019). Sexual attitudes and behaviors among men who are victims, perpetrators, or both victims and perpetrators of adult sexual assault. Psychology of Violence, 9(2), 221–234.

QUESTION 16
What are the four phases of therapy with male survivors of sexual abuse? Record the letter of the correct answer the CE Test.