Magazine article Clinical Psychiatry News

Dissociative Reenactments May Help Abuse Victims: Expert Says Using Four Paradigms Can Lead to Breakthroughs in Treatment of Male Patients

Magazine article Clinical Psychiatry News

Dissociative Reenactments May Help Abuse Victims: Expert Says Using Four Paradigms Can Lead to Breakthroughs in Treatment of Male Patients

Article excerpt

NEW ORLEANS -- Dissociative reenactments of childhood sexual abuse play an important but particularly challenging role in the treatment of male victims of such abuse, Richard B. Gartner, Ph.D., said at the annual conference of the International Society for the Study of Dissociation.

A lack of attention to the occurrence and significance of these reenactments in the transference and countertransference in the therapeutic relationship can derail therapy. But recognition of them can lead to important breakthroughs in the treatment process, said Dr. Gartner, founding director of the sexual abuse program at the William Alanson White Psychoanalytic Clinic, New York City.

It's important to view transference and countertransference in this setting as a potentially positive factor in treatment, he added. "As you consider transferential reenactments, think of them as necessary communications, rather than acting out; by analyzing verbally what is communicated through behavior, the patient and therapist initiate a process in which dissociated material becomes encoded in language," Dr. Gartner said.

Four relational paradigms that effectively illustrate this process were described by Jody Messler Davies, Ph.D., and Mary Gail Frawley, Ph.D., in their book "Treating the Adult Survivor of Sexual Abuse: A Psychoanalytic Perspective," Dr. Gartner said.

He elaborated on these paradigms, which focused on the treatment of female victims of childhood sexual abuse, and described how they play out differently in men, largely because of the way in which societal ideals about masculinity--and a number of related myths--impose problems for men in the treatment process. (See sidebar.)

The Abuser and the Abused

Like all four paradigms, this one can be alternately enacted by the patient and the therapist, Dr. Gartner said.

When the patients identifies with his abuser, he can become transferentially abusive toward the therapist and reenact his own abuse he experienced as a child. This can lead to a bond with the victimizer through unconscious identification that wards off feelings of helplessness; the feelings of helplessness are projected onto the therapist, whom the patient may then devalue.

Boundary violations are common in this paradigm. For example, the patient may make contact with people or institutions in the therapist's personal life, leaving the therapist feeling intruded upon.

"The therapist must walk a tightrope between ignoring the abusive behavior, thereby becoming the unseeing parent, and expressing a feeling of victimization that evokes the patient's guilt," Dr. Gartner said.

In some cases, the roles are reversed: The patient takes on the role of the abused, and the therapist becomes the abuser--usually, but not always, in a symbolic way. The patient, for example, may feel victimized by the therapist's fee, or the therapist may become controlling and intrusive.

The reenactments can be subtle and symbolic--manifesting covertly as a tendency to manipulate and exploit--or they can be direct and overt. In one example, Dr. Gartner described a patient who "exploded in rage" when during therapy he commented on the patient's abrasiveness.

"He thought I hadn't comprehended the extent of his vulnerability ... and I assumed he was right about at least a partial failure of empathy," he said.

But the patient's reaction was out of control, and the intensity of the interaction escalated to a screaming match. Eventually during the encounter, Dr. Gartner and the patient arrived at a "point of mutual respect."

"I'd been at least symbolically abusive ... but reacted to his subsequent transferential victimization of me by modeling how to remain in a significant relationship without permitting mistreatment," he said.

Ultimately, the event changed how the patient approached interpersonal relationships and improved his ability to avoid abusive and exploitative relationships. …

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