May/June Issue

Therapist’s Notebook
Social Work Today
Vol. 9 No. 3 P. 26

Read the case of a young man referred by a student health center for therapy after being treated for his third instance of a sexually transmitted disease. See how your observations compare with the presenter and the discussants.

Editor’s Note: Cases are fictitious. Any resemblance to actual clients is coincidental.

Case of Jacob
By Bruce Buchanan, ACSW, LISW, BCD

Jacob was referred to me by a local college student health center following his third incident of gonorrhea during the previous two years. The physician noted that Jacob also reported intense anxiety related to school, home, and relationships with others.

Jacob was a 20 year old who came from an intact family. He had two younger siblings: a sister, aged 17, and a brother, aged 14. His mother and father had married young, and Jacob was born within a year. His mother had just turned 21 at the time of his birth. Both parents stayed in school and completed college. His father worked for an insurance company, and his mother was a teacher.

During the initial interview, Jacob stated that he was frustrated about being referred to me and said the physician was “blackmailing” him regarding therapy. He said that the physician would not prescribe him any medication unless he came for therapy.

Upon initial presentation, he was an extremely anxious young man, fidgeting throughout the interview. He wanted to talk about his sexual prowess and the fact that he could have, according to him, “any woman on campus I wanted.” He described occasional panic symptoms, including trembling, sweating, and a racing heart. He stated that he was able to sleep better this school year rather than last because he had a room to himself.

Jacob reported that when he became really worried and anxious, he would simply find someone to have sex with. We discussed the fact that sex isn’t always the answer because it can create future anxiety within the context of the relationship. Jacob stated that he kept a journal of the women he had sex with and rated them on a scale of 1 to 10. He said he was always looking for women who he could rate above an 8.

Jacob was reluctant to agree to ongoing sessions. With young male college and high school students, I typically recommend that we meet for five sessions and then decide whether there’s a need for more. Framing the therapy with a starting point and ending point often reduces anxiety in clients like Jacob. He agreed to the five sessions and signed releases for me to contact the physician at the student health center.

During Jacob’s second interview, he was less anxious, less defensive, and more talkative. He was able to discuss other symptoms that he didn’t present at the first interview, including hypervigilance and reoccurring dreams that sometimes bothered him a great deal. He also reported avoiding family reunions.

Jacob persisted in discussing his sexual prowess. Initially, I considered whether he had symptoms of a sexual addiction. However, his continued discussion about his wanting to see women again if they rated as an 8 or higher intensified. Toward the end of the session, I became concerned about possible sexual abuse. I told Jacob that I had one other client who kept a record of her sexual involvement. I told him that this was a young woman who had been sexually abused by her father and continually attempted to find men who could give her better orgasms than her father had. Jacob immediately became sullen and withdrawn, his affect changed remarkably, and his eye contact diminished.

I told Jacob that in this country, a lot of boys are sexually abused by adults, particularly women. I told him that men didn’t really talk about being sexually abused by a woman because people typically make light of an older woman seducing a younger man. They talk about how lucky someone is if they have been seduced into having sex with an older woman. I explained to Jacob that young men his age are reluctant to report that they’ve been abused because they do not want to be perceived as being weak.

As I talked about this whole issue, Jacob began to get tears in his eyes. He finally confessed that his aunt had been having sex with him since he was 12 years old. The sexual activity had continued during his most recent visit home.

I assured Jacob that he was not alone, that there were other adult males who had been sexually abused by aunts, babysitters, older sisters, and other women in their lives. I told him that the sex was not mutual and not his fault.

As the session came to a close, he was quite concerned about my contacting his parents and his aunt. I told him that he was an adult and that we would need to work on how to move forward. I assured him that it was not something I would be doing any time soon, if at all. As he left the second session, he told me he hoped the nightmares would go away.

The sessions to follow will be difficult and challenging as we begin to break down the social stigma of the abuse. Not only does this young man have anxiety and panic symptoms but, in my opinion, he also shows symptoms of depression and posttraumatic stress disorder.

— Bruce Buchanan, ACSW, LISW, BCD, is a private practitioner in Des Moines, IA.

Discussion No. 1
By Marlene I. Shapiro, LCSW-C

The therapist did an excellent job of quickly engaging this young man and helping him feel comfortable enough to return to therapy for the second interview. Often, people of this age are reluctant to believe that they need to see a therapist; they cannot imagine anything being wrong with them either mentally or physically.

Perhaps the therapist realized that, as a 20 year old (despite his contention that his physician was “blackmailing” him into therapy), Jacob could have avoided seeing a therapist simply by going to a different physician, an urgent care center, or even an emergency department to get the medication needed to treat his gonorrhea. And, given the therapist’s observation of anxiety and panic during the first interview, perhaps Jacob was aware on some level that he wanted relief from these symptoms, with no overt intention of dealing with the sexual abuse.

When the therapist opened the door and invited Jacob in for a limited number of sessions, he calmed down, took up the challenge, and committed to doing some work. In the second interview, when the therapist suspected abuse, he quickly put into perspective the trauma this client was still suffering in several ways.

First, the therapist offered a real-life story of another client who had been abused by her father and who had kept a similar journal of her sexual encounters. Second, he quickly educated Jacob about the existence of male sexual abuse, assuring him that men can also be victims, it was not unusual, and it wasn’t consensual or the client’s fault. He addressed Jacob’s reluctance to discuss the abuse due to a fear of appearing weak and noted a problem with our society’s view that men who are sexually abused are often not understood as being traumatized but “lucky” if they are “seduced into having sex with an older woman.”

The therapist is justified in wondering how to proceed after the second session because Jacob committed to only five sessions. Jacob may be so upset after the second session that he would not return for more. It is not unusual for a client to reveal abuse in one session and then not discuss it again for a while or not return to therapy at all.

In this case, Jacob did not reveal the information but acknowledged that it occurred. Since he was led by the therapist to this discovery of the abuse, Jacob may feel too ashamed to return. Shame is a major element in abuse cases, as well as the attempt to “guard the family secret.”

Jacob did return for the second session, attesting to the developing therapeutic alliance, and revealed more symptoms, showing the depth of his problems. Jacob was also concerned that the therapist may contact his parents or his aunt about the abuse, something he was not ready to do. The therapist appropriately assured him that since Jacob was an adult, this would not be done soon, if at all. Revelation of the abuse and possible confrontation with the abuser and other family members must be carefully planned, and the client must navigate this scenario with the therapist’s support. The therapist considered focusing on breaking down the social stigma of the abuse for the next sessions, but he must discover what is of primary importance to Jacob that can be addressed in only a few sessions. Having kept this secret since the age of 12, the repercussions of this revelation may be all that can be addressed in a short time.

What else could be accomplished in a short course of treatment? Besides the education the therapist has already provided, focusing on the client’s personal safety could be another goal. Jacob presents with two unsafe situations that need to be discussed and solved at least temporarily. One, he has already contracted a sexually transmitted disease several times, indicating that he is having unprotected sex at least some of the time. He may be in danger of acquiring more serious and permanent illnesses such as HIV or herpes. He needs to understand the relationship between the abuse and his current sexual behavior and discuss methods of protection, given that he may not wish to and/or be able to change his sexual activity. Two, the abuse is ongoing, so Jacob needs a plan to avoid future abuse and further trauma.

If the treatment proves to be short term, the therapist may want to consider a solution-focused approach to emphasize the client’s strengths, assure the client that he is in control of how much he wishes to share, continue educating the client about male sexual abuse, acknowledge that his current symptoms are likely connected to the abuse, and recognize that these symptoms are common to individuals who are abuse victims. It is important to use caution in eliciting details of the abuse to avoid retraumatization, especially if the therapist does not have the time to provide suitable interventions.

Finally, it is possible that if Jacob adheres to the five-session limit, he will continue to experience his symptoms and, after disclosure of the abuse in therapy, he may even feel worse for a time. The therapist needs to prepare him for this and provide what I call “reassurance inoculation” for the inevitable feelings of shame and blame experienced by individuals who are victims of sexual abuse. He can continue to assure the client that he is not to blame for the abuse nor did he deserve it; his aunt is responsible for her behavior; since the abuse began when he was 12, Jacob was a child and not in control of the situation; that he is a survivor and can recover from this trauma; and the therapist will maintain his confidentiality, and Jacob can return any time he wishes to continue treatment. Before leaving therapy, the therapist may wish to explore with Jacob any supports he may have within his family or community. Jacob could also be referred to hotlines, books, support groups, and/or Web sites for support and information. He should be informed about what to do in the event of a psychological emergency—increased depression, suicidal feelings, panic symptoms, etc.

Long-standing abuse needs to be addressed in more than five sessions. However, in true social work fashion, the therapist needs to start from where the client is, leaving him with some confidence that even this problem has solutions and that the therapist is willing to undertake this journey further when Jacob is ready.

— Marlene I. Shapiro, LCSW-C, is the program director of a partial hospitalization program for patients with psychotic disorders at Sheppard Pratt Hospital in Baltimore. In addition, she sees patients and families in a private practice.

Discussion No. 2
By Jeanette Sinibaldi, MSW, LCSW

This case is a difficult one for short-term work. The primary concern for any therapist would be to open up this client to emotions without sufficient time to explore and help him deal with the intensity of what has happened to him. If the therapist only has three more sessions left, I would suggest a directive approach with this young man to help him find his way as much as possible with the situation presented.

The remaining sessions should be about helping this client with two main issues: educating the client about incest and molestation and helping him understand the ramifications of the sexual abuse. The goal will be to help him decide how he should proceed after the fifth session. In the next three sessions, the therapist should emphasize the importance of continuing treatment but with an understanding of Jacob’s underlying fragility. Leaving the client with a sense of control is important in such short-term treatment.

The therapist’s assurances are not enough to undo the years of probable brainwashing and guilt this young man has experienced. A reeducation process takes months of work, but the therapist can put this man on the right track. There are many underlying thoughts that men who are victims of sexual abuse hold. The reality of sexual arousal or orgasm from the abuse leads a young man to think he was a willing participant in the act and even desired it. This thought needs to be explored with the client, and the realities of biological stimulation and pleasure as opposed to consensual sexuality are the educational pieces.

Another myth the therapist can work on debunking is that initiation of an adolescent boy into sex by an older female is a rite of passage and a boy is “lucky” to have had that outlet. The victim may convince himself or is told that this is for his own benefit as a man. The therapist should educate the client about power inequity in a relationship and that sexual behavior on the part of the more powerful person is always abusive and exploitative. Males often are exposed to other boys of their own age having sex talk and curiosity about adult female sexuality. If there was any flirting going on from a boy exploring his adolescent attractiveness with the aunt, it is her responsibility as an adult to understand him as a growing individual and not respond sexually. The client’s fears of the therapist relating any of this information to his family indicated there is guilt and fear that he will be held responsible for this sexual abuse.

Since time is limited, homework becomes an important part of the therapy process. Asking the client to check Web sites about male abuse for additional information to bring to the next session would be helpful. A suggestion that he might look for some information on any groups that are formed by others with similar experiences would also be a good assignment. I would explain that this is a fact-finding assignment and not encourage him to be involved in any such groups at this time. This client is at the first step of acknowledging his experiences, and the main goal of this treatment is to help him understand the roots of his issues without overwhelming him.

Educating this young man that he was used as a sex object is essential in his recovery process. A discussion about the objectification of people and what that means, certainly in light of his own sexual acting out, will help him tremendously. He can understand that we live out what we have been taught. At this point, the therapist can investigate Jacob’s emotional connection to any of the women with whom he has had sexual relations. Objectification of other people can be discussed in a general sense and also in relation to sex; this discussion may take one whole session. Universalized discussion of how that might make one feel would be a good introduction into how people block feelings. An explanation of the consequences of ignoring feelings may be helpful in light of the nightmares that are a major symptom the client discusses. These issues would be the topic for the next-to-last session.

The final session should allow the client to recap what he has learned and feels he has gotten out of the previous four sessions. Written notes, taken by the therapist, should provide a review of the topics and discussions of previous times together. The therapist should investigate what the client felt was helpful and what he would have liked to have done differently. This is an important part of treatment diagnostically for the therapist. At this point, the therapist can assess how realistically and in what context the treatment and discussions were taken.

Jacob is filled with residual anger along with the shame and guilt. A therapist must be alert to any unconscious processes that may be at work with such a traumatized individual. In opening up issues in severely abused clients, the underlying denied emotional impact may be turned in many directions. The therapist should be alert to any subtle misdirected projections of that anger. It should be noted in the records and perhaps gently addressed. The client can be asked about issues that he would have liked to talk more about and what he would like to explore in any way in the future. At this time, if it is an option for the therapist, a contract for treatment can be established. If this is not possible or the client does not want further treatment, referrals can be made and noted.

Five sessions will challenge any therapist with providing a client with some benefits to serious and long-standing issues. It requires a lot of work and creativity.

— Jeannette Sinibaldi, MSW, LCSW, is in private practice in Queens and Long Island, NY.