Chuka Nestor Emezue //
“Laying the pus-covered pad on the desk in front of him, he gave up his secret. During his escape from the civil war in neighbouring Congo, he had been separated from his wife and taken by rebels. His captors raped him, three times a day, every day for three years. And he wasn’t the only one. He watched as man after man was taken and raped. The wounds of one were so grievous that he died in the cell in front of him.” – Excerpt from The Guardian, interview by Will Storr, July 17, 2011 
Here, I introduce the concept of the Therapeutic Alliance using one of Dr. Sigmund Freud’s famously dramatized case studies (often, of eccentric patients) as summarized in his contentious publication “Fragments of an Analysis of a Case of Hysteria (1905). In this case, Dr. Freud’s popularizing of the terms ‘transference’ and ‘countertransference’ as products of the therapeutic alliance between provider and patient is of note.
In October 1900, Dr. Freud was called in to treat a now famous hysterical patient, Dora, whose real name was Ida Bauer (1882–1945). Dora had been branded a sufferer of the ‘typical signs of hysteria’ – having disclosed to her father (Philip Bauer, Viennese businessman) the relentless sexual harassment she suffered since age 14 at the hands of a close family friend, Herr K, a man whose young wife was a longtime mistress of Dora’s father.
A despicable exchange of daughter for wife had transpired – or was at play. Once, her father’s ceaseless denials and victim-blaming provoked Dora to strike her abuser, Herr K. Shortly after, Dora regressed into a rebellious fugue of clinical depression, unexplainable coughing, suicidal ideation, and ultimately, aphonia (loss of voice).
Enter Dr. Freud.
Theoretically curious, Dr. Freud confessed in a letter to a close friend the straightforwardness of this particularly curious case. He wrote, this case “has smoothly opened to the existing collection of picklocks” (Freud, 1985: 427). Despite this therapeutic optimism, Dora proved precociously assertive, gaming their therapeutic encounters with rhetorics, metaphors, witty comebacks, and soon, feigned interest in what at the time was Freud’s early days in psychoanalysis. Not one to indulge Freud’s profoundly sexist (and phallocentric!) psychoanalytic nit-picking, Dora, a non-conformist, terminated their therapeutic alliance, abruptly, after only eleven weeks of therapy.
Freud, having irritated and ostracized his patient, later dubbed this self-critical experience an exemplar of therapeutic failure. He criticized himself for failing to comprehend the significance of establishing a therapeutic alliance. Several hours wasted as he moonshined bogus theories for Dora’s hysteria – including his probing dream analysis: insisting, alas, that an enigmatic jewel box in one of Dora’s dreams was connotative of the female genitalia, to which Dora replied “I knew you would say that” (105) [11-12]. Freud, straw-grasping, would posit that the adolescent girl nursed profoundly and truly sexually desirous feelings towards her father (Philip Bauer), her harasser (Herr K.), and the woman between then, Frau K.
In later years, a contrite Freud grew skeptical of the unconscious redirection, projection, and transference of feelings, trauma, and emotions, that transpired bi-directionally between therapists and their clients – a commonality in the realm of psychotherapy and psychoanalysis. Notwithstanding, Freud would later recount, with hesitancy, his confidence in the essential powers of transference in this space of therapeutic alliance. Specifically, how transference had the capacity to bring to the fore erstwhile restrained feelings, beliefs, cognitions, and traumatic experiences relevant to the future planning of treatment goals so that subsequent rehabilitation and healing from trauma could occur meaningfully. Needless to say, the therapeutic alliance remains a privileged relationship for the treater and the treated. In Freud’s case, a missed opportunity.
In a previous article, I acknowledged how victim service providers (VSPs) working with male sexual assault victims narrated the concept of victim stigma faced by the male victims in their care. Particularly, how this narration could be further stigmatizing of male victims and profoundly prescriptive of the formation of a therapeutic alliance. From further inquiry, I found that VSPs were not immune to societal canons of hegemonic masculinity, including the discrediting of male rape victims (i.e. male rape myths), comparable to Freud’s discrediting of Dora, so that in some ways, VSPs were complicit in the creation of victim stigma – at least by their stigma narratives.
“Everybody has heard the women’s stories. But nobody has heard the men’s.” – Excerpt from The Guardian, interview by Will Storr, July 17, 2011 
In this two-part essay, the utility of the therapeutic alliance formed between VSPs and their male victims is deliberated. In part one, I discuss the influencing antecedents of therapeutic alliances – what it implies. In part two, I discuss the stigma-related consequences of this therapeutic alliance and its potential efficacy as a de-stigmatizing process for interrupting male victim stigma.
Stigma remains latently ubiquitous. Beyond race, class, gender, sexual orientations, creed, and other routine socio-demographic factors that are determinative of stigma, exactly how stigmatized members of society manage stigma remains a vital module of the health care package for highly stigmatized groups. If anything, it has rekindled vigilant stigma research with assorted stigmatized groups – such as, people with impaired fertility, PLWHIV, people with cognitive impairments, people with addictions, morbidly obese people, homeless and unstably housed people, and victims of rape (91% are female, and 9% are male) — to name a few.
In short, stigma management processes reliably affects the health and wellbeing of members of these groups, enough to have significant bearings on if, how, and when they seek help (and health) from traditional health care establishments. Further, stigma management processes determine if they choose to form a therapeutic alliance with their care provider – a sign of favorable clinical and non-clinical outcome. This advantage of the therapeutic alliance in question is the crux of this essay.
For clarity, I describe a therapeutic alliance as the premeditated essence of a functional rapport, or “a non-neurotic and non-transferential relational component established between patient and therapist”  citing . Overall, the therapeutic alliance remains powerful enough to curate the nature, regularity, and caliber of care pursued and received by male victims of rape and sexual assault, particularly for worst-affected sexual and gender minority men (same gender loving, bisexual, and trans men), incarcerated men, and male victims of sexual torture in conflict situations. I have endeavored to gain entrée to the stigma narratives of members of this worst-affected men. However, not through narratives by male victims of rape and sexual assault, but through those they have elected to trust with their stories of both trauma and empowerment. By leveraging narrative inquiry techniques (or “the study of experience understood narratively”) [6, 7], I have investigated male sexual violence narratives as offered by VSPs across professions and US regions.
In brief, VSPs are trained or licensed professionals (and para-professionals) who provide vital victim support services to victims of sexual assault (SA), not limited to health care, shelter, logistical, crisis hotlines, victim advocacy, legal, emotional, counseling, spiritual, mental health, etc. VSPs form a vital part of a victim’s trusted support system. Professionals in this field can include therapists, counsellors, sexual assault nurses, social workers, victim advocates, rape crisis hotline attendants, etc.
Male victims face a preponderance of social stereotypes and stigmas that presumes them as weak and unmanly – notably in patriarchal societies. As a result, grave implications exist for their health utilization behaviors linked to social canons of who qualifies as an ‘ideal victim.’ These social stereotypes also determine rape disclosure – if they so choose to disclose the abuse (a rare feat!). Usually, the careful construction of a therapeutic alliance is the first step to disclosure. However, in clinical and non-clinical spaces, a therapeutic alliance between the victim and the care provider is a sacred thing. Done well, this partnership is vital to disrupting the miasma of social and internalized stigma prevalent with male victims of rape, by offering unique healing and rehabilitative pathways that occur sincerely in that space of therapeutic relief. Still, forming a therapeutic alliance is a challenging undertaking, especially with male rape victims, as the provider must possess the aptitude to cognize and understand, genuinely, the lived experiences and intersectional social realities of male rape victims – especially worst-affected men facing and internalizing shame and stigma.
In addition, therapeutic alliances take weeks (if not months) to gain critical mass. First, the provider and victim must overcome negative victim attributions ordinarily used by male victims – these include feelings of anger, denial, minimization, personal devaluation, social avoidance, etc. [personal communication with a VSP]. For male victims of sexual assault, eventual trust and disclosure of rape and sexual violence is hard-won — particularly with male-to-male victimization, and victims of childhood sexual abuse. Expectedly, a ‘safe space’ materializes between the care provider and victims (who now form a transference dyad, coined by Carl Jung in his 1969 opus “The Psychology of the Transference”)  on the condition that patient-provider trust is established, and the provider expertise is verified. Still, a number of influential factors affects the genuine co-materialization of the therapeutic alliance. For example, the gender of the provider (especially if female), the gender of the perpetrator of the rape (especially if male), the nature of the relationship between the victim and his abuser, and importantly, societal canons on masculinity – including the stigma narratives of VSPs.
Despite these practical Freudian considerations, a lesser proposed ingredient of the therapeutic alliance — rarely clarified in victim discourse — is Authentic Empathy (AE). I describe AE as the aptitude to experience, genuinely, a shared suffering, informed by past or current membership in a stigmatized group, or a well-earned involvement with members of the same group (i.e. through Associative stigma) . By this definition, my research questions elicited stigma-related narratives from VSPs, asking if they had had (1) a history of sexual abuse, (2) if that history provoked their involvement in this line of work, and (3) if it bettered their care through authentic empathy. Initial findings were affirmative of the first two hypotheses. However, the jury is still out on the third, as this part of my study will entail the incorporation of qualitative and quantitative inquiry. I found that a majority of VSPs in my sample of eleven professionals had a prior history of victimization, thus, serving as a frame of trauma reference, and realistically familiarizing them with the tribulations victims of rape and sexual violence face, and informing their instinct to help others in their profession, albeit authentically.
I close by noting, however, that whereas to nurture authenticity in health care, interventionists have included members of the treatment group in the design and planning of their own care , questions remain as to how we can better apply the authenticity of empathy in forming productive therapeutic alliances, especially with stigma-accustomed male victims of rape. In the absence of a personal history of trauma, can a VSP be unconditionally stigma-free in their praxis as reflected in their narrative discourse of male sexual victimization? Can male victims trust that VSPs truly understand? I adress these quandaries in part 2.
Author’s note: Here, I am aware of the stigmatizing role of victim labeling , and the several ideological, situational, epistemological, political, and personal nomenclatures that exist for this group; however, I have used the term victim for editorial coherence. Please note: as a gender-based violence researcher, I like to think of a continuum of emancipation, empowerment and rehabilitation that meaningfully transforms a sufferer of abuse from a state of victimhood to survivorship. Arguably, this transformative process requires premeditated, emancipatory, and meaningful activities, making the use of the term ‘survivor’ oratorical in most violence narratives, consecrating an identity of ‘forced heroism”  or “compulsory survivorship” on victims of abuse who are pedestalized and made faces of serious movements, on a pathway to fast-tracked normalcy, in lieu of real and enacted perpetrator accountability. Ironically, in the late eighties and early ninties, Dora (Ida Bauer) was also considered a feminist anti-heroine, albeit, controversially, owing to “feminist questioning of psychoanalysis” .
- Hlavka, H.R., Speaking of Stigma and the Silence of Shame: Young Men and Sexual Victimization. Men and Masculinities, 2016. 20(4): p. 482-505.
- Link, B.G. and J.C. Phelan, Conceptualizing Stigma. Annual Review of Sociology, 2001. 27: p. 363-385.
- Alcoff, L. and L. Gray, Survivor Discourse: Transgression or Recuperation? Signs, 1993. 18(2): p. 260-290.
- Ardito, R.B. and D. Rabellino, Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research. Frontiers in psychology, 2011. 2: p. 270-270.
- Zetzel, E.R. and M. BOSTON, Current concepts of transference. 1956.
- Clandinin, D.J., Narrative Inquiry: A Methodology for Studying Lived Experience. Research Studies in Music Education, 2006. 27(1): p. 44-54.
- Connelly, F.M. and D.J. Clandinin, Stories of Experience and Narrative Inquiry. Educational Researcher, 1990. 19(5): p. 2-14.
- Enriquez, M. and V.S. Conn, Peers as Facilitators of Medication Adherence Interventions: A Review. Journal of primary care & community health, 2016. 7(1): p. 44-55.
- Smith, R.A., X. Zhu, and M. Quesnell, Stigma and Health/Risk Communication. 2016, Oxford University Press.
- Storr, W. (2011, July 17). The rape of men: the darkest secret of war. Retrieved from https://www.theguardian.com/society/2011/jul/17/the-rape-of-men
- Fragments of an Analysis of a Case of Hysteria (1905 , Standard Edition Vol. 7, pp. 1–122).
- Billig, M. (1997). Freud and Dora: repressing an oppressed identity. British Journal of Social Psychology, 216-252. doi:10.1017/cbo9780511490088.008
Image: Ida Bauer [Dora] and her brother Otto, 1890. Copyprint. Verein für Geschichte der Arbeiterbewegung. Vienna (50)