Chuka Nestor Emezue //

The “alliance” doesn’t necessarily solve problems in its own, but it sets the foundation for healing…” [1]

In a previous Synapsis post, I introduced the notion of the Therapeutic Alliance (TA) – an active ingredient of psychopathology and psychotherapy. I discussed the antecedence of therapeutic relationships formed between victim service providers (VSPs) and male victims of sexual assault (e.g. rape, molestation, sodomy, etc.). My interest? Their therapeutic and extra-therapeutic rehabilitation and healing, and how this process (a continuum of healing, more or less) is impacted by social stigma. Male victims infrequently seek care, making further scholarship in this domain problematical, but welcoming.

The Therapeutic Alliance (TA), in my opinion, facilitates what is typically a fraught relationship between therapist and client, clinician and patient, advocate and survivor. In the absence of a well-oiled TA, the therapeutic process is mechanical at best;  like a blind date.

A reliable therapeutic tool in the realm of psychotherapy, the concept of the TA was popularized in the US by Dr. Elizabeth Zetzel after WWII (a one-time associate clinical professor of psychiatry at the Harvard Medical School and VP of the International Psychoanalytical Association) [2].

In this post, I review the advantages of a well-formed TA—specifically, as a de-stigmatizing process for interrupting male victim stigma. Stigma, if you recall, can be an obstruction to seeking supportive care services post-assault, sometimes rated a “dishonorable” practice by male victims of sexual violence, especially male-to-male perpetrated sexual violence[3].

In trying to make sense of the origins of the TA, I stumbled on one of Freud’s infamous case-study: a story of 21-year-old Bertha Pappenheim (aka Anna O). Anna O was diagnosed as a ‘hysterical’ patient, attended to by both Freud and her original doctor, Dr. Josef Breuer. Following a series of experimental treatments (what would form the basis of psychoanalysis), including hypnosis and free association, Freud realized that Anna O projected daughterly emotions towards Dr. Josef Breuer, who in turn reciprocated with filial feelings of his own, considering Anna O to be daughter-like. This case-study was grounding for Freud’s commentary and subsequent popularization of the psychoanalytic terms: ‘transference’ and ‘countertransference’ – both of which are common by-products of the TA presented here [4]. Whereas a TA can develop at the proximal stage of care, the counterpart states of transference-countertransference co-happen at the distal phase of care. Thus, both the TA and transference-countertransference states substantially sway the outcome of care for victims of sexual assault.

However, a little quandary emerges. The field of domestic violence praxis has not before now been enthused about researching stigma management strategies used by male victims of assault (often in competition with female victim care) and those who they imbue with their therapeutic confidence.

In these new waters, where the primary intention of a TA is to provide rehabilitation for victims of sexual violence, I argue that VSPs who provide a slew of services—”including shelter programs, advocacy services, transitional housing, support groups, supervised visitation centers, outreach, and counseling services”—remain in the best position to interrupt outcomes of social stigma faced by male victims of sexual violence. Having formed a hard-earned rapport with skeptical male victims, they remain pertinent players in providing validating authentic empathy (AE).

“Healing is achieved through love,” Freud wrote to his friend (and later nemesis), Swiss psychoanalyst Carl Gustav Jung (December 6, 1906, letter correspondence ).

Sitting in an office (that hallowed therapeutic space) paying close attention to the hesitant grunts of a male victim of sexual violence, implicates VSPs in my research. While most researchers rightly turn to the victims themselves for needed insight, I find that VSPs occupy a position of rare privilege. Making them privy to the direct and indirect expressions of negative victim attributions common with male victims of sexual assault (i.e. anger, self-blame, denial, debility, suicidal ideation, depression, and suggestive PTSD) [5] and how they manage stigma – among other things. When asked in-depth, VSP will reveal that negative victim attributions for male victims can involve feelings of disempowerment (or a lack of individual agency), feelings of being feminized by the traumatic experience, all of which can result in hesitancy to seek help from formal establishments (e.g. rape crisis centers), particularly with males who have experienced childhood sexual assault [6]. But there is a twist. Unsurprisingly, male victims have implicated care providers are agents of this stigmatizing processes.

It is no surprise that social psychologists have noted the therapeutic tension that molds at the nexus of therapeutic communication between stigmatized and non-stigmatized group members. The hypothesis is that those who have never been impacted by sexual violence are perhaps unable to authentically empathize. This hypothesis is of interest to me. I propose that it is such a big deal, enough to be of detriment to the quality of care sought by victims, especially where this stigma-non-stigma encounters can easily replicate the social ostracizations faced by male victims in larger society [9]. Thus begging the questions: are there palpable variations in the quality of victim care provided when the service provider cannot authentically empathize? Simply put, am I a better care provider if I share with my client a history of sexual assault? To answer this question, I am currently conducting in-depth formal and informal interviews with multi-disciplinary VSPs across the country.

But for now: Some Benefits of the TA

Not surprisingly, one benefit of establishing the TA is the construction of empowerment (some may say co-empowerment). Done right, empowerment includes the creation of dignity and self-efficacy, enough to place a victim (gender irrespective) on the part to survivorship – I mean, genuine survivorship. Not the placatory and political connotation of the term used to assuage victims of assault into a sense of compulsory heroism and to fatten up mission statements into political correctness.

To get male victims of sexual assault to contend with (and overcome) social stigma to receiving care and healing from trauma, a useful TA is a key mitigator. In fact, males rarely make up the epidemiological samples of any kind of health promotion intervention. With the male victim of sexual assault, social stigma can be paralyzing in view of hegemonic masculine stands that are reliably punitive of weakness in men, making it unlikely that they seek out any kind of support, or even disclose the violence to begin with. VSPs must remain aware of their roles in managing victim stigma, and the formal and informal spaces in which stigma management can be intentionally stimulated and pro-actively sustained.

Another advantage of the TA, leads me to acknowledge Goodman et al’s (2016) reference to Dr. Stevan E. Hobfoll’s Conservation of Resources (COR) resource-oriented theory from the field of organizational psychology, organizational burnout, and family distress [1]. Hobfall’s COR posits the Primacy of Resource Loss principle, that is, it is more harmful to lose resources than it is helpful to gain resources. Goodman et al’s (2016) apply this theory to victims of violence. The retrieval of social, emotional, and personal assets lost (i.e. social capital, dignity, autonomy) during the process of victimization is crucial to their rehabilitation. Too often, the loss of vital resources can send a victim into a “trauma spiral,” impacting every aspect of their lives. It becomes a function of the TA to identify this loss and proffer support towards rehabilitation. For example, helping a female victim of violence with a safety plan that includes financial empowerment (i.e. useful employment and stable housing). The fragility of the TA makes it a crucial ingredient on this road to resource recovery.

Long before my study reached conception, the moral and ethical liberties of un-stigmatized or “outsider” scholars who study stigmatized groups have been called into question by other researchers [7]. Their proposition is that “scholars who do not belong to stigmatized groups may fail to understand the lived experiences of those who do belong to stigmatized groups and may favor a priori concepts and fail to adjust their scholarship to those insights” [7]. The odds of mischaracterizing and misunderstanding the needs of a male victim seems highly plausible if the VSP does not fully understand the sociocultural, political, and psychosocial dynamics of stigma with the subgroup.

However, it is worth considering that the improvement of mental, behavioral, and psychosocial care outcomes for members of clinically stigmatized groups—where the health care provider is not authentically privy to the stigma in question – remains a vexing point of debate.

Another point of divergence is in the use of positivist models in addressing psychosocial issues such as stigma, as opposed to psychosocial models that take into consideration the social context of stigma, which may be sociocultural in nature (e.g. hegemonic masculinity and the gendering of violence), socioeconomic in texture (e.g. shelter services unable to cater to male victims), and social-structural in scope (e.g. female-facing rape laws).

Researchers agree that alliances formed based on survivor empowerment models between survivors and their advocates can reduce PTSD and depression [1]. However, between them, this relationship is moderated by complex and intersectional socioecological factors (i.e. gender dynamics, race, and socioeconomic status) and temporal factors (i.e. duration of the relationship) [1]. Thus, the psychosocial compensations of an alliance are undisputable. However, what is seldom discussed is if this relationship is better improved if the care provider has had a primary (or secondary) encounter with sexual violence and if this history further enriches their care. Over 90% of VSPs I sampled for my study have had a history of abuse. This may speak to the ubiquity of gender-based violence (GBV) in our society (35% of women and 28% of men in America). But does it speak to why VSPs chose this line of work in the first place?

Naturally, this is controversial. We would not expect a neurologist to have had a traumatic brain injury (TBI) to better appreciate its damage, or anticipate that a judge in criminal court will bring her criminal past to bear in deciding what punishment is commensurate for a violent rapist. However, if care providers and organizations designed to offer victim support services have been implicated as part of the stigmatizing process, could a nuanced understanding of stigma management in the hallowed space of the therapeutic alliance be a starting point for research, praxis, and stigma-informed survivor rehabilitation?

Work Cited

  1. Goodman, L.A., et al., Domestic violence survivors’ empowerment and mental health: Exploring the role of the alliance with advocates. Am J Orthopsychiatry, 2016. 86(3): p. 286-96.
  2. Zetzel, E.R., Current concepts of transference. Int J Psychoanal, 1956. 37(4-5): p. 369-76.
  3. Lyons, B. and L. Dolezal, Shame, stigma and medicine. Medical humanities, 2017. 43(4): p. 208-210.
  4. Meissner, W. W. (2007). Therapeutic alliance: Theme and variations. Psychoanalytic Psychology24(2), 231-254. doi:10.1037/0736-9735.24.2.231
  5. Davies, M., Male sexual assault victims: a selective review of the literature and implications for support services. Aggression and Violent Behavior, 2002. 7(3): p. 203-214.
  6. 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.
  7. Smith, R.A., X. Zhu, and M. Quesnell, Stigma and Health/Risk Communication. 2016, Oxford University Press.

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