ChrldAbuse& Ne&ct, Vol. 16, pp. 585-593, Primed in the U.S.A. All rights reserved.
1992 Copyright
0145~2134/92 $5.00 + .OO Q 1992 Pergamon Press Ltd.
COUNTERTRANSFERENCE IN THE FAMILY THERAPY OF SURVIVORS OF SEXUAL ABUSE JOSEPH J. SHAY McLean Hospital Institute for Couples and Families, Belmont, MA; Harvard Medical School, Boston, MA
Abstract-As family therapy of sexual abuse survivors has become more common, theoretical and technical issues have received considerable attention. Less attention has been devoted to the countertransference experience of the therapist. Unexamined therapist countertransference is a critical element in the treatment of these families, which markedly influences the nature and direction of treatment. Particular types ofcountertransference are presented here. In addition, the contention is made that counte~ransference is not only evoked by the particular presentation of the family members, but also by the therapist’s unexplored political and moral beliefs. Key Words-Countertransference,
Survivors, Sexual abuse.
INTRODUCTION FAMILY THERAPY WITH survivors of sexual abuse has become increasingly common, and many articles and texts have been written about this area (Courtois, 1989; Friedrich, 1990; Gelinas, 1986, 1988; Goodwin, 1989; Herman, 1983; Schatzow & Herman, 1989; Wheeler, 1990). As this modality of treatment is explored, particular technical and theoretical questions are raised, for example, questions about disclosure, responsiblity, inclusion of the perpetrator, the goals of treatment, and others. This paper suggests that the family therapy of this population, while immensely complicated technically and theoretically, is made even more complicated by the therapist’s countertransference experience which is significantly underemphasized in our work (Attias & Goodwin, 1985; Danieli, 1988; Jones, 1986; Krell & Okin, 1984; Lisman-Pieczanski, 1990; McCann & Pearlman, 1990; Parson, 1988; Pollak & Levy, 1989; Wilson, 1989). It is also suggested that our counte~ransference experience is made up not only of our individualized emotional reactions, conscious and unconscious, evoked by the patient, but even more centrally by our political and moral beliefs and by our working assumptions of male-female interactions. This paper sugests that the therapist’s sexual politics are inextricably interwoven with his or her countertransference experience. While our understanding of families in which there is sexual abuse shares some commonalities with our undemanding of other dysfunctional families (Stiver, 1990), there are also profoundly important differences. Specifically, the differences are in the ways in which our societal institutions have been unable
Presented on October 20, 1990 in a McLean Hospital Conference entitled “Sexual abuse: Long-term effects and treatment dilemmas.” Received for publication November 16, 1990; final revision received July 18, 199 1;accepted for publication August 30, 1991. Requests for reprints may be sent to Joseph J. Shay, Ph.D., Mclean Hospital, 115 Mill St., Belmont, MA 02 178. 585
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to integrate or deal constructively and progressively with the areas of sexuality, violence, and power. First it may be useful to describe a particular family therapy situation in which the author experienced marked counter-transference reactions which are readily recognizable to the experienced clinician.(In this paper, the “totalistic” approach to countertransference [Kernberg, 19651 is used, referring to “the total emotional reaction” of the therapist to the patient.) After describing this clinical situation, which occurred more than 10 years ago, these countertransference reactions will be placed in a larger social and political context.
CONFRONTING
THE FAMILY
Mary O’Brien was an adolescent in a comprehensive adolescent day treatment program for 2 years. She had come to the program at age 17 after several brief hospitalizations for depression, withdrawal, paranoid psychotic delusions, and suicidal ideation. Her father was an Irish immigrant who had been disabled for 20 years by arthritis that left him with a severe limp and in need of a cane. Her mother was a dietary worker, prone to serious medical problems of the circulatory system, partly due to being at least 150 pounds overweight. Mary had assumed many of the household functions, despite having four siblings (three brothers and an older sister). Throughout Mary’s stay in the program, as her case administrator and group therapist, I grew very attached to her. She was the kind of intermittently psychotic, forlorn, sad-eyed teenager toward whom one often experiences rescue fantasies, a common countertransference reaction with child or adolescent survivors of abuse. It is possible that such rescue fantasies exist as a defense against the overwhelming countertransference sadness which is so common in talking with depressed survivors of abuse. After a year and a half in the day program, and just prior to her projected termination date, she revealed to me that her wish to die was related to a secret she could not share. I notified her individual therapist, Ms. James, who helped Mary reveal a history of sexual abuse by her father from the ages of 5 to 14. The couples therapist, Ms. Davis, a colleague of Ms. James, was also notified, although the information was not to be shared with the parents. Ms. Davis, who had been treating the couple using a parent guidance model, shared with me her evaluations offather and mother and her conceptualization of the couple as dysfunctional in their parental and marital roles, and unwilling to recognize the severity of the difficulties in their daughter and in the family. Subsequent to Mary’s disclosure, she was depressed and anxious for 2 weeks, followed by a period of increased animation and brightened spirits. She decided to discontinue her antipsychotic medications (against medical advice), and remained in good spirits for the next month. Having treated very few abuse victims, my initial countertransference experience was one of disbelief and then of minimization of the situation, experiences which are not uncommon (Goodwin, 1989; Lister, 1982; Pollak & Levy, 1989). Nonetheless, I arranged a consultation with a local expert on father-daughter incest. The expert recommended that Mary’s individual therapy focus on her disappointment in her parents and on her need to grieve for the caretaking of which she had so clearly been deprived. In addition, the expert also recommended delaying any family involvement with respect to the “alleged molestation” (as my notes read) because Mary was too unstable. Shortly after this, Mary’s condition worsened, with increasing depression, profound suicidal ideation, and on one occasion, flashbacks of the molestation by father, with whom Mary was still living. She was admitted to McLean Hospital, a private psychiatric hospital within which the day program was located, having been granted 2 weeks of free care. After several consultations with senior clinicians (all male), and
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multiple conversations with a grudgingly approving Mary, a decision was made to confront the family. Because I had established a good relationship with the family, it was decided by the senior consultants that I should confront the father. I was petrified. First, I had never done this before. Second, I was not completely convinced that the sexual abuse had occurred. Even the consultant had not expressed complete conviction at the time. Third, I did not know how the family would react. Mary, who agreed to the confrontation, but refused to be present, had already warned me that if her oldest brother was present, he would assault me. I decided I didn’t want to meet him. We did invite him and the other two brothers, and her sister, but the three brothers were going to meet with another therapist for history-gathering purposes, while the sister would be with Ms. James and Ms. Davis to be questioned about whether she had been abused. Here is a portion of my notes from the confrontation many years ago based on the guidance of the senior consultants who had few suggestions except to be direct and firm. These notes are as clear as they are because I wrote them before the confrontation, and practiced them several times. Confrontation: “I need your help, Mr. and Mrs. O’Brien, because without it, I think Mary will kill herself. I need to talk with you about some very serious and painful issues from the past that we know about that contribute to making Mary sick. It’s very important to be open, direct, and honest with each other. This may make you very depressed or very angry, but we need to do it anyway because otherwise Mary may kill herself. . Keep in mind, I’m a mental health professional. I’m not here to criticize you or judge you, but to help Mary and help the family because we believe the whole family has serious problems. Several months ago, Mary told us that she had a secret, and the memory of the secret was making her want to die. You know what the secret is. She told us when she was a child, you had sexual contact with her. We need to talk about this, and together try to figure out what caused it to happen, and how the family can live with what happened, and how the family can get better. Mr. O’Brien, it must have been awful for you to have to carry this secret all these years?”
I remember being grateful that I was through because I was completely breathless at this point, on the edge of hyperventilating. I have rarely experienced such anxiety as a professional. (The other occasion I can recall was during my graduate school training when I first discussed sexual intercourse in detail with a couple who were the same age as my parents.) Reaction Father, to my surprise, was neither angry nor upset. He said, immediately, “My right hand to God, I swear it never happened, and if it did happen, I have no memory of it.” Father added that Mary must have imagined it. He knew that when such allegations came before a judge, “9 out of 10 times, you believe the doctor,” and he could understand how someone would, but “it’s my word against hers.” He went on to describe how such behavior was “animalistic” and “the shame and the guilt” of being accused. Having regained my breath, I was starting to lose my bearings. I was confused. I had expected him to confess. I began to wonder whether I’d made a terrible mistake, although my doubts suddenly gave way as my mind finally heard what father had said: “If it did happen, I have no memory of it.” I now felt certain. I persisted, stating that Mary was very believable, that I believed her, that such behavior was not animalistic but a part of human nature, and that, of course, father would have to deny it because of his shame and guilt. I added that we had no intention of recommending legal action. I said again how painful it must have been for father to have lived with this sense of being so awful. Father said if it had happened he would have confessed it to a priest, and if it didn’t a confession wouldn’t have meant anything. “What if Theresa, Mary’s sister, says it also happened to her?’ I asked. Mother giggled, and said, “I’d say his memory’s goin’ bad on him.” Mother then changed the subject, with what I
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noted as “inappropriate laughter,” and when returned to the subject said “If he did it, I’d throw him out. I’d put him through the roof. There wouldn’t be anything left of him.” Mother denied any knowledge of this, including denial of Mary’s allegation that mother had once walked in when father was in Mary’s bed. I remember feeling angry at mother at this point, with a sense of revulsion. I do not recall experiencing anger at father. (Please remember, I am not defending my reactions, but just describing them.) But then, surprising to me, I was completely calm. I would actually say I was dissociated. Having had this experience on subsequent occasions, I have come to call this experience “counterdissociation,” namely dissociation that occurs defensively to protect the clinician from overwhelming confusion or other intense affect in the presence of abusers who deny the abuse or victims who describe it. Father then asked, “Exactly when did Mary say this happened?” “On several occasions,” I said. At first father understood me to mean several times during a brief period, and once he understood that I meant over a period of years, he said, “Oh, no, definitely not. It didn’t happen over a period of years. My right hand to God, it didn’t happen. I have to say then, she’s a liar.” My notes end at this point, except to say that the parents were reluctant to go to their couples therapy in a few hours, with mother complaining of tiredness, and father complaining of his arthritis. I asked father to return to meet with me alone the following day, and he asked whether he should visit Mary on the inpatient hall. I did not discourage him from this. (I certainly would today.)
In subsequent days, Theresa, the sister, denied anything had ever happened to her, and suggested that Mary was not lying but distorting father’s “overaffectionateness.” Mary later recovered a memory of hearing Theresa scream, having blood on her bedsheets, with father nearby with blood on his hand. Father, following the confrontation, spent several sleepless nights praying and tearful, according to family members, but continued to deny the abuse. Mary reported in much more detail the specifics of the abuse, to the point where she was entirely credible. But nothing ever came of this. At other times, Mary wondered whether she had imagined the abuse. Her recantation, which 1 did not then know was a common occurence, relieved me, and made me wonder whether I had been abusive to the father, as I recanted my certainty. Mary’s condition continued to fluctuate, with a clear downward trajectory, and she wanted no more pursuit of the issue with her father. The clinical team simply dropped the issue. Mary was rehospitalized once during the following 4 months, with depression and suicidality, and after graduation from the adolescent day program, went into an adult day hospital program. I heard from her and about her during the next several years, and her condition looked chronic. Mother died 2 years ago, and sister died last year, with Mary living at home with father. She has remained in individual treatment intermittently with her therapist from years before and has required multiple hospitalizations. I continue to feel guilty about this situation and in writing about it for this article, I also feel ashamed that I had not done more.
COMMON
COUNTERTRANSFERENCE
REACTIONS
In this description, I have attempted to highlight specific countertransference experiences which I believe are relatively common in working with survivors of abuse and their families, for example, rescue fantasies, overwhelming sadness, disbelief, anger, revulsion, confusion,
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with survivors
dissociation, guilt, shame, and premature forgiveness. Other typical reactions described in the literature are rage at the perpetrator, identification with the perpetrator (especially in the absence of the victim), fear, titillation, and sexual feelings toward the survivor (Ganzarain & Buchele, 1986; Kohan, Pothier, & Norbeck, 1987; Krieger, Rosenfeld, Gordon, & Bennett, 1980; McCann $2 Pearlman, 1990; Morris, Johnson, & Clasen, 1985; Pollak & Levy, 1989). It may not be surprising to the reader that these experiences are similar to those experienced by the survivor herself and the family, with these countertransference experiences providing a window into the experience of the family members who cannot always communicate the experience directly. The reader may also recognize that, in Mary’s case, the treatment team recapitulated the family dynamics, that is, Mary disclosed the abuse to us, and eventually, we did nothing about it and acted as though it had never occurred. Impact on Treatment In retrospect, I believe that I failed to help this young woman and her family because I did not understand or appreciate my countertransference experience or the beliefs, values, attitudes, and politics that underly it. Overwhelming confusion is incompatible with successful treatment. To combat my confusion, I resorted to oversimplification of the situation, and fell back on unexamined personal beliefs, that is, unexamined countertransference biases, which were not entirely appropriate to the situation. Among these beliefs were: Incest reports are frequently untrue; disclosure and confrontation of the abuser are essential to progress; confrontation met by responsibility of the perpetrator can result in rapid improvement; forgiveness by the abused person is essential to progress; the mother’s underlying role, including collusive support of the father, is central to the dynamics of the situation; and, the abuse experience, while profound, may not have long-lasting sequelae if the family can acknowledge the abuse. I invite the reader to think about his/her beliefs in response to the following four questions, because the direction of treatment ofthese families rests upon the answers to these questions. I do not have to begin with the question upon which I foundered more than 10 years ago, namely, whether abuse can be a profound and persisting trauma in someone’s life. This idea is now well-documented (Browne & Finkelhor, 1986; Finkelhor, 1984, 1988; Finkelhor & Browne, 1985; Gelinas, 1983; Goodwin, 1989; Lindberg & Distad, 1985; Westen, Ludolph, Misle, Ruffins, & Block, 1990; Wolf, Gentile, & Wolfe, 1989). The reader will recognize that these questions may not always be answered simply “yes” or “no,” without regard to the particulars of a situation. Nonetheless, I suggest here that all therapists have their own countertransferential predispositions which are critical to recognize.
AN EXPLORATION
OF PERSONAL
BELIEFS
The Question of Collusion Do you believe that the mother colludes in the sexual abuse of the child? Many authors (Furniss, 1983; Gutheil & Avery, 1977; Zuelzer & Reposa, 1983) have argued this postion, but few so forcefully as Lustig, Dresser, Spellman, & Murray ( 1966) who wrote, “It is interesting that despite the formal innocence of the mother in the actual incestuous event, she seems to emerge as the key figure in the pathological transactions involved. . . . Despite the overt culpability of the fathers, we were impressed with their psychological passivity in the transactions leading to incest. The mother appeared to be the cornerstone in the pathological family system.” James & MacKinnon ( 1990), in providing a feminist critique of this arguement, decry the
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“myth of pathological fathers and inadequate mothers” (p. 73). This critique is also taken up by Goodrich, Rampage, Ellman, & Halstead (1988) who says that “by turning the light on Mother-her failure to satisfy her husband, her failure to enact a proper executive role, her failure to stand guard, her failure to know-a therapist conceals the reproaching truth that domination by Father can lead to abuse. Father’s absolute power as head of the household can corrupt absolutely” (p. 18). (The reader is also directed to Caplan & Hall-McCorquodale (1985) who identify 72 different psychological disorders that are attributable to mother’s failings.) The Question of Blame Do you believe that the therapist should tell the victim of abuse that he or she is in no way responsible, that he or she is not to blame? Is it true that “Nothing you did caused the abuse; nothing within your power could ever have stopped it . . . It’s never your fault . . . it is always the responsibility of the adult to behave with respect to children” (Bass & Davis 1988, pp. 104, 105, 107). Or are your therapeutic interventions based around the idea that “Therapists must take care not to confer victim status on these children, thereby diminishing a feeling of power that may be important to the child in the future . . . Saying ‘it’s not your fault’ is not helpful because it does not address the sense of power and control that children who have experienced sexual abuse often feel in addition to their guilt” (Lamb, 1986, pp. 303-305). The Question of Family Reunion The third key question centers around the therapist’s belief in the possibility of genuine and profound change in these families, which would allow the family to be reunited. Herman (198 1) describes the view of many therapists who “feel strongly that it is in the best interests of all concerned for fathers to return to their families. The very names of such self-help groups as Parents United or Families Re-United make it clear that the emphasis is on re-establishing the nuclear family” (p. 159). Other therapists argue with equal vigor that “the sexual abuser forfeits the possibility of reconciliation by virtue of his actions against his victim and that the vast majority of victims do better, and are safer, when their therapy and their future lives do not include their abusers. . In fact, the goal of some therapists to reconstitute the family may be largely an impossible one, at least on a psychological level” (Briere, 1989, p. 138). The Question of Power Finally, each therapist must ask whether he or she believes that the abuser is meeting needs for sex, for nurturance, or for power? Is sexual abuse an attempt at gaining sexual gratification? Or is it “. . . an expression of the search for interpersonal attention, affection, and nurturance by the adult offender. . . Holding center stage in incest is not sex, but need-and the need is usually for relatedness” (Gelinas, 1986, p. 344). Or is sexual abuse rape? “Rape is rape: rape is about power. Each single time a Father approaches a Daughter sexually, it is rape.” (Ward, 1985, p. 138). There are a number of other important questions to be considered as well. For example, should an abuse survivor be encouraged to disclose the abuse to the family and to confront the abuser? Should the survivor be encouraged to forgive the abuser? Should a male therapist be treating female victims of abuse or their families? Finally, one last question which, in terms of counter-transference, may be the most perplexing question of all: If you hold the abuser, the victimizer, entirely responsible for the abuse, what is your countertransference reaction to-
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ward him when you learn that he was a victim as a child? At what point does responsibility occur?
THE POLITICS
OF TREATMENT
In my review of these questions and ideas, I hope that the reader has noticed that our vocabulary of treatment is not only clinical but also political, moral, and legal. This treatment involves the political vocabulary of power, patriarchy, and submission; the moral vocabulary of forgiveness, blame, and responsiblity; the legal vocabulary of innocence, guilt, rape, victim and perpetrator. Is there any other patient population with which we work where this larger societal influence is so centrally present? My argument is as follows: We, who are to become family therapists, grow up in and participate in the social arrangements of society. Once we become family therapists, we experience the social arrangements of the family as they engage in these arrangements in therapy. Our experience of the family, however, including the inevitable and profound countertransference reactions that we develop, occurs not only in the context of their social arrangements, but also against the silent backdrop of our own earlier participation in society. That is, there is an inextricable relationship between the way we, as family therapists, grow up in and participate in the social arrangements of society, and the way we experience and develop countertransference reactions to the family members in family therapy. This is powerfully true in the family therapy of survivors of sexual abuse because of the pervasive and unavoidable effects of sociocultural factors on our personal experience of sexuality and power.
CONCLUSION My contention is that where we stand in these areas, our political, moral, and institutional beliefs, undergird our counter-transference reactions in therapy, and consequently underlie our interventions. Our therapy interventions related to collusion, blame, forgiveness, restoration of the family, treatment, or punishment, do not grow simply out of our clinical knowledge base, but grow centrally from our personal beliefs and values in these realms. These personal beliefs and values are the soil out of which our countertransference grows, in combination with the specific nutrients provided by the particular patients with whom we work. As with all countertransference, the goal is not to eliminate countertransference, even if that were possible, but to understand and appreciate it. Such understanding grants the therapist an awareness of potential blindspots, prejudices, and stereotypes, highlighting areas in which he or she will have a harder time empathizing with the patient’s experience because of a pre-existing belief. Intense countertransference of which the therapist is unaware interferes with the capacity for empathy when the patient is articulating an experience that does not fit with the therapist’s model. The closer the therapist can get to the experience of all the patients in the family, the better he or she is able to understand them and to empathize with them. Finally, the contention of this paper can be simplified even further: Countertransference does not begin in the office, it begins at home. Counter-transference begins at birth. Acknowledgements-The author thanks Laura Zimmerman an earlier version of this paper.
and Carolynn Maltas, Ph.D., for helpful comments on
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REFERENCES Attias, R., & Goodwin, J. (1985). Knowledge and management strategies in incest cases: A survey of physicians, psychologists and family counselors. Child Abuse & Neglect, 9, 521-533. Bass, E., & Davis, L. (1988). The courage to heal: A guide for women survivors of child sexual abuse. New York: Harper and Row. Briere, J. (1989). Therapyfor adults molested as children: Beyond survival. New York: Springer. Browne, A., & Finkelhor, D. (I 986). Impact of child sexual abuse: A review of the literature. Psychological Bulletin,
99,66-77. P. J., & Hall-McCorquodale, I. (1985). Mother-blaming in major clinical journals. American Journal of Orthopsychiatry, 55, 345-353. Courtois, C. A. (1989). Healing the incest wound: Adult survivors in therapy. New York: Norton. Danieli, Y. (1988). Treating survivors and children ofsurvivors of the Nazi Holocust. In F. Ochberg (Ed.), Post-traumatic therapy and victirk of violence (pp. 278-295). New York: Brunner/Mazel. Finkelhor. D. (1984). Child sexual abuse: New theorv and research. New York: Free Press. Finkelhor; D. (1988j. The trauma of child sexual ab&e: Two models. In G. E. Wyatt & G. J. Powell (Eds.), Lasting effects qf child sexual abuse, (pp. 6 l-82). Beverly Hills, CA: Sage. Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55, 530-54 1. Friedrich. W. N. C1990). Psvchotheraov of sexuallv abused children and their families. New York: Norton. Furniss, T. (1983)‘. Family process in&e ireatmeni of intrafamilial child sexual abuse. Journal of Family Therapy,& 263-278. Ganzarain, R., & Buchele, B. (1986).Countertransference when incest is the problem. International Journal of Group Psychotherapy, 36, 549-566. Gelinas, D. J. (1983). The persisting negative effects of incest. Psychiatry, 46, 3 12-332. Gelinas, D. J. (1986). Unexpected resources in treating incest families. In M. Karpel (Ed.), Family resources: The hidden partner in,family therapy (pp. 327-358). New York: Guilford. Gelinas, D. J. (1988). Family therapy: Critical early structuring. In S.M. Sgroi (Ed.), Vulnerable populations (pp. Caplan,
5 l-77, Vol. 1). Lexington, MA: Lexington Books. Goodrich, T. J., Rampage, C., Ellman, B., & Halstead, K. (1988). Feminist family therapy: A casebook. New York: Norton. Goodwin, J. (1989). Se_xualabuse: Incest victims and theirfamilies. Chicago, IL: Yearbook Medical publications. Gutheil, T., & Avery, N. (1977). Multiple overt incest as family defense against loss. Family Process, 16, 105-I 16. Herman, J. L. (1981). Father-daughter incest. Cambridge, MA: Harvard University Press. Herman, J. L. (I 983). Recognition and treatment of incestuous families. International Journal ofFamily Therapy, 5,
81-91. James,
K., & MacKinnon,
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Journal of Marital and Family Therapy, 16,11-78. Jones, D. P. H. (I 986). Individual psychotherapy for the sexually abused child. Child Abuse & Neglect, 10,377-385. Kernberg, 0. F. (1965). Countertransference. Journal of the American Psychoanalytic Association, 13, 38-56. Kohan, M. J., Pothier, P., & Norbeck, J. S. (1987). Hospitalized children with history of sexual abuse: Incidence and care issues. American Journal of Orthopsychiatry, 57, 258-264. Krell, H. L., & Okin, R. L. (1984).Countertransference issues in child abuse and neglect cases. American Journal of Forensic Psychiatry, 5, 7- 16. Krieger, M. J.. Rosenfeld, A. A., Gordon, A., & Bennett, M. ( 1980). Problems in the psychotherapy of children with histories of incest. American Journal ofPsychotherapy, 34, 81-881 Lamb, S. (1986). Treating sexually abused children: Issues of blame and responsibility. American Journal cjf Orthop-
sychiatry. 56, 303-307. Lindberg.
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Child Abuse and Neglect, 9, 329-334. Lisman-Pieczanski, N. (1990). Countertransference in the analysis of an adult who was sexually abused as a child. In H. Levine (Ed.), Adultanalysis and childhood sexual abuse (pp. 137-147). Hillsdale, NJ: Analytic Press. Lister, D. (1982). Forced silence: A neglected dimension of trauma. American Journal of Psychiatry, 139, 872-875. Lustig, N., Dresser, J. W., Spellman, S. W., &Murray, T. B. (1966). Incest: A family group survival pattern. Archives
of General Psychiatry, 14, 3 l-40. McCann, I. L., & Pearlman, L. A. ( 1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. iJournal of Traumatic Stress, 3, 13 1- 149. Morris. J. L.. Johnson. C. F.. & Clasen. M. (1985). To report or not to report: Physicians attitudes toward discipline and child abuse. American Journal of Disease of Children, 139, 194- i97. _ Parson, E. R. (1988). Post-traumatic self disorders (PTsfD): Theoretical and practical considerations in psychotherapy ofvietnam war veterans. In J. P. Wilson, Z. Harel, and B. Kahana (Eds.), Human adaptation to extremestress: From the Holocaust to Vietnam (pp. 245-284). New York: Plenum Press. Pollak, J., & Levy, S. (1989). Countertransference and failure to report child abuse and neglect. Child Abuse di Neglect, 13, 5 15-522.
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Schatzow, E., & Herman, J. L. (1989). Breaking secrecy: Adult survivors disclose to their families. Psychiatric Clinics of North America,, 12, 331-349. Stiver, I. P. (1990). Dysfunctional families and wounded relationships, Part 1. #4 1. Stone Center for Developmental Studies, Wellesley, MA, (work in progress). Ward, E. (1985). Father-daughter rape. New York: Grove Press. Westen, D., Ludolph, P., Misle, B., Ruffins, S., & Block, J. (1990). Physical and sexual abuse in adolescent girls with borderline personality disorder. American Journal of OrthopsychiatryM, 60, 55-66. Wheeler, D. (1990). Father-daughter incest: Considerations for the family therapist. In M. P. Mirkin (Ed.), The social and political contexts offamily therapy (pp. 139- 157). Boston, MA: Allyn and Bacon. Wilson, J. P. (1989). Trauma, transformation, and healing: An integrativeapproach to theory, research, andpost-traumatic therapyM. New York: Brunner/Mazel. Wolfe, V.V., Gentile, C., & Wolfe, D. A. (1989). The impact of sexual abuse on children: A PTSD formulation. Behavior Therapy, 20, 2 15-228. Zuelzer, N., & Reposa, R. (1983). Mothers in incestuous families. International Journal of Family Therapy, 5, 98-109.
Resume-L’utilisation de la thtrapie familiale dans la prise en charge des survivants d’abus sexuel est devenue plus courante ce qui a entrain6 un inttret considerable pour les aspects theoriques et techniques. Cependant moins d’attention a et6 consacree au contre-transfert du thtrapeute. L’absence d’analyse du contre-transfert du therapeute est consider6 comme un Clement critique du traitement de ces familles, influencant non settlement la nature mais aussi la direction du traitement. Des types particuliers de contre-transfert sont analyses. L’hypothese forrnulee est que le contre-transfert du therapeute n’est pas seulement determine par la presentation particulitre des differents membres de la famille, mais aussi par les croyances politiques et morales inexplorees du thtrapeute. Resumen-Cada di es mas comlin la terapia familiar de 10s sobrevivientes de1 abuso sexual, 10s aspectos tebricos y tecnicos han recibido una atencion considerable. Se le ha dedicado menos atencion a la contratransferencia que experimenta el terapista. La contratransferencia de1 terapista que no es tomada en cuenta, es considerada coma un element0 critic0 en el tratamiento de estas familias que influye necesariamente en la naturaleza y la direccidn de1 tratamiento. Algunas reacciones especificas de contratransferencia son: Fantasias de restate, tristeza sobrecogedora, incred-.ilidad, rabia, repulsion, confusion, disociacibn, culpa, vergtienza, perdon prematuro, rabia contra el perpetrador, identificacibn con el perpetrador (especialmente cuando la victima no esta), miedo, pulsion y sentimientos sexuales hacia el sobreviviente. Ademb, se sugiere que la contratransferencia estl formada no solo de nuestras reacciones emocionales individuales conscientes 6 inconscientes evocadas por el paciente, sino que de manera mk central, por nuestras creencias politicas y morales y por nuestros supuestos de trabajo en relation a las interacciones entre el hombre y la mujer.
1992 Copyright
0145~2134/92 $5.00 + .OO Q 1992 Pergamon Press Ltd.
COUNTERTRANSFERENCE IN THE FAMILY THERAPY OF SURVIVORS OF SEXUAL ABUSE JOSEPH J. SHAY McLean Hospital Institute for Couples and Families, Belmont, MA; Harvard Medical School, Boston, MA
Abstract-As family therapy of sexual abuse survivors has become more common, theoretical and technical issues have received considerable attention. Less attention has been devoted to the countertransference experience of the therapist. Unexamined therapist countertransference is a critical element in the treatment of these families, which markedly influences the nature and direction of treatment. Particular types ofcountertransference are presented here. In addition, the contention is made that counte~ransference is not only evoked by the particular presentation of the family members, but also by the therapist’s unexplored political and moral beliefs. Key Words-Countertransference,
Survivors, Sexual abuse.
INTRODUCTION FAMILY THERAPY WITH survivors of sexual abuse has become increasingly common, and many articles and texts have been written about this area (Courtois, 1989; Friedrich, 1990; Gelinas, 1986, 1988; Goodwin, 1989; Herman, 1983; Schatzow & Herman, 1989; Wheeler, 1990). As this modality of treatment is explored, particular technical and theoretical questions are raised, for example, questions about disclosure, responsiblity, inclusion of the perpetrator, the goals of treatment, and others. This paper suggests that the family therapy of this population, while immensely complicated technically and theoretically, is made even more complicated by the therapist’s countertransference experience which is significantly underemphasized in our work (Attias & Goodwin, 1985; Danieli, 1988; Jones, 1986; Krell & Okin, 1984; Lisman-Pieczanski, 1990; McCann & Pearlman, 1990; Parson, 1988; Pollak & Levy, 1989; Wilson, 1989). It is also suggested that our counte~ransference experience is made up not only of our individualized emotional reactions, conscious and unconscious, evoked by the patient, but even more centrally by our political and moral beliefs and by our working assumptions of male-female interactions. This paper sugests that the therapist’s sexual politics are inextricably interwoven with his or her countertransference experience. While our understanding of families in which there is sexual abuse shares some commonalities with our undemanding of other dysfunctional families (Stiver, 1990), there are also profoundly important differences. Specifically, the differences are in the ways in which our societal institutions have been unable
Presented on October 20, 1990 in a McLean Hospital Conference entitled “Sexual abuse: Long-term effects and treatment dilemmas.” Received for publication November 16, 1990; final revision received July 18, 199 1;accepted for publication August 30, 1991. Requests for reprints may be sent to Joseph J. Shay, Ph.D., Mclean Hospital, 115 Mill St., Belmont, MA 02 178. 585
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to integrate or deal constructively and progressively with the areas of sexuality, violence, and power. First it may be useful to describe a particular family therapy situation in which the author experienced marked counter-transference reactions which are readily recognizable to the experienced clinician.(In this paper, the “totalistic” approach to countertransference [Kernberg, 19651 is used, referring to “the total emotional reaction” of the therapist to the patient.) After describing this clinical situation, which occurred more than 10 years ago, these countertransference reactions will be placed in a larger social and political context.
CONFRONTING
THE FAMILY
Mary O’Brien was an adolescent in a comprehensive adolescent day treatment program for 2 years. She had come to the program at age 17 after several brief hospitalizations for depression, withdrawal, paranoid psychotic delusions, and suicidal ideation. Her father was an Irish immigrant who had been disabled for 20 years by arthritis that left him with a severe limp and in need of a cane. Her mother was a dietary worker, prone to serious medical problems of the circulatory system, partly due to being at least 150 pounds overweight. Mary had assumed many of the household functions, despite having four siblings (three brothers and an older sister). Throughout Mary’s stay in the program, as her case administrator and group therapist, I grew very attached to her. She was the kind of intermittently psychotic, forlorn, sad-eyed teenager toward whom one often experiences rescue fantasies, a common countertransference reaction with child or adolescent survivors of abuse. It is possible that such rescue fantasies exist as a defense against the overwhelming countertransference sadness which is so common in talking with depressed survivors of abuse. After a year and a half in the day program, and just prior to her projected termination date, she revealed to me that her wish to die was related to a secret she could not share. I notified her individual therapist, Ms. James, who helped Mary reveal a history of sexual abuse by her father from the ages of 5 to 14. The couples therapist, Ms. Davis, a colleague of Ms. James, was also notified, although the information was not to be shared with the parents. Ms. Davis, who had been treating the couple using a parent guidance model, shared with me her evaluations offather and mother and her conceptualization of the couple as dysfunctional in their parental and marital roles, and unwilling to recognize the severity of the difficulties in their daughter and in the family. Subsequent to Mary’s disclosure, she was depressed and anxious for 2 weeks, followed by a period of increased animation and brightened spirits. She decided to discontinue her antipsychotic medications (against medical advice), and remained in good spirits for the next month. Having treated very few abuse victims, my initial countertransference experience was one of disbelief and then of minimization of the situation, experiences which are not uncommon (Goodwin, 1989; Lister, 1982; Pollak & Levy, 1989). Nonetheless, I arranged a consultation with a local expert on father-daughter incest. The expert recommended that Mary’s individual therapy focus on her disappointment in her parents and on her need to grieve for the caretaking of which she had so clearly been deprived. In addition, the expert also recommended delaying any family involvement with respect to the “alleged molestation” (as my notes read) because Mary was too unstable. Shortly after this, Mary’s condition worsened, with increasing depression, profound suicidal ideation, and on one occasion, flashbacks of the molestation by father, with whom Mary was still living. She was admitted to McLean Hospital, a private psychiatric hospital within which the day program was located, having been granted 2 weeks of free care. After several consultations with senior clinicians (all male), and
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multiple conversations with a grudgingly approving Mary, a decision was made to confront the family. Because I had established a good relationship with the family, it was decided by the senior consultants that I should confront the father. I was petrified. First, I had never done this before. Second, I was not completely convinced that the sexual abuse had occurred. Even the consultant had not expressed complete conviction at the time. Third, I did not know how the family would react. Mary, who agreed to the confrontation, but refused to be present, had already warned me that if her oldest brother was present, he would assault me. I decided I didn’t want to meet him. We did invite him and the other two brothers, and her sister, but the three brothers were going to meet with another therapist for history-gathering purposes, while the sister would be with Ms. James and Ms. Davis to be questioned about whether she had been abused. Here is a portion of my notes from the confrontation many years ago based on the guidance of the senior consultants who had few suggestions except to be direct and firm. These notes are as clear as they are because I wrote them before the confrontation, and practiced them several times. Confrontation: “I need your help, Mr. and Mrs. O’Brien, because without it, I think Mary will kill herself. I need to talk with you about some very serious and painful issues from the past that we know about that contribute to making Mary sick. It’s very important to be open, direct, and honest with each other. This may make you very depressed or very angry, but we need to do it anyway because otherwise Mary may kill herself. . Keep in mind, I’m a mental health professional. I’m not here to criticize you or judge you, but to help Mary and help the family because we believe the whole family has serious problems. Several months ago, Mary told us that she had a secret, and the memory of the secret was making her want to die. You know what the secret is. She told us when she was a child, you had sexual contact with her. We need to talk about this, and together try to figure out what caused it to happen, and how the family can live with what happened, and how the family can get better. Mr. O’Brien, it must have been awful for you to have to carry this secret all these years?”
I remember being grateful that I was through because I was completely breathless at this point, on the edge of hyperventilating. I have rarely experienced such anxiety as a professional. (The other occasion I can recall was during my graduate school training when I first discussed sexual intercourse in detail with a couple who were the same age as my parents.) Reaction Father, to my surprise, was neither angry nor upset. He said, immediately, “My right hand to God, I swear it never happened, and if it did happen, I have no memory of it.” Father added that Mary must have imagined it. He knew that when such allegations came before a judge, “9 out of 10 times, you believe the doctor,” and he could understand how someone would, but “it’s my word against hers.” He went on to describe how such behavior was “animalistic” and “the shame and the guilt” of being accused. Having regained my breath, I was starting to lose my bearings. I was confused. I had expected him to confess. I began to wonder whether I’d made a terrible mistake, although my doubts suddenly gave way as my mind finally heard what father had said: “If it did happen, I have no memory of it.” I now felt certain. I persisted, stating that Mary was very believable, that I believed her, that such behavior was not animalistic but a part of human nature, and that, of course, father would have to deny it because of his shame and guilt. I added that we had no intention of recommending legal action. I said again how painful it must have been for father to have lived with this sense of being so awful. Father said if it had happened he would have confessed it to a priest, and if it didn’t a confession wouldn’t have meant anything. “What if Theresa, Mary’s sister, says it also happened to her?’ I asked. Mother giggled, and said, “I’d say his memory’s goin’ bad on him.” Mother then changed the subject, with what I
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noted as “inappropriate laughter,” and when returned to the subject said “If he did it, I’d throw him out. I’d put him through the roof. There wouldn’t be anything left of him.” Mother denied any knowledge of this, including denial of Mary’s allegation that mother had once walked in when father was in Mary’s bed. I remember feeling angry at mother at this point, with a sense of revulsion. I do not recall experiencing anger at father. (Please remember, I am not defending my reactions, but just describing them.) But then, surprising to me, I was completely calm. I would actually say I was dissociated. Having had this experience on subsequent occasions, I have come to call this experience “counterdissociation,” namely dissociation that occurs defensively to protect the clinician from overwhelming confusion or other intense affect in the presence of abusers who deny the abuse or victims who describe it. Father then asked, “Exactly when did Mary say this happened?” “On several occasions,” I said. At first father understood me to mean several times during a brief period, and once he understood that I meant over a period of years, he said, “Oh, no, definitely not. It didn’t happen over a period of years. My right hand to God, it didn’t happen. I have to say then, she’s a liar.” My notes end at this point, except to say that the parents were reluctant to go to their couples therapy in a few hours, with mother complaining of tiredness, and father complaining of his arthritis. I asked father to return to meet with me alone the following day, and he asked whether he should visit Mary on the inpatient hall. I did not discourage him from this. (I certainly would today.)
In subsequent days, Theresa, the sister, denied anything had ever happened to her, and suggested that Mary was not lying but distorting father’s “overaffectionateness.” Mary later recovered a memory of hearing Theresa scream, having blood on her bedsheets, with father nearby with blood on his hand. Father, following the confrontation, spent several sleepless nights praying and tearful, according to family members, but continued to deny the abuse. Mary reported in much more detail the specifics of the abuse, to the point where she was entirely credible. But nothing ever came of this. At other times, Mary wondered whether she had imagined the abuse. Her recantation, which 1 did not then know was a common occurence, relieved me, and made me wonder whether I had been abusive to the father, as I recanted my certainty. Mary’s condition continued to fluctuate, with a clear downward trajectory, and she wanted no more pursuit of the issue with her father. The clinical team simply dropped the issue. Mary was rehospitalized once during the following 4 months, with depression and suicidality, and after graduation from the adolescent day program, went into an adult day hospital program. I heard from her and about her during the next several years, and her condition looked chronic. Mother died 2 years ago, and sister died last year, with Mary living at home with father. She has remained in individual treatment intermittently with her therapist from years before and has required multiple hospitalizations. I continue to feel guilty about this situation and in writing about it for this article, I also feel ashamed that I had not done more.
COMMON
COUNTERTRANSFERENCE
REACTIONS
In this description, I have attempted to highlight specific countertransference experiences which I believe are relatively common in working with survivors of abuse and their families, for example, rescue fantasies, overwhelming sadness, disbelief, anger, revulsion, confusion,
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dissociation, guilt, shame, and premature forgiveness. Other typical reactions described in the literature are rage at the perpetrator, identification with the perpetrator (especially in the absence of the victim), fear, titillation, and sexual feelings toward the survivor (Ganzarain & Buchele, 1986; Kohan, Pothier, & Norbeck, 1987; Krieger, Rosenfeld, Gordon, & Bennett, 1980; McCann $2 Pearlman, 1990; Morris, Johnson, & Clasen, 1985; Pollak & Levy, 1989). It may not be surprising to the reader that these experiences are similar to those experienced by the survivor herself and the family, with these countertransference experiences providing a window into the experience of the family members who cannot always communicate the experience directly. The reader may also recognize that, in Mary’s case, the treatment team recapitulated the family dynamics, that is, Mary disclosed the abuse to us, and eventually, we did nothing about it and acted as though it had never occurred. Impact on Treatment In retrospect, I believe that I failed to help this young woman and her family because I did not understand or appreciate my countertransference experience or the beliefs, values, attitudes, and politics that underly it. Overwhelming confusion is incompatible with successful treatment. To combat my confusion, I resorted to oversimplification of the situation, and fell back on unexamined personal beliefs, that is, unexamined countertransference biases, which were not entirely appropriate to the situation. Among these beliefs were: Incest reports are frequently untrue; disclosure and confrontation of the abuser are essential to progress; confrontation met by responsibility of the perpetrator can result in rapid improvement; forgiveness by the abused person is essential to progress; the mother’s underlying role, including collusive support of the father, is central to the dynamics of the situation; and, the abuse experience, while profound, may not have long-lasting sequelae if the family can acknowledge the abuse. I invite the reader to think about his/her beliefs in response to the following four questions, because the direction of treatment ofthese families rests upon the answers to these questions. I do not have to begin with the question upon which I foundered more than 10 years ago, namely, whether abuse can be a profound and persisting trauma in someone’s life. This idea is now well-documented (Browne & Finkelhor, 1986; Finkelhor, 1984, 1988; Finkelhor & Browne, 1985; Gelinas, 1983; Goodwin, 1989; Lindberg & Distad, 1985; Westen, Ludolph, Misle, Ruffins, & Block, 1990; Wolf, Gentile, & Wolfe, 1989). The reader will recognize that these questions may not always be answered simply “yes” or “no,” without regard to the particulars of a situation. Nonetheless, I suggest here that all therapists have their own countertransferential predispositions which are critical to recognize.
AN EXPLORATION
OF PERSONAL
BELIEFS
The Question of Collusion Do you believe that the mother colludes in the sexual abuse of the child? Many authors (Furniss, 1983; Gutheil & Avery, 1977; Zuelzer & Reposa, 1983) have argued this postion, but few so forcefully as Lustig, Dresser, Spellman, & Murray ( 1966) who wrote, “It is interesting that despite the formal innocence of the mother in the actual incestuous event, she seems to emerge as the key figure in the pathological transactions involved. . . . Despite the overt culpability of the fathers, we were impressed with their psychological passivity in the transactions leading to incest. The mother appeared to be the cornerstone in the pathological family system.” James & MacKinnon ( 1990), in providing a feminist critique of this arguement, decry the
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“myth of pathological fathers and inadequate mothers” (p. 73). This critique is also taken up by Goodrich, Rampage, Ellman, & Halstead (1988) who says that “by turning the light on Mother-her failure to satisfy her husband, her failure to enact a proper executive role, her failure to stand guard, her failure to know-a therapist conceals the reproaching truth that domination by Father can lead to abuse. Father’s absolute power as head of the household can corrupt absolutely” (p. 18). (The reader is also directed to Caplan & Hall-McCorquodale (1985) who identify 72 different psychological disorders that are attributable to mother’s failings.) The Question of Blame Do you believe that the therapist should tell the victim of abuse that he or she is in no way responsible, that he or she is not to blame? Is it true that “Nothing you did caused the abuse; nothing within your power could ever have stopped it . . . It’s never your fault . . . it is always the responsibility of the adult to behave with respect to children” (Bass & Davis 1988, pp. 104, 105, 107). Or are your therapeutic interventions based around the idea that “Therapists must take care not to confer victim status on these children, thereby diminishing a feeling of power that may be important to the child in the future . . . Saying ‘it’s not your fault’ is not helpful because it does not address the sense of power and control that children who have experienced sexual abuse often feel in addition to their guilt” (Lamb, 1986, pp. 303-305). The Question of Family Reunion The third key question centers around the therapist’s belief in the possibility of genuine and profound change in these families, which would allow the family to be reunited. Herman (198 1) describes the view of many therapists who “feel strongly that it is in the best interests of all concerned for fathers to return to their families. The very names of such self-help groups as Parents United or Families Re-United make it clear that the emphasis is on re-establishing the nuclear family” (p. 159). Other therapists argue with equal vigor that “the sexual abuser forfeits the possibility of reconciliation by virtue of his actions against his victim and that the vast majority of victims do better, and are safer, when their therapy and their future lives do not include their abusers. . In fact, the goal of some therapists to reconstitute the family may be largely an impossible one, at least on a psychological level” (Briere, 1989, p. 138). The Question of Power Finally, each therapist must ask whether he or she believes that the abuser is meeting needs for sex, for nurturance, or for power? Is sexual abuse an attempt at gaining sexual gratification? Or is it “. . . an expression of the search for interpersonal attention, affection, and nurturance by the adult offender. . . Holding center stage in incest is not sex, but need-and the need is usually for relatedness” (Gelinas, 1986, p. 344). Or is sexual abuse rape? “Rape is rape: rape is about power. Each single time a Father approaches a Daughter sexually, it is rape.” (Ward, 1985, p. 138). There are a number of other important questions to be considered as well. For example, should an abuse survivor be encouraged to disclose the abuse to the family and to confront the abuser? Should the survivor be encouraged to forgive the abuser? Should a male therapist be treating female victims of abuse or their families? Finally, one last question which, in terms of counter-transference, may be the most perplexing question of all: If you hold the abuser, the victimizer, entirely responsible for the abuse, what is your countertransference reaction to-
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ward him when you learn that he was a victim as a child? At what point does responsibility occur?
THE POLITICS
OF TREATMENT
In my review of these questions and ideas, I hope that the reader has noticed that our vocabulary of treatment is not only clinical but also political, moral, and legal. This treatment involves the political vocabulary of power, patriarchy, and submission; the moral vocabulary of forgiveness, blame, and responsiblity; the legal vocabulary of innocence, guilt, rape, victim and perpetrator. Is there any other patient population with which we work where this larger societal influence is so centrally present? My argument is as follows: We, who are to become family therapists, grow up in and participate in the social arrangements of society. Once we become family therapists, we experience the social arrangements of the family as they engage in these arrangements in therapy. Our experience of the family, however, including the inevitable and profound countertransference reactions that we develop, occurs not only in the context of their social arrangements, but also against the silent backdrop of our own earlier participation in society. That is, there is an inextricable relationship between the way we, as family therapists, grow up in and participate in the social arrangements of society, and the way we experience and develop countertransference reactions to the family members in family therapy. This is powerfully true in the family therapy of survivors of sexual abuse because of the pervasive and unavoidable effects of sociocultural factors on our personal experience of sexuality and power.
CONCLUSION My contention is that where we stand in these areas, our political, moral, and institutional beliefs, undergird our counter-transference reactions in therapy, and consequently underlie our interventions. Our therapy interventions related to collusion, blame, forgiveness, restoration of the family, treatment, or punishment, do not grow simply out of our clinical knowledge base, but grow centrally from our personal beliefs and values in these realms. These personal beliefs and values are the soil out of which our countertransference grows, in combination with the specific nutrients provided by the particular patients with whom we work. As with all countertransference, the goal is not to eliminate countertransference, even if that were possible, but to understand and appreciate it. Such understanding grants the therapist an awareness of potential blindspots, prejudices, and stereotypes, highlighting areas in which he or she will have a harder time empathizing with the patient’s experience because of a pre-existing belief. Intense countertransference of which the therapist is unaware interferes with the capacity for empathy when the patient is articulating an experience that does not fit with the therapist’s model. The closer the therapist can get to the experience of all the patients in the family, the better he or she is able to understand them and to empathize with them. Finally, the contention of this paper can be simplified even further: Countertransference does not begin in the office, it begins at home. Counter-transference begins at birth. Acknowledgements-The author thanks Laura Zimmerman an earlier version of this paper.
and Carolynn Maltas, Ph.D., for helpful comments on
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REFERENCES Attias, R., & Goodwin, J. (1985). Knowledge and management strategies in incest cases: A survey of physicians, psychologists and family counselors. Child Abuse & Neglect, 9, 521-533. Bass, E., & Davis, L. (1988). The courage to heal: A guide for women survivors of child sexual abuse. New York: Harper and Row. Briere, J. (1989). Therapyfor adults molested as children: Beyond survival. New York: Springer. Browne, A., & Finkelhor, D. (I 986). Impact of child sexual abuse: A review of the literature. Psychological Bulletin,
99,66-77. P. J., & Hall-McCorquodale, I. (1985). Mother-blaming in major clinical journals. American Journal of Orthopsychiatry, 55, 345-353. Courtois, C. A. (1989). Healing the incest wound: Adult survivors in therapy. New York: Norton. Danieli, Y. (1988). Treating survivors and children ofsurvivors of the Nazi Holocust. In F. Ochberg (Ed.), Post-traumatic therapy and victirk of violence (pp. 278-295). New York: Brunner/Mazel. Finkelhor. D. (1984). Child sexual abuse: New theorv and research. New York: Free Press. Finkelhor; D. (1988j. The trauma of child sexual ab&e: Two models. In G. E. Wyatt & G. J. Powell (Eds.), Lasting effects qf child sexual abuse, (pp. 6 l-82). Beverly Hills, CA: Sage. Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55, 530-54 1. Friedrich. W. N. C1990). Psvchotheraov of sexuallv abused children and their families. New York: Norton. Furniss, T. (1983)‘. Family process in&e ireatmeni of intrafamilial child sexual abuse. Journal of Family Therapy,& 263-278. Ganzarain, R., & Buchele, B. (1986).Countertransference when incest is the problem. International Journal of Group Psychotherapy, 36, 549-566. Gelinas, D. J. (1983). The persisting negative effects of incest. Psychiatry, 46, 3 12-332. Gelinas, D. J. (1986). Unexpected resources in treating incest families. In M. Karpel (Ed.), Family resources: The hidden partner in,family therapy (pp. 327-358). New York: Guilford. Gelinas, D. J. (1988). Family therapy: Critical early structuring. In S.M. Sgroi (Ed.), Vulnerable populations (pp. Caplan,
5 l-77, Vol. 1). Lexington, MA: Lexington Books. Goodrich, T. J., Rampage, C., Ellman, B., & Halstead, K. (1988). Feminist family therapy: A casebook. New York: Norton. Goodwin, J. (1989). Se_xualabuse: Incest victims and theirfamilies. Chicago, IL: Yearbook Medical publications. Gutheil, T., & Avery, N. (1977). Multiple overt incest as family defense against loss. Family Process, 16, 105-I 16. Herman, J. L. (1981). Father-daughter incest. Cambridge, MA: Harvard University Press. Herman, J. L. (I 983). Recognition and treatment of incestuous families. International Journal ofFamily Therapy, 5,
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of General Psychiatry, 14, 3 l-40. McCann, I. L., & Pearlman, L. A. ( 1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. iJournal of Traumatic Stress, 3, 13 1- 149. Morris. J. L.. Johnson. C. F.. & Clasen. M. (1985). To report or not to report: Physicians attitudes toward discipline and child abuse. American Journal of Disease of Children, 139, 194- i97. _ Parson, E. R. (1988). Post-traumatic self disorders (PTsfD): Theoretical and practical considerations in psychotherapy ofvietnam war veterans. In J. P. Wilson, Z. Harel, and B. Kahana (Eds.), Human adaptation to extremestress: From the Holocaust to Vietnam (pp. 245-284). New York: Plenum Press. Pollak, J., & Levy, S. (1989). Countertransference and failure to report child abuse and neglect. Child Abuse di Neglect, 13, 5 15-522.
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Schatzow, E., & Herman, J. L. (1989). Breaking secrecy: Adult survivors disclose to their families. Psychiatric Clinics of North America,, 12, 331-349. Stiver, I. P. (1990). Dysfunctional families and wounded relationships, Part 1. #4 1. Stone Center for Developmental Studies, Wellesley, MA, (work in progress). Ward, E. (1985). Father-daughter rape. New York: Grove Press. Westen, D., Ludolph, P., Misle, B., Ruffins, S., & Block, J. (1990). Physical and sexual abuse in adolescent girls with borderline personality disorder. American Journal of OrthopsychiatryM, 60, 55-66. Wheeler, D. (1990). Father-daughter incest: Considerations for the family therapist. In M. P. Mirkin (Ed.), The social and political contexts offamily therapy (pp. 139- 157). Boston, MA: Allyn and Bacon. Wilson, J. P. (1989). Trauma, transformation, and healing: An integrativeapproach to theory, research, andpost-traumatic therapyM. New York: Brunner/Mazel. Wolfe, V.V., Gentile, C., & Wolfe, D. A. (1989). The impact of sexual abuse on children: A PTSD formulation. Behavior Therapy, 20, 2 15-228. Zuelzer, N., & Reposa, R. (1983). Mothers in incestuous families. International Journal of Family Therapy, 5, 98-109.
Resume-L’utilisation de la thtrapie familiale dans la prise en charge des survivants d’abus sexuel est devenue plus courante ce qui a entrain6 un inttret considerable pour les aspects theoriques et techniques. Cependant moins d’attention a et6 consacree au contre-transfert du thtrapeute. L’absence d’analyse du contre-transfert du therapeute est consider6 comme un Clement critique du traitement de ces familles, influencant non settlement la nature mais aussi la direction du traitement. Des types particuliers de contre-transfert sont analyses. L’hypothese forrnulee est que le contre-transfert du therapeute n’est pas seulement determine par la presentation particulitre des differents membres de la famille, mais aussi par les croyances politiques et morales inexplorees du thtrapeute. Resumen-Cada di es mas comlin la terapia familiar de 10s sobrevivientes de1 abuso sexual, 10s aspectos tebricos y tecnicos han recibido una atencion considerable. Se le ha dedicado menos atencion a la contratransferencia que experimenta el terapista. La contratransferencia de1 terapista que no es tomada en cuenta, es considerada coma un element0 critic0 en el tratamiento de estas familias que influye necesariamente en la naturaleza y la direccidn de1 tratamiento. Algunas reacciones especificas de contratransferencia son: Fantasias de restate, tristeza sobrecogedora, incred-.ilidad, rabia, repulsion, confusion, disociacibn, culpa, vergtienza, perdon prematuro, rabia contra el perpetrador, identificacibn con el perpetrador (especialmente cuando la victima no esta), miedo, pulsion y sentimientos sexuales hacia el sobreviviente. Ademb, se sugiere que la contratransferencia estl formada no solo de nuestras reacciones emocionales individuales conscientes 6 inconscientes evocadas por el paciente, sino que de manera mk central, por nuestras creencias politicas y morales y por nuestros supuestos de trabajo en relation a las interacciones entre el hombre y la mujer.
