The Social Role of Psychotherapy in the 21st Century in Preventing and Responding To Sexual Misconduct: A Multidimensional Perspective

Vol 4 #1

Authors:

1. Caroline Giroux MD*, Ana Hategan MD,  Alan Eppel MB

* Corresponding author: Associate Clinical Professor; [email protected]

 Affiliations:

1. University of California, Davis Medical Center, Sacramento, California, USA
2. McMaster University, Hamilton, Ontario, Canada
3. McMaster University, Hamilton, Ontario, Canada

Conflict of interest: None

Introduction

Over the past recent months, since the rise of the #MeToo movement, more women and men victims of sexual trauma have come forward and denounced past and current misconduct from prominent figures in the media and entertainment industry and political arenas. There has been a crescendo of reports and widespread awareness and support from the public. This increased disclosure from survivors, as painful as this process can be, represents the welcome tipping point for initiating an essential culture shift: from entitlement to attunement.

In an attempt to support this culture shift, help the trauma survivors heal and prevent such misconduct in the future, the authors herein attempt to give an overview of the main mechanisms leading to sexual assault (including rape myths), and explain the multifaceted role of the contemporary psychotherapist in educating to intercept maladaptive scripts that lead to damaging behaviors, and repairing. The educational and therapeutic components will occur at the individual (both perpetrator and victim) and the society’s level and will assist in developing healthier beliefs about the self and how it navigates through various stages of intimacy.

Sexual assault is fundamentally a “public issue” of betrayal of the citizen trust, not just a collection of “private troubles” [1]. It is perplexing to think that what is finally public knowledge has been known by psychoanalysts and clinicians working in the trenches for over a century now. But how is our field of psychiatry doing in this respect? The allocation of resources, the time spent researching and teaching the impact of trauma (including sexual abuse) seem to have been significantly lower than the extent of the dedication towards certain causes such as schizophrenia. Without diminishing its impacts on affected patients and their families, schizophrenia affects 1% of the population worldwide, while the lifetime prevalence of rape was 19.3% for women vs. 1.7% for men in a 2011 US national survey (likely still underestimated because of the attached stigma and society’s victim-blaming attitudes) [2]. Ninety-four percent will develop trauma-related symptoms within 2 weeks and 50% may be affected on the long term. But an increase in 200% in the calls to lines supporting victims of sexual assaults has been noted since the recent political arena in the USA has publicly unfolded an old allegation of sexual misconduct in a certain male prominent figure. As mental health professionals we must be prepared to assist our patients who will reach out to us and who will become more and more vocal, hoping the “symbolic protest” [1] will incite effective measures and durable changes.

Definitions

• Sexual abuse/misconduct can mean anything nonconsensual that a person does or says, to your body, or in your presence that is perceived as intrusive, not development-appropriate, or both.
• Sexual assault is a gendered crime generated at a societal level by a rape culture and its myths.
• Sexual trauma can encompass the two terms above. It is more multifaceted and can include elements such as the meaning of the abuse or assault and the impact on the person’s views of self, others and life. Trauma in general creates a disruption in the sense of self and safety. Table 1 shows a few examples of sexual trauma. Some types can belong to multiple categories (for instance, a verbal or physical sexual trauma can both also have a psychological component).

Table 1. Examples of sexual trauma

 

Verbal	Psychological	Physical
Offensive comments	Harassment, intimidation, threats	Inappropriate touching, kissing, groping, fondling
Indiscrete questions	Discrimination based on gender, menstrual cycle, pregnancy, sexual orientation	Invasive procedures
Derogatory statements	Disturbing stories (secondary trauma)	Contraceptive sabotage
Unwelcome compliments	Premature exposure to porn	Genital or breast mutilation
Any sound or word with a sexual connotation making the recipient uncomfortable	Being exposed to someone’s unwelcome masturbating	Ritual (object insertion)
Catcalling	Being forced to perform sexual acts in front of others	Human trafficking
Rape jokes	Human trafficking	Rape (victim conscious or not)
	Transactional sex
	Rape (victim conscious or not)

 

Sexual trauma, whether it is considered a micro-aggression like denigrating comments, or inappropriate touching, or rape can be conceptualized as part of a continuum. People must realize that even micro-aggressions are not trivial because they become embedded in a broader social narrative that supports a rape culture. Even if not all men engaging in locker room talk end up assaulting women, such attitudes nonetheless constitute a script that basically says it is ok, or appropriate and even valued to be hostile and rape women or people, so perpetrators (the ones who are the most severe narcissists or have poorer impulse control) end up being reinforced by such attitudes that are so pervasive.

The more severe and repeated the predatory behavior, the more likely there are needs for self-gratification that are disproportionately higher than a capacity for compassion. In other words, too much entitlement is coupled with too little attunement. The culture of entitlement is rampant in our modern North American society [3]. It is the by-product of a poorly developed, highly insecure sense of self that compensates by creating an inflated self-image with maladaptive defenses. Entitlement translates into unreasonable requests or expectations on the basis of one’s perceived sense of greatness with no regards to others, and low empathy and prominent arrogance or contempt. The more narcissistically injured an individual is (correlated with the severity, significance and young age of attachment trauma), the more layers of narcissistic defenses will be created to protect the true, yet, still embryonic self. In such states, attunement, this compassionate ability to remain attentive to others as separate and worthwhile beings (as described by Daniel Stern’s intersubjectivity), is usually low due to prominent self-centeredness generally compensating for misattunement in childhood.

Pathological narcissism tends to affect more men than women, and this has had implications in social inequities and abuse to this day. Identifying individuals with such wounding and encouraging them to engage in psychotherapy can help them avoid the accumulation of defensive sediments and expand self-awareness, attunement and decrease entitlement. In other words, restoring a healthier sense of self in people would potentially make them less likely to take the path of sexual misconduct.

 

When intervening among perpetrators or sex offenders, the psychotherapist’s role is to identify such defenses, challenge them and dig through them to access suffering (intolerable and massively denied by such personalities) to elicit empathy and not reinforce entitlement. One must remain realistic with that population since strong antisocial traits constitute a poor prognosis. Pedophiles also have a poor prognosis because of limited empathy and a high recidivism rate. Because they cannot be trusted and their acting-outs affect minors, they often require a highly structured and tightly monitored environment, with certain restrictions (e.g., no access to playgrounds, sex offender registry). In such a situation, forensic psychiatrists would be more equipped to rehabilitate them and minimize recidivism. A challenging aspect remains the difficulty for a provider who is also a parent to hear about stories of child molestation, and sometimes a referral to a colleague is preferable.

 

Rape is a shame-inducing trauma, which creates a lifelong membership to humiliation and terror. It is often precipitated by the perpetrator’s need to disown his shame by projecting it unto a victim during the assault. It is used as a war weapon to humiliate the enemy. In certain cultures, women who are raped are further shamed, shunned and even stoned to death. It is as if there is this unbearable collective shame that a whole religious or cultural group is defending against. Even in North America, it is believed that only 16-35% of all sexual assaults are reported to the police. Taylor and Norma (2012) have argued that women report is “symbolic protest” against a criminal justice system that is not generally supportive of women’s interests [4]. From a feminist perspective, Muldoon et al. [1] quoted Rozee & Koss (2001) who listed the levels of society that are structurally integrated to support a rape culture: the institutionalization of patriarchal values; the socialization practices that teach non-overlapping notions of masculinity and femininity (with men viewed as tough, competitive and aggressive and woman [sic] as tender, nurturing and weak); social familial, political, legal, media, educational, religious, and economic systems that favor men; and criminal justice and legal systems that fail to protect women. Feminists also redefined rape as a method of political control, enforcing the subordination of women through terror [5].

But it is our role to be vocal and assertive about where the shame really lives: within the perpetrator’s ego. We need to denounce all types of misconduct, name and put the magnifying glass on the perpetrators to make them accountable for their actions.

It is easy to understand that the trauma-centered therapist for now will help the survivor regain a sense of safety, validate the post-traumatic experience and difficult emotions (e.g., fear, anger, despair), identify feelings of shame and poor self-esteem and educate the person about the mechanisms of interpersonal trauma to normalize reactions and move away from self-blame and shame.

Society’s Education

Psychologists, psychiatrists and counselors advocating for survivors of trauma should be at the forefront of the movement that seeks to break the silence and help society emerge from its obliviousness. There are various ways one could initiate the dialogue to try to understand each other better and behave towards one another with the highest moral standards. For instance, explaining in the media why victims often do not report will help dispel myths and prejudices (see Table 2). Sexual scripts may inform both rape myths (e.g., since women “should” have lower sex drives, women with higher sex drives must have “asked for it”) and rape scripts (e.g., since women control sexual activity, failure to do so resulting in rape should be accompanied by evidence—such as physical injury—that she could not control) [6].

The concepts of triggers, re-enactments, fight, flight or freeze reactions and the dysregulation of stress response systems could provide crucial insights in terms of why someone took so long to identify what had happened as traumatic, or why a woman acts out (many women have had post-traumatic reactivations due to being triggered by a person reminding them of their aggressor, blurring the line between past and present, having a powerful impression that the traumatic scene was occurring, which could lead to fatal attack since this time they were in position to defend themselves). Table 2 summarizes several common rape myths [1, 6, 7].

Table 2. Rape Myths

 

Rape myths	Reality
“Real” rape involves the use of physical force	Victims can experience a shock, be stunned or appear compliant because verbal threats made them feel they would die if they did not comply
Rape implies a forceful/obvious resistance by the victim
Sexual assault victims experience severe physical and/or anogenital injuries	The injuries are not always visible and in addition to the psychological damage, there can be STIs, unwanted pregnancies, etc
Sexual assault victims immediately report the crime	Because of the initial shock, feelings of shame, fear of stigma and generally lack of support from criminal justice and legal systems (avoidance due to fear of re-traumatization/invalidation), some never report to the authorities
Rapists are strangers and sexually deviant	It is widely recognized that sex offenders often know their victims
Husbands/partners are entitled to unlimited sex “on demand”	A person still owns her/his body and has a right to say no, married or not
“No” often means “yes”	Entitlement and lack of frustration tolerance (narcissistic issues in perpetrator)
Women who are sexually assaulted under the influence of alcohol intoxication are “at least somewhat responsible”	Unlike drunk drivers who should be held responsible for causing deaths or injuries on the road, a person who is intoxicated while raped is taken advantage of. Plus, is the validity of   “consent” for sexual activity while inebriated questionable?
“Dressing provocatively means the victim asked for it”	Consent should be explicit, unambiguous and not obtained through coercion. This myth is a dangerous rationalization and externalization of blame for a behavior that is criminal. Even on a naked person, sexual assault is unacceptable

 

Some basic reframing should be provided on websites and through the media for individuals who cling onto victim-blaming comments such as “what was she wearing” or “why did she go out that late at night”. Simple restructuring such as the distinction between outfit and sexual consent should be initiated whenever needed. Additionally, the double standard (how men reporting abuse are taken seriously in the USA compared to women) should be questioned.

A bottom-up approach that includes challenging the gender stereotypes will help people transcend their differences (sometimes perceived as threatening) to learn to interact on the level of their shared humanness instead of polarizing each other based on (often) socially determined differences. Mental health workers should offer trainings to parents on child-rearing practices, and healthy personality development through harmonious and secure attachment. It is important to address entitlement “mine! this is mine” from toddlerhood on and teach the concepts of “mine” but also “yours”, and that “sharing” cannot be forced. Sex education classes from a young age are recommended. It is crucial to share information about what is acceptable and what is not when it comes to interactions, and to remind each person to listen to their inner voice, otherwise a young victim who has never been introduced to the idea of owning his/her own body might be taken by surprise and experience confusion, shock and stay silent if they are inappropriately touched. If they were also threatened and feared for their life, they might be inclined to suppress the memory or be less likely to seek help, convinced by the perpetrator that they have been “bad”.

Among teenagers, we have to assist them in revising the scripts associated with seduction, boundaries, and intimacy to develop healthy ones. Sexual development throughout the lifespan, empathy, and respect of boundaries are important themes. The foundation of psychotherapy is skills-building for healthy relationships with self (e.g., life hygiene: mindfulness) to decrease the autonomic reactivity and risk of acting-outs in general, and others (e.g., mentalization). It supports meaning through storytelling (e.g., narrative therapy) which can lead to transcendence. By healing the individual, we can help the family heal, then the community, the group and the society.

 

The Power of Language

Modeling empowering, positive and non-ambiguous terminology (e.g., avoid euphemisms) is another important aspect of the culture shift. Think about the following terms:

• Date rape
• College campus rape
• Military rape
• Gang rape
• Statutory rape

 

All those adjectives and subtypes dilute the experience of assault and seem to validate somehow this alarming rape culture… as if to lessen the seriousness, to distract us from this 4-letter word, rape, viol (in French), euphemizing the gravity of the act. Overfocussing on classification also distracts us from the wounds, and creates a sense of invalidation in the victims, whose shocking experience is reduced to a rhetorical battle between lapse, misdemeanor or felony. The “minor/serious” sexual assault legal distinction is meaningless to survivors and conceals a shared felt experience [1]. Survivors rarely, if ever, consider an assault “minor”. In fact, it often produces profound deleterious effects on victims. What we should pay attention to are all the permutations to end the collective and historical denial, but most importantly, the consequences (for the victim, and for the society): a unique loss of trust. Such a trauma (intentionally perpetrated by another person) adds another dimension and makes sexual assault distinct from the trauma experienced in bereavement or motor vehicle accidents and warrants special attention.

It might even be preferable to use the term “shock” instead of trauma because it is closer to the experience of the survivor. It also involves railing against the social system and culture than permits this crime to continue unabated despite decades of reform [1]. Regardless of the nature and degree of sexual violence, many victims are initially stunned. They cannot believe what has just happened, and this reaction of disbelief, and the need to withdraw likely contribute to delay in reporting. For instance, a survivor of incest might have been unable to accept the reality of being abused by a parent and cannot report the assault until a more confident self develops in later years [1].

Additionally, Muldoon et al. [1] quoted Astbury (2006) when they emphasized that since PTSD is a psychiatric diagnosis, it tends to pathologize the victim, and by focusing on the victim or survivor as a person with a mental illness, attention is deflected from the social causation of rape and the generalized oppression of women.

For example the point of view that a man’s sexual misconduct was because he felt aroused by a woman who was dressed in a sexually “provocative” way,  puts the blame on the woman (i.e., to provoke sounds much more forceful than to misbehave). One should clearly state “he sexually assaulted this person”. It is important to emphasize that this is the offender’s problem, “the offender-citizen’s violation of civic trust through wielding power over fellow citizens that constitutes the heart of the event and that accordingly requires redress– even if the survivor herself, although men are victimized too, seeks personal peace through an individualized remedy” [1].

Women and men should initiate a dialogue with each other and participate in panel discussions for instance. A new language should be developed as needed to capture the reality of victims as a way to legitimate their experience and dismantle the taboo. For instance, Lin Falrey was a leader in calling attention to the problems faced by women in the workforce, and with colleagues at Cornell University she coined and popularized the term “sexual harassment.”

Blind Spots

It can happen that a female victim turns to a therapist, male or female, to be told, after the disclosure of a rape during a party, that she might have had some degree of responsibility in it. Such rape myth-perpetuating attitudes are damaging and re-traumatizing for the victim seeking help and a safe environment to process difficult emotions. We would remind the counselor without hesitation that one should never question the veracity of a traumatic event, especially if the patient comes in with clear signs and symptoms of autonomic reactivity (such as panic attacks, hypervigilance, insomnia, paranoid thinking, etc.) and compensatory behaviors (like substance abuse). It is important to be aware of biases on seduction and maintain integrity and empathy. In the situation when psychotherapists have a strong negative counter-transference towards a certain subset of victims, a metapsychotherapy or tight supervision is strongly recommended to explore misconceptions. Our role is to support the patient. It took a tremendous amount of courage for these victims to disclose intimate details that they are often ashamed of, and we should honor that. Listening to the story non-judgmentally is our duty. As a reminder, the American Psychiatric Association and the American Psychological Association, and the Canadian Psychiatric Association should emit advocacy and psychoeducational statements to the public and their members to ensure mental health workers continue to support their patients who are survivors of sexual misconduct.

Compassionate care should also translate into teaching meditation practices to our patients and potential offenders as a healing force and a coping mechanism but also as a tool that challenges unhealthy ego defenses. Awareness that is elicited by mindfulness practices will be some kind of “entitlement-suppressing” machine.

 

Practical Considerations and Future Directions

A great deal of attention has been given to PTSD in war vets. But given that women victims of rape are 4 times more likely than soldiers to suffer from PTSD, we are faced with a serious access to care gap: looking at all the VA centers, one should wonder if there are enough sexual assault survivor centers or clinics, with a multidisciplinary approach. Mental health workers should unite their forces and pioneer such initiatives. They should also use their voice and bring to light the unfortunate collusion between law enforcement, therapists, judiciary system and perpetrators, an often predominantly male, victim-blaming systems where it is challenging for a victim to feel supported and safe.

Now that there is an accrued interest in trauma-related disorders, we have access to a growing literature. But are studies mostly about victims? Is that just another way to “blame” them, to divert attention from perpetrators? Conversely, studying the perpetrators might incite society to make them more accountable, by conveying that the study of human interactions is deeply rooted in brain science and self development, and that trained professionals can more and more easily tell if a person in position of power is at risk of exploiting others, and generate hypotheses in terms of their frail narcissism.

Just like changing the scripts of seduction, intimacy, and human body will be important,  our society will need to take responsibility and redefine heroes (the ones who can be remembered, who will make history will be the ones protecting victims and challenging the tale of silence). It is time to put aggressive attributes on trial and glorify compassion instead.

In conclusion, psychotherapists should be committed to breaking the cycle of abuse, to having a voice and sharing their knowledge to promote the development of egalitarian and trauma-informed institutions and foster empowerment of trauma survivors. It is about time that the fields of psychology and medicine assert their growing expertise in self psychology and brain science to help the future generations develop a solid foundation of mentalization. The dissemination of mindfulness, as an “ego-dissolving” approach for better attunement and respect between human beings, is within our reach.

 

References

1. Muldoon SD, Taylor C, Norma C. The survivor master narrative in sexual assault. Violence Against Women. 2016;22(5):565-587

2.Breiding MJ, Smith SG, Basile KC, Walters ML, Chen J, Merrick MT. Prevalence and characteristics of sexualviolence, stalking,and  intimate partner violence victimization–national intimate partner and sexual violence survey, United States, 2011. MMWR Surveill Summ. 2014;63(8):1-18.

3. Rourke KS. You owe me: examining a generation of entitlement. Inquiries Journal/Student Pulse. 2011; 3(01). http://www.inquiriesjournal.com/a?id=362. Accessed Oct 1, 2018

4. Norma C, Taylor S C. Towards More Effective Policing of Sex Trafficking. In S. Caroline Taylor, Daniel Joseph Torpy and Dilip K. Das (Eds.). Policing Global Movement: Tourism, Migration, Human trafficking, and Terrorism. Boca Raton, FL: CRC Press, 2012, pp. 187-203.

5. Herman J. Trauma and Recovery: The Aftermath of Violence – from Domestic Abuse to Political terror. Basic Books. New York, NY.  1997

6. Hockett JM, Saucier DA, Badke C. Rape myths, rape scripts, and common rape experiences of college women: differences in perceptions of women who have been raped. Violence Against Women. 2016;22(3);307-323

7. Carr M, Thomas AJ, Atwood D, Muhar A, Jarvis K, Wewerka SS. Debunking three rape myths. J Forensic Nurs. 2014;10(4):217-225