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J Can Acad Child Adolesc Psychiatry. 2010 August; 19(3): 231–232.
PMCID: PMC2938759

Boys Who Have Abused: Psychoanalytic Psychotherapy with Victim / Perpetrators of Sexual Abuse

Reviewed by Armand Boisjoli, MD

Boys Who Have Abused: Psychoanalytic Psychotherapy with Victim / Perpetrators of Sexual Abuse.
John Woods , with a contribution by  Anne Alvarez .  Jessica Kingsley Publishers:  New York, NY,  2003.  240 pages.  $39.95 (US). 

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In the foreword to this book, Arnon Bentovim points out that John Woods has described the impact of violence on a child victim’s self-esteem, using, in part, Winnicott’s concept of the false self. Exposure to repeated violence results in never knowing when to expect it to return, and aggression is used as a defense. Abuse of another in turn becomes a way of relieving pain. Female identification is not uncommon, used in order to avoid identification with the aggressor.

In chapter one, Woods describes the hopelessness and outrage of therapists treating victims who enjoy becoming abusers, with particular concern about therapists who become an abusers to their patients. Woods reports that these aggressors need violence for emotional survival — out of feeling victimized and condemned by society, the abuser internalizes the abuse he endured. Woods concludes that interactional psychoanalytic psychotherapy is the most flexible treatment available in such cases, combined with appropriate residential placement.

In chapter two, Woods compares psychoanalytic psychotherapy to other therapies. Modern shifts toward case management and behaviour control at the expense of psychotherapy can re-enact family dynamics, with therapists being identified with the victim and agencies taking on an authoritarian role. The best treatment is described as being that which addresses multiple needs: social, educational, behavioural and psychological.

Chapter three describes common themes in treatment: denial, abandonment, feelings of inadequacy, aggressive defensiveness, powerlessness, the struggle for control, and interpretations being perceived as abuse. Case reports exemplify bullying and being bullied, the boundary of the therapeutic relationship, sexualization of the therapeutic relationship, the re-enactment of trauma, and the emergence of creativity.

Chapter four, “Regression, Trauma and False Self in the Treatment of an Adolescent – Abused or Abuser”, illustrates the need for containment, nurturance and a facilitating environment in analytic treatment. The necessary regression, which may otherwise be frightening, takes place in a safe environment. Thoughts, fantasies, and feelings are handled within the therapy; impulses, desires, and intentions meant to hurt others must be reported to the treatment team to contain them and avoid trauma to others.

Chapter five illustrates the interplay between individual therapy, residential setting, and staff group dynamics. Open communication is key for staff to overcome the atmosphere of secrecy which enclosed the abuse. Instead of control by punishment or pressure, ideal treatment provides self-expression, which eventually brings acceptance of responsibility for one’s own actions. A case here illustrates the projection of anxiety on residential staff by a client, with staff anxiety rising and devaluation of their roles to being “just caretakers”.

Chapter six illustrates the process of group therapy with boys who have abused. Because the co-therapists represent the need to confront painful and traumatic events, the group can strive to overpower them. Therapists can attempt to exert too much authority, or become too permissive. Reacting too quickly removes the incentive of self-regulation for the group; permissiveness allows acting out. A gang mentality can develop, as a refuge from the adult world, to avoid responsibility, and to let loose destructive fantasies.

Chapter seven discusses the dynamics of street sex offenders, who attack women arbitrarily, often in daytime and in public places. The chapter concludes that attacks are more like a failed attempt to find a solution to feelings of inadequacy. It is as if “the body of any woman on the street was available for him to touch, pull or grab, perhaps in order to refute a terrible sense of prohibition against such access to the woman. In this way he could evacuate feelings of humiliation and vulnerability into his victims. . .”

Chapter eight discusses disturbances of gender identity in the young abuser / victim. Abused boys tend to identify with the aggressor, and in turn to be male is equated with being powerful. During his socialization a boy accepts authority with the view that he will grow to be an adequate male. He needs to avoid being destroyed by authority figures, and to relinquish his first love (mother) to resolve the Oedipal complex. Neither of these requisites are present in an abusive environment, causing a break in the boundaries defining gender identity.

Chapter nine, “Paedophilia as a perverse Solution to Adolescent Conflicts”, presents a case of a man with paedophilia, Mr. D, who presented with panic attacks and fear of breakdown. Mr. D seduced early adolescent boys, and with time his perversion required that the boy victims be sadistic to him. His fear of being caught caused his panic attacks. Over the course of therapy, Mr. D relinquished young boys and initiated a satisfying homosexual relationship.

The last chapter, written by Anne Alvarez, discusses the role of the supervisor, who is removed from the heat of the therapy, available for the sharing and the projection of disturbance aroused in the therapist, and able to more easily see the healthy part of the patient. Alvarez elaborated on the timeliness of interpretations, two types of aggression, delay and deficits in deviant persons, symbolization, and therapy as a transitional area.

Woods gave case histories in all chapters to illustrate his material. I enjoyed this book very much.

Articles from Journal of the Canadian Academy of Child and Adolescent Psychiatry are provided here courtesy of Canadian Academy of Child and Adolescent Psychiatry