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Self-Harm and the 'Saying Goodbye' Technique
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In the last section, we discussed traits of anxiety related
to sexual abuse and techniques to deal with the anxiety.
this section, we will examine the depression that many sexually abused boys experience
and techniques to facilitate recovery. In the area of family history, rewards,
self-esteem, self-harm, anger issues, and losses.
Depression is probably
the most pervasive of symptoms when dealing with boy sexual abuse. It leaks
into every aspect of the client's life: school, friends, and family. Irritability
and sullenness often accompany depression. Clients who exhibit these symptoms
hold the dogma that "If I pretend not to care about anything and if I keep
myself distant from people, then I won't be hurt again or lose anything else that
is important to me."
Six Issues Indicating Depression
Many times, this can also occur in a client who feels
guilt or responsibility for the abuse. Ultimately, he has given up all sense of
control and has made the decision to be passive and helpless. When
a client is indicating depression, there are six issues that may need to be addressed:
family history, rewards, self-esteem, self-harm, anger issues, and losses.
Issue # 1: Family History
First, I consider if the client has a history of
depression in the family. This is of course important because, should there be
an indication of familial history, medication might be needed in the early stages
of therapy. Also, if there is a depressive adult that consistently comes into
contact with the client, that adult could be detrimental to the boy's development.
This is especially true in the case of a depressive parent. Obviously, the client
is not learning healthy coping skills from that parent. Also, the depressive parent
does not provide a stable support system that is essential for a depressed boy.
If you should discover that there is currently a depressive adult in the client's
household that is not seeking treatment, you might consider that the parent be
referred for treatment. In the meantime, it is important that the client find
a more efficient supportive adult (i.e. a counselor, another parent, or relative).
Stan, an eleven year old sexual abuse client of mine, was exhibiting symptoms
of depression. To find out if he happened to have a history of depression in his
family, I asked Stan, "Did an aunt or an uncle act real sad after a traumatic event? What about your mom or your dad?" Stan told me that, since his father
lost his job, he's been drinking much more than he used to.
Stan stated, "He
gets mad real easy too, at least when he's not sleeping. He sleeps a lot more
now. Sometimes, he sleeps until three in the afternoon." In such a case,
I didn't believe medication was necessary, but I did recommend that Stan stay
with his aunt, who he was close to. I also spoke with his father and referred
him to a colleague of mine.
♦ Issue # 2: Depression for
Secondly, after history, I examine the family's influence on
the client and if they are unintentionally rewarding his depression. Commonly,
parents tend to pamper the client, especially after such a traumatic experience
as child sexual abuse. While this does provide nurture and support that is needed
for recover, many times, parents do not realize that their lack of boundaries
is encouraging the client's depressive moods.
Kyle was a 9 year old client of
my colleague, Dr. Krussel. Kyle's parents were much more lenient with him after
the abuse occurred. If he broke the rules, he was not punished while his siblings
were. Kyle constantly skipped chores. If he was reprimanded, he became sullen
and his parents attributed it to the abuse, not their own lack of discipline.
In therapy, Dr. Krussel wasn't as indulgent as his parents.
When Kyle wanted to
continue playing video games for the third session in a row, Dr. Krussel told
him no. Kyle became sullen, but since Dr. Krussel stayed firm, Kyle decided that
his show wouldn't work for him and soon became cooperative. In this case, the
parents were the cause of the depressive behavior.
Dr. Krussel talked to them
and asked them to make a strict contract with Kyle over which chores he will have
to do. If he should break this contract, there would be consequences. By establishing
stricter control over their son, Kyle soon dropped his depressive act.
Issue # 3: Understanding the Impact on their Self-Esteem
In addition to family
history and rewards, the third area to consider when facing a depressive sexual
abuse male client is whether they understand the impact of the abuse on their
self-esteem. As you know, sexual abuse can destroy a young boy's self-image. The
shame and humiliation felt soon manifest themselves through depression.
age 17, was exhibiting signs of depression. He had played high school varsity
soccer until he had been raped by an uncle at Christmas. Because he was an athlete,
much of Brian's self-esteem lay in his physical prowess and the validation won
by his trophies and medals. What Brian needed to establish was an unconditional
self-esteem, something that wasn't certified by titles or tournaments. To help
him do this, I found the "Aspirations and Affirmations" technique helpful.
♦ Using the Aspirations and Affirmations Technique
asked Brian to make a list of the opportunities that lay before him and the abilities
that exist within him. On this list, he included: College, Foreign Travel, Stamina,
Ambition, Loyalty, and Love.
I then asked Brian to place this list where he
would be able to see it at least twice a day. He put it on the inside of his medicine
cabinet, which he opened everyday to get out his toothbrush and razor. This list
helped to remind him of his worthiness.
♦ Issue # 4: Potential
The fourth issue to consider when treating a depressive sexual
abuse client is the boy's potential for self-harm due to suicidal thoughts, anger,
desire for revenge, ongoing hopelessness, or guilt. Theo, age 14, was referred
to me after he revealed to his counselor that he had suicidal thoughts after being
abused by his baseball coach.
I explained to Theo that there is a difference between
acknowledging his feelings and choosing to act on them. Because he felt that he
could not control his impulses, I sat down with Theo and wrote out a plan in case
he felt unable to control himself. This included who he would tell (in this case,
it was his supportive step-mother), what he would tell himself, and ways to cope
with the oppressive feelings of disempowerment, which we discussed in section 2.
♦ Issue # 5: Understanding the link between Depression and
The fifth issue to consider is whether or not the client understands
the connection between anger and depression. As we discussed earlier, the inability
to express angry feelings can lead to profound depression. Refer to section 11 for
more information on how suppression of angry thoughts can lead to a depressive
♦ Issue # 6: Emotional Losses
In addition to
family history, rewards, self-esteem, self-harm, and anger issues, the last concern
when a client is in a depressive state is the losses the client has experienced
as a result of the abuse. Often, boy clients think of loss as a sense of the physical,
not emotional. They do not consider such things as childhood, self-esteem, peer
relationships as things to be lost. Matthew, age 16, was a sexual abuse client
of my colleague Ronald.
Matthew was going through the painful loss of a father,
who had molested him, and through a loss of security and safety. He stated, "I
can't feel safe in my own house anymore. I'm always on edge and I know it's because
of what my dad did to me. I shouldn't feel this way, and I know in my head that
what I'm feeling has no basis, but I feel it all the same." Many times, when
experiencing this type of loss, a state of grieving needs to follow in order for
recovery to take place.
♦ Saying Goodbye Technique
To help Matthew understand that he
was going through a loss of security as well as a loss of a strong father figure,
Ronald found the "Saying Good-bye" technique helpful. Ronald asked Matthew
to take the losses of his father and security and create a symbol or metaphor
that exemplifies those losses. Matthew, who was an excellent writer, wrote a description
of two lion cubs playing on the savannah.
He explained to Ronald, "See, they're
playing and relaxed in the most dangerous landscape of all. I mean, they are two
huge water buffalo not 100 feet away from them that could squash them at any moment,
yet they're totally ignorant of that. I miss that. I miss that ignorance."
Ronald then told Matthew to do whatever he wanted with the story to help him cope
with loss. Matthew decided to laminate his story and bury it in the backyard,
so, as he said, "When I get through my therapy, I can just dig it up and
remind myself of how I came through without security."
this section, we discussed the depression that many sexually abused boy clients
experience and techniques to facilitate recovery.
What are six issues that need to be considered when dealing with depression
in a young male sexual abuse client?To select and enter your answer go to .
This CD has covered such topics as: Isolation,
Disempowerment, Individual over Group Therapy, Family Participation in Therapy,
Therapeutic Challenges, Sexual Identity, Post Traumatic Stress Disorder, Social
Pressure, Environment Concerns, Anger Issues, Anger Management, the Causes of
Anger, Anxiety, and Depression with Sexually Abused Boys.
I hope you have found
the information to be both practical and beneficial. We appreciate that you've
chosen the Healthcare Training Institute as a means for receiving
your continuing education credit.
Home Study Courses we offer include: Treating Self Mutilating . . . Teen "Cutters"
"Physical Pain Stops My Pain" Treating Teen Self Mutilation; Treating
Post Holiday Let-Down and Depression; Living with Secrets: Treating Childhood
Sexual Trauma; Interventions for Anxiety Disorders with Children and Adults; and
Balancing the Power Dynamic in the Therapeutic Relationship.
I wish you the best of luck in your practice.
Thank you. Please consider us for future home study needs.