HOW TO FIND A THERAPIST and What to Expect in Psychotherapy
By Richard Gartner from Beyond Betrayal: Taking Charge of Your Life after Boyhood Sexual Abuse


This is an excerpt from Beyond Betrayal: Taking Charge of Your Life after Boyhood Sexual Abuse. It comes from Chapter 12, Helping Yourself Heal. This excerpt is intended to be a guide, a way to help you think about the choices you need to make. Ultimately, those choices are entirely up to you.
For simplicity's sake, all references to therapists' gender are "he" or "him," but many therapists who work with male survivors are female, and are likely to be as competent (or incompetent) as male therapists.
Parts of this discussion are adapted from A Consumer's Guide to Therapist Shopping, by Ken Singer, L.C.S.W. Those parts are reprinted with permission from www.malesurvivor.org, web site of MaleSurvivor: National Organization against Male Sexual Victimization.

What goes on in psychotherapy?
A therapist's job is to help you put your life's story back together. To accomplish this, he listens to you without judging you and helps you keep track of "yourself." He may also help you learn some of the techniques we talk about elsewhere in this book, like journaling or meditating.
A therapist should create a non-judgmental atmosphere that facilitates your telling your story in an organized way. In doing so, you'll identify, express, and reflect on your emotions, making links between parts of your life that seemed unconnected before.
Your therapist may talk to you about how to approach everyday problems differently. You may learn about patterns of behavior, some of them learned in childhood, that stop you from getting what you want in relationships, at work, and elsewhere in your life. This will help you choose whether these patterns need revising, and plan any changes you need.
Because your therapist is (or ought to be) knowledgeable about male sexual victimization, he can answer your questions about it and help you sort out the facts. He may help you locate the boy inside yourself and speak to that boy, creating a dialogue that keeps you in touch with the parts of you that still feel child-like. You may start to see how complicated your feelings are about your abuse and your abuser, especially if he is someone about whom you have both negative and positive feelings.
At times, a therapist may work with you directly to make you feel less anxious or afraid. For example, if you were abused in the woods, you may feel frightened of being in the woods, or in parks, or even anywhere with trees or open spaces. A therapist may help you alleviate this kind of phobia by teaching you to relax while you think about what frightens you. This process is called desensitization.
Also, a therapist may interrupt your usual thought processes and offer you new ways of thinking. For example, if you obsess about some part of your story, such as why you went back to your abuser's house after you knew it was dangerous, the therapist may directly interrupt that flow of thinking, which serves you no good in the present. This will teach you to interrupt yourself when you begin to ruminate.
The therapeutic relationship
All of these are important. But most important of all is the relationship you have with your therapist. In the end, this is what will make the therapy successful.
Because of your early betrayal, you may have a very hard time trusting even the most seemingly responsive and compassionate of therapists. After all, you were betrayed in an important early relationship. You may be especially suspicious of relationships that seem loving, nurturing, and kind.
It's important that you find a way to establish a different kind of relationship with your therapist than you had with your abuser, one in which you experience understanding, trust, and empathy in a nonjudgmental atmosphere. Having this kind of relationship will take you a long way toward restoring your beliefs about what's possible in relationships.
Ideally, your experience with your therapist will give you tools to enable you to develop relationships with others. As you do, you can talk with your therapist about those relationships and get feedback about what's happening.
The person of the therapist is crucial, because your relationship with him may be the single most important component of your healing. When a therapeutic relationship is healing, it's because the therapist has integrity, is not exploitative, and is sensitive, empathic, consistent, and trustworthy. Assuming the therapist is well-trained and licensed--issues we'll address in a moment--it's more important to consider who the therapist is than what he does.
It's certainly vital that you put your life story together as best you can. But huge gaps may remain in your memory of your childhood betrayal. Even so, you'll heal if you experience a different, more positive relationship with your therapist than you had with your molester and with others who enabled abuse to occur. If therapy goes well, you and your therapist together will create a bond that will change your ideas about what's possible between two people.
Throughout all this, your therapist should be able to establish and maintain a protected place for you to come and safely think through things that have been out of your awareness or too scary to contemplate. This isn't easy to accomplish. It may take a long time before you feel secure enough with your therapist to share some of your darkest thoughts or memories.

Locating a therapist
You shouldn't simply pick a therapist at random out of the phone book. Do some research. Ask around. Get opinions. Interview potential therapists.
Sometimes you can locate good therapists familiar with male survivor issues through recommendations from other survivors. If you have a support group available to you--such as one for survivors or sexual addictions--you can ask who has a therapist to recommend. You can also call rape crisis hotlines or mental health agencies in your area and get a referral specifically for sexual abuse issues. But be aware that some competent rape and sex abuse counselors are inexperienced with male survivor issues. Ask lots of questions both before you go and when you meet the therapist.
Agencies can help if you need a sliding scale fee. However, many agencies are field placements for graduate students or interns. There's nothing wrong with having a therapist who is a graduate student—they're often well supervised. But be sure the intern and his supervisor know what they're doing, and ask how long he'll be able to work with you before ending his placement.
Perhaps you're in recovery without the benefit of a male survivor support system from which to get referrals. You may live in an area with few mental health resources and be unable to find a therapist experienced with male survivors. If so, look for an otherwise qualified therapist with whom you can establish a good rapport. Show him the list of books about male survivors on the MaleSurvivor web site (see the next paragraph). If he's open to learning about male survivor issues rather than saying his inexperience doesn't matter, you may have a very satisfying experience in therapy with him.
Web sites helpful in locating therapists who deal with sexual abuse include those maintained by MaleSurvivor: National Organization against Male Sexual Victimization (www.malesurvivor.org), RAINN (Rape, Abuse & Incest National Network: www.rainn.org), the Sidran Institute (www.sidran.org), or the links on these sites.

Interviewing a therapist
When you interview a therapist, you should be able to get answers to these questions, which appear here through the courtesy of Carlos Loredo, Ph.D.:

What is your academic degree?
Are you licensed by a board? Which one?
How many years have you been practicing therapy?
What internships, special training, or workshops in sexual abuse or male sexual victimization have you attended or conducted? Where and when?
How many sexual abuse cases do you treat each year? How many do you currently have? What percentage are men?
Do you specialize in any area of sexual abuse (working with offenders, clergy abuse, ritual abuse, etc.)?
How much experience do you have working with gay men and gay survivors (if this is a consideration for you)?
Is supervision/consultation available to you?
Has a complaint ever been filed against you?
What is your fee? Billing, payment, cancellation, "no show," and vacation policies?
Do you charge for telephone consultation or calls between sessions?
What is your policy on confidentiality?

If the therapist seems annoyed or puts you off for asking, consider that person someone you don't want to see.
You can always ask for professional references, but don't expect the therapist to give you names of "satisfied customers" the way a painter might. That would be a breach of other people's confidentiality.
Try to find a therapist who has worked with other sexually abused men. Sometimes a therapist fails to acknowledge he doesn't have sufficient experience with male survivor issues. His experience may be limited to having attended a single workshop or read a book on the subject. Or, maybe he's only worked with female survivors. He may be sincerely interested in working with male survivors, but he may be learning on the job while you're paying.
A therapist's lack of awareness and respect for your boundaries is a big red flag. Everyone who's been sexually victimized has had boundaries ignored and violated. A therapist who gives hugs without an invitation from you to do so is crossing your boundaries. This can also include less personal (but unwanted) contact, such as shaking hands, sitting too close, or even intrusive eye contact. Your gut feeling is the best indicator of someone who doesn't respect your boundaries. If you feel uncomfortable when interviewing a potential therapist, trust your instincts.
If you're considering participating in group therapy, ask your therapist if he runs male survivor groups. If not, ask if he would refer you to a group and if he'd feel comfortable working with you while you participate in one.
Ask a potential therapist if he's read about sexual abuse, and especially about male sexual abuse. Look at the reading list on the MaleSurvivor web site (www.malesurvivor.org), and ask if he has read any of the books there, or would be willing to read any.
Don't be afraid to give your therapist a copy of this book, or of my book for professionals, Betrayed as Boys: Psychodynamic Treatment of Sexually Abused Men. In fact, don't hesitate to give your therapist anything you think might help him understand and help you.
All of these factors are important in choosing a therapist. But, assuming a therapist is well trained, what matters most is how you relate to him. So, monitor your own feelings during and after your initial contacts with a potential therapist. The therapeutic relationship is a partnership between you and your therapist. You're both responsible for how it goes. But you're the one who chooses him. Don't let it be a passive choice!

Professional background and credentials
It can be confusing to sort out the meaning of therapists' degrees and licenses. Therapists may be psychiatrists, psychologists, clinical social workers, or "counselors" with different degrees of training. In therapy, there's no hard-and-fast rule that the "higher" the degree (for example, MD vs. MSW), the better the treatment. Therapists' competency has more to do with how much supervised training they've had doing therapy, either before or after they got their degree. Ask any therapist how much supervised experience they've had doing psychotherapy.
You have the right to know a potential therapist's qualifications and whether he meets the standards of your state or province to practice psychotherapy. Different states offer licenses to therapists according to different standards, although they all have licensing boards for psychiatrists, psychologists, social workers, and nurses. Ask whether he has a license. There may be no license available to a particular therapist in your state if he has a background not in these professions. If he doesn't have a license, ask why, and question him about his clinical training. One advantage of seeing a therapist with a license is that the state holds him responsible to uphold standards of clinical practice, which unlicensed therapists may or may not adhere to.
Psychiatrists (M.D.) are physicians who usually do mental status exams and prescribe medication. If you have depression, anxiety, or other problems that may require medication, he can evaluate this and prescribe something to alleviate the symptoms. But psychiatrists' time is expensive. If you want or need to see one for therapy (beyond medication or maintenance), it will be costly to you or your insurance plan. In addition, some psychiatrists don't have as much training doing psychotherapy as other professionals. Ask! You may decide to see another professional for therapy and occasionally see a psychiatrist for medication evaluations.
Psychologists (Ph.D. or Psy.D.) are trained to do psychological testing in addition to therapy. But unless you need testing done for some reason, you're simply looking for competent therapy from a qualified therapist. This may be a clinical or counseling psychologist, or a clinical social worker (M.S.W., L.C.S.W., or A.C.S.W.) who has had supervised experience doing therapy. Certain nurses, also have this training. Sometimes professionals get further psychotherapy training after receiving their professional degrees. Ask how much psychotherapy training this individual has had.
A psychoanalyst has specialized intensive training using psychoanalytic principles. There are several legitimate schools of psychoanalysis, including the interpersonal, relational, object relations, and classical Freudian schools. If a therapist has received a certificate from a psychoanalytic institute, he has had considerable supervised experience doing psychotherapy and psychoanalysis. But be careful, because in many states anyone can call himself a psychoanalyst. Check that this individual has credentials from a reputable analytic institute.
If someone advertises himself as a "counselor" or "psychotherapist," you need to question what this means. Regulations about this change from state to state. There are a number of degrees, like M.A., M.S., and L.M.F.T., whose practitioners are trained and may be licensed, depending on your location. In many (but not all) states, clinicians are licensed to use the letters "L.P.C." or something similar after their names. This indicates he has met licensing standards for that state. Find out what the initials after a therapist's name mean, and whether he has a license.
On the other hand, individuals in some states can legally call themselves "counselor" or "psychotherapist" without meeting any training and educational criteria. Someone like this may have had good training, but he may be totally untrained in clinical treatment or have had inadequate supervision. Be especially careful of a layperson "counselor" who may be working through his own issues, or a pastoral counselor with a religious agenda but little clinical training.

Theoretical background
Different therapists will emphasize different issues, based on personal style, training, and the school of thought on which the treatment is based. For example, a cognitive-behavioral therapist will challenge some of your beliefs, like, "I must be bad because my father treated me so badly," or "I'm not really a man because I allowed abuse," or "No woman will ever want me because I am a victim," or "I'm only gay because my abuser made me that way." Other therapists may put more emphasis on different aspects of your experience, like your fantasy life, your family dynamics, or your relationships.
All therapists need to have a frame of reference for therapeutic work, so it's fine when a therapist subscribes to a legitimate school of thought. Be skeptical, however, of therapists who rigidly adhere to one school and ignore other aspects of your experience. An example of this would be a cognitive-behavioral therapist who only speaks to you about your beliefs and behaviors, dismissing talk about your emotions or family relationships.
A clue to identifying (and avoiding) a therapist with a theoretical bias is his over-stressing an approach or technique (like emphasizing his analytic, cognitive behavioral, or EMDR training). These approaches can help, but an over-emphasis on a specialty may indicate he will fit your issues and experience into his theoretical framework. Be sure he'll see you as an individual.

Therapists' personal characteristics
Think of the kind of person with whom you would feel comfortable and safe. Try to locate the boy inside of you. With whom would he feel most safe and comfortable? What kinds of things matter to you in a therapist? Male or female? Older or closer to your age? Business-like and practical, or warm and empathic? Gay or straight?
Think carefully about why you want one characteristic or another in a therapist. For example, you might feel you need to see a male therapist because you'd be ashamed to reveal to a woman your "weakness" as a victim. But, similarly, you might feel you must have a female therapist because you're ashamed to reveal your "weakness" to a man! Or, you may feel that only a man could understand how painful it would be for a boy to be sexually violated. On the other hand, you may think that only a woman could comprehend this!
If you feel very strongly about the sex of your therapist, then go with that feeling. But, as you examine the reasons for your preference, you may find your reasoning is flawed. After all, some men are empathic with a boy who has been raped and others aren't. Some women would make it easy for a man to talk about victimization without shame, and others wouldn't. What matters is the individual, and the atmosphere the two of you create.
Likewise, if you have questions about your own sexual orientation or gender identity, you may feel you must know your therapist's sexual orientation. Perhaps you feel it's essential you see an openly gay therapist because you think only a gay individual can understand your gender and orientation struggles. Or, perhaps you feel you'd only be comfortable with a straight therapist because you worry a gay therapist will push you in the direction of being gay.
A good therapist—gay or straight--won't push you one way or the other about your sexual orientation, but will help you figure things out for yourself. Many competent therapists don't disclose their sexual orientation, believing that any given individual may sometimes need to think of them as gay and sometimes as straight. And many people don't want to know their therapist's sexual orientation, feeling that the knowledge would distract or overstimulate them. How do you feel?
A well-trained therapist will be open to talking your concerns through with you. Maybe this will reassure you about his ability to work with you. You may change your mind about how important it is that he be exactly what you'd had in mind. Still, if you're very worried about an issue and feel strongly it, then choose someone of the sex, age, or sexual orientation that you feel you need in a therapist.

Should my therapist be a survivor?
The idea that a therapist's personal history of sexual victimization makes him a more effective helper is questionable. Therapists' effectiveness is determined by skill, not simply by life experience. Sometimes survivor therapists' personal experiences with sexual victimization help them understand what you went through. Being stuck in their own experience, however, handicaps others. They may be unhelpful to you.
Likewise, non-survivor therapists may or may not be effective. If they don't understand your trauma, they won't do you any good. But if they're empathic, they may be useful because of their objectivity about the problem. So, there's no clear rule of thumb about whether it's better to have therapist who's a survivor.

Talking about sex
It's important that you be able to your therapist frankly about sex. But watch out if he shows too much interest in "gory details." For example, describing what happened (as you are comfortable disclosing) is important. Or, knowing that a particular assault involved your having an erection and orgasm may be a valid question when you're talking about self-blame you feel for "enjoying" the abuse. But if questioning gets into minute detail or feels like pornography, let the therapist know you feel uncomfortable.
On the other hand, a therapist who avoids any discussion of sexual details, who talks in generalities or euphemisms, is probably uncomfortable with sexual abuse. You need someone who can address your questions about your experiences and feelings, someone not anxious when hearing them. There are plenty of other people in your life who are uncomfortable with sexual victimization to whom you can talk for free. Your therapist shouldn't be one of them!
You may discover you're attracted to your therapist, whether you're straight or gay, and whether the therapist is male, female, straight, or gay. Whatever your feelings, it's important to express them to your therapist. This should be safe. No ethical therapist would take advantage of hearing about your attraction. Bringing your feelings to light—even embarrassing or sexual ones--will help you recover. This is how to learn to deal with feelings rather than have them rule your life.

Questioning the relationship
It's okay for you to question your relationship with your therapist. Does he become defensive and cut off your questions, or does he listen to your reservations? Do you feel invited to explore your doubts in a collaborative way? At the end of the discussion, do you feel reassured? If so, why? What have you learned about the therapist and his capacity to be criticized? What have you learned about his perceptiveness about you? Do you feel understood?
In a therapeutic relationship, you're allowed to make mistakes that might disturb, or even end, a more traditional relationship. As you take risks with your therapist, there may be stormy times when you feel very angry. You may feel something inexcusable has happened. If your relationship has been a trusting one in the past, try to weather the storm. Talk about what's on your mind. Be angry if that's how you feel. A good therapist will listen to your anger and respond.
You may test your therapist many times, often without even knowing that's what you're doing. There may be moments when you have doubts that he's the right person to work with. You may be right, but bring up your doubts to him and see how the interchange goes. Through exchanges like this, you'll develop and deepen your relationship with your therapist.

Rough times in therapy
As you talk about your early betrayal, you may go through bumpy periods. Old memories will regain their power. New memories may emerge. There may come a time when you actually feel worse as you see your betrayal in a new light or from another perspective. Things may click into place that throw you. You may need to have extra sessions or take medication for a while.
Stay the course. As your capacity to endure and deal with this kind of pain increases, the pain itself will subside.
Be aware of what your therapist may represent to you. If you were betrayed by an authority figure, you may discover you feel hostile about his "authority." Since you learned as a boy that primary relationships can be betrayed, you may expect him to betray you. If you feel this way, voice it. There's nothing you should hold back.
Or, you may decide there has been a betrayal of some sort in the therapy. I'm not talking here about a sexual transgression, which is completely unacceptable. But there may be something that falls in the tolerable range of human behavior even though it shouldn't have happened. Something like your therapist forgetting something you told him or mis-scheduling an appointment may trigger a rage reaction from you out of proportion to the misdeed. Use this as an opportunity to find out more about how you get triggered and how to negotiate with someone who treats you badly.

Evaluating therapy
After you've been in therapy with a therapist for a while, ask yourself:
Am I intimidated by this therapist?
Does he listen to me?
Do I feel I can disagree with him?
How does he handle crisis and conflict?
Is he comfortable with the feelings and content I bring out?

If your therapist isn't psychologically healthy, it's important to change. Some therapists get caught up in their own issues and project them onto survivors. Perhaps your issues trigger old unresolved areas in his life. Talk to him about this. See what he says. Remember, you're paying him. If he needs to work on personal issues, he should pay someone for his own therapy. Or, perhaps a conversation with him will clear up your concerns.
A clue to a therapist's overinvolvement is his becoming too emotional about some aspect of your situation. Not that he should be impassive and cold. However, if he seems uncharacteristically interested, avoidant, or upset about something you've said, be alert. Also, if he strongly wants you to do something, for example, confront or forgive a perpetrator, this might indicate a personal issue for him.
If he begins to disclose personal information, more than you're interested in or comfortable hearing, this may also indicate an unresolved area for him. It's all right to use personal anecdotes or experiences from time to time, for example, to illustrate a point or demonstrate that someone's behavior is perfectly normal. However, talking about things like personal sexual, drug, alcohol, or similar problems blurs the boundaries between you. Tell him how you feel. If his response doesn't make you more comfortable, pay attention to that and act accordingly. If necessary, find a new therapist!
Beware of therapists with a mission. An example would be someone who wants to fit you into a group that's wrong for you or that you're not ready to join. And watch out for the dogmatically religious counselor or one who maintains you need to forgive your perpetrator to be truly healed. Likewise, beware of someone who wants you to confront your perpetrator before you're willing or ready. Confrontation—when appropriate--is a serious undertaking needing careful preparation and safety.

If the therapy seems unhelpful
You may encounter misdirected, inadequate, or harmful therapy. What if you're already in treatment with a therapist you feel is incompetent, inexperienced, of a philosophical direction you don't see as helpful, not respectful of your boundaries, or just plain makes you feel uncomfortable?
FIRE THE THERAPIST!
"Whoa! I can't do that," you might be thinking. "He's an expert, a professional!"
Remember, you are the consumer of the therapist's services. Unless you're court ordered to be in therapy, you have the absolute right to enter and leave therapy when you want and with whom you want.
If you've been seeing a therapist for some time and feel the therapy isn't working out, talk it over with him. If you can't come to a resolution, you can leave. Don't stay just because you're worrying about your therapist's feelings. If he takes it personally, that's further evidence you're making the right decision! When you find a new therapist, tell him how and why the earlier relationship ended. Try to learn with the new therapist what you couldn't figure out with the first one.
But it's a good idea to first talk to your therapist about your problem with him. You may find this hard to do. Being assertive, saying what's on your mind, getting what's due you, and speaking up for your rights, are frequently difficult for survivors. Therefore, when a survivor tells a therapist the therapy isn't working, he's taking a positive step in being assertive.
Remember, above all else, that you're the consumer. When you were being abused, you were, for whatever reasons, in a situation you couldn't get away from. That doesn't have to happen in therapy. If the therapy or the therapist doesn't feel right, get out. In your recovery work, you need help from the right person. Your therapist should be a trusted partner in your healing.