7

Staying Safe

The Paradox of Self-Care

The concept of self-care for adult survivors of childhood abuse is an inherent paradox. Learning self-care is an essential early step in the treatment of traumatized patients, but most persons who have been victims of early abuse have a very debased sense of self—as worthless and defective—and have no concept of the need to care for one’s self. Not only do traumatized patients often fail to care for their emotional well-being, but they also often fail to take basic care of their physical health. Adults who have been chronically abused, particularly those who have been physically or sexually abused, have little sense of ownership of their own bodies, which derives from the depersonalization that was necessary to tolerate the noxious physical experiences. Patients often describe a kind of discomfort about their bodies: “I know that somehow this body belongs to me, but it doesn’t feel like my body.” When they look in the mirror, they sometimes feel as though they are seeing someone else. Most of the feelings that traumatized patients have about their own bodies are negative—echoes of what they were told and how they were treated: “ugly,” “fat,” “disgusting,” “cheap.” Patients with dissociative identity disorder (DID) have the most extreme distortions of the way they see their bodies; with a bit of mental leger-de-main, reflections in the mirror or photographs of themselves are perceived as having the imagined physical appearance and bodies of their alternate identities.

One of the extremely destructive paradigms in abusive families is that the victimized child’s mind and body are available for exploitation. Thus, adult impulses such as rage, sadism, or sexual tension are vented on the child. It is not at all surprising that children who have been exploited in this way employ the same paradigm when they become adults: they use themselves and their bodies to relieve tension or to act out impulses that often result in self-harm. This tendency to use the self as a vehicle for tension release is heightened by the relational disturbances that result from the abusive early environment. When distressed, most humans seek connection with others in order to feel understood and to alleviate the distress. This avenue of assistance is unavailable to many abuse survivors, because their cries for help have been met with either further abuse or indifference at best, and they have learned to avoid human connection.

The need for comfort and soothing is evident in all of our relationships and is especially prominent with young children (see Chapter 4). Even the most independent toddler or young child seeks a protective adult when the child is stressed or frightened. A normally nurturing parent establishes physical contact and comfort, by picking up and holding an infant or toddler, or by making connection through eye contact or words with an older child once the child has acquired some ability to use verbal communication. This behavior of seeking support from another human being is innate and is in marked contrast to the reactions of many patients with backgrounds of childhood abuse. In times of stress or difficulty, these patients flee from any kind of contact with others into a dysfunctional isolation, relying only on their own resources. The innate response to seek contact with others when in distress has clearly been replaced by the conviction that opening oneself to another when vulnerable will inevitably result in more harm.

MANAGING COMORBID SUBSTANCE ABUSE, EATING DISORDERS, AND SOMATIZATION

Being unable to effectively utilize others for support, many abuse survivors seek relief in a variety of dysfunctional behaviors that do not rely on anyone else. Some persons attempt to numb themselves through drug or alcohol abuse or excessive reliance on prescription medications. Others change the focus of their distress by engaging in eating disordered behavior or by becoming excessively preoccupied with real or imagined somatic problems. Not surprisingly, histories of childhood abuse are extremely common in patients with substance abuse, eating disorders, hypochondriasis, and somatization (see Chapter 2). Sometimes these problems are relatively minor in terms of impact—patients who occasionally abuse alcohol or drugs, who struggle to be able to eat properly, or who try to avoid becoming preoccupied with somatic concerns. In other instances, these problems are major impediments to effective treatment. To the extent that these problems are a prominent and consuming focus in patients’ daily lives, they must be addressed as a priority in treatment. Little, if any, work on learning the skills needed to address trauma-related difficulties can be done with patients who are recurrently intoxicated, endangering their lives through starving, bingeing, or purging, or whose activities center almost entirely around somatic concerns. In that these difficulties offer a kind of relief for patients, there is often considerable ambivalence to addressing them as problems. Patients sometimes regard them as secondary difficulties that will remit if only work is done on trauma-related issues. I have often heard patients minimize their difficulties: “I only lose control of my drinking (or drugging, or eating) when I have flashbacks, and I need to work on my trauma,” or the patients with DID who maintain, “I don’t have a drinking problem—I don’t even like to take aspirin; it’s my alters who drink.” This last statement is probably familiar to those who work in the addictions field as a form of common denial.

Among experts in both the trauma and substance abuse fields, the conventional wisdom has been that any serious substance abuse in trauma patients must be the primary focus of treatment (i.e., that patients must achieve stable sobriety before working on trauma issues). However, psychologist Lisa Najavits, PhD, has proposed an evidence-based model called Seeking Safety that provides integrated substance abuse and PTSD treatment (Najavits, 2004). She has pointed out that common messages such as “Don’t work on the PTSD until you’ve been sober for a year,” or “Substance abuse is the only thing you need to focus on” can be experienced as invalidating for traumatized patients (Najavits, 2002).

Furthermore, in clinical practice, it has been particularly difficult for patients with PTSD to maintain abstinence with traditional treatment, especially if they have more intrusive PTSD symptoms when they stop abusing substances (Ruzek, Polusny, & Abueg, 1998; Solomon, Gerrity, & Muff, 1992). The Seeking Safety model has an integrated treatment approach for the concomitant treatment of both disorders. Using structured sessions, cognitive-behavioral approaches, attention to interpersonal processes, and case management, the model emphasizes safety as a priority of treatment, including stopping substance abuse, reducing self-harming and risky behaviors, establishing healthy relationships, and gaining control over the symptoms of both disorders. In many respects, the Seeking Safety model is a dual-diagnosis approach that incorporates many of the elements of the early phase of trauma treatment.

Addressing and modulating out-of-control behaviors should be a prerequisite task that must be undertaken as a part of any trauma-related treatment, and clinicians must be clear in their advice and expectations. Referral to inpatient or outpatient substance abuse treatment programs, Alcoholics Anonymous, Narcotics Anonymous, eating disorders programs, or other resources, or establishing effective protocols for somatization may be an important part of addressing self-care. Somatization may offer particular difficulties in terms of treatment, as most work in this area has been focused on patients in medical and surgical settings, not on psychiatric patients. It may be useful to establish a program of regular and predictable medical appointments with a primary care physician who can both provide support and exercise appropriate limits concerning access to excessive and harmful medical care (Barsky, 1996). In addition, an educationally oriented cognitive-behavioral treatment, particularly in a group format, has been found helpful for some patients to alleviate their somatic concerns (Salkovskis, 1989).

SILENT CRIES: SELF-HARMING IN ABUSE SURVIVORS1

Self-cutting is known to be common among a variety of populations including adolescents (Kumar, Pepe, & Steer, 2004; S. Ross & Health, 2002), patients with eating disorders (Favazza, DeRosario, & Conteiro, 1989; Paul, Schroeter, Dahme, & Nutzinger, 2002), patients with dissociative disorders (Putnam et al., 1986), and patients with borderline personality disorder (Russ, Shearin, Clarkin, Harrison, & Hull, 1993; Shearer, 1994). Repetitive self-cutting has been correlated with histories of childhood sexual abuse (Briere & Runtz, 1987; Himber, 1994; Shapiro, 1987; van der Kolk et al., 1991; Wise, 1989) and is by far the most common kind of bodily self-harm seen in adolescents and adults with abuse backgrounds. Either delicate or substantial cuts to the arms, abdomen, breasts, genitals, legs, throat, or face (in approximate decreasing order of prevalence) are used as repetitive tension-reducing mechanisms. I have seen a variety of similarly destructive behaviors that seem to be variants on this behavior, including picking at, burning, or abrading the skin; repetitive banging of the hands, arms, head, or feet; swallowing objects such as razor blades, glass, or pieces of metal; and inserting objects or foreign bodies into body orifices (most commonly vaginally) or actually into the flesh or veins. While this kind of self-harming behavior may seem somewhat horrifying and perplexing, it is widespread among patients who experience explosive inner tensions and who cannot access support from others. In most cases, these self-harmful activities are considered to be parasuicidal and not truly attempts to kill or endanger the self; one of the more dramatic examples I can recall was a young woman who repetitively swallowed broken razor blades but became quite concerned and immediately sought help about her medical condition immediately after swallowing them.

The primary gain for many self-harming behaviors is often an immediate relief of tension. Patients use self-cutting to manage their dysphoric internal states; there are two opposite patterns—most commonly, to induce a relaxation response, or conversely, to cause pain in order to end unpleasant depersonalized states (Grunebaum & Klerman, 1967; Himber, 1994). Most patients act in a way that is stereotyped and consistent over time; that is, most patients seem to choose specific forms and methods of activities (e.g., cutting in specific places with certain kinds of sharp objects). In the most common variant of repetitive self-harm, there is usually very little pain associated with the behavior. Before patients cut themselves or engage in other parasuicidal behavior, they often describe experiencing an intolerable sense of inner tension that may include anxiety, dysphoric dissociative states, or anger, which is immediately alleviated after the self-harming behavior. If cutting is involved, it is often the visualization of blood that results in the feeling of relief from tension (Himber, 1994). The underlying mechanism is thought to derive from the release of endogenous opioids—perhaps a bodily response to an evolutionarily adaptive reaction to the sight of blood—which in some studies has been blocked by naltrexone, an opioid antagonist (see, for example, Roth, Ostroff, & Hoffman, 1996). Thus, repetitive self-harming acts are remarkably prompt and effective solutions for self-soothing in patients who cannot obtain comfort or support from others.

In addition to tension relief, self-cutting and other similar behaviors are often an acting out of patients’ deep-seated sense of defectiveness and self-hate. Some patients describe the need to “get the bad blood” out, or the impulse to cut out something bad from inside of them (Grunebaum & Klerman, 1967; Himber, 1994). Although repetitive self-cutting results in substantial psychological and physiological gains, it almost always is associated with shame and secrecy. Patients are generally quite aware that self-cutting is aberrant in terms of normal human behavior and that others tend to react to this behavior with horror and disgust. Some patients also describe their cutting as compulsive and out of control, requiring more frequent or extensive cutting to achieve the desired outcome. This kind of loss of control also leads to increased feelings of shame.

Nonlethal self-cutting or similar behavior has also been described as a mode of communicating distress. Otto Kernberg, MD (1968, 1984), a psychiatrist who helped establish the current understanding of borderline personality disorder, has interpreted self-harming behavior as acting out—for example, as attempts to discharge transferential anger. Other experts have noted the motivation to manipulate others, to gain attention, or to deal with threatened loss (Grunebaum & Klerman, 1967). Some patients may harm themselves for these reasons, particularly in situations of acute distress and explosive anger. When cutting occurs in the context of intense rage over feeling abandoned, ungratified, or misunderstood, cutting may convey messages such as: “This shows you how angry I am!” “Now do you take me seriously?” or “See what you made me do?” However, I infer from my clinical experience that the central intent of self-harmful behavior is not always about attempts to influence the response from others, or at least not the primary motivation. After all, most patients began this kind of activity in isolation and secrecy, long before it came to the attention of anyone else. Much self-cutting begins as an inarticulate cry of pain from patients who have no words to adequately describe their distress and/or who feel repeatedly unheard and unseen. Self-cutting almost always originates as a solitary act that occurs when patients feel intensely alone, overcome by their distress, without a conscious intent to communicate or manipulate.

When revealed in the context of a therapeutic relationship, self-harming behavior may take on the additional role of conveying unspoken messages. Revealing self-injury is a mute cry for help, but it often also appears to be an invitation for a reenactment of abuse-related scenarios. There is a nonverbal communication of, “Do you see how much I hurt?” as well as an almost defiant statement of, “Do you see how different I am from other people, and how I don’t need help from anyone else?” The therapist is in a difficult position in terms of knowing how to respond. A response of only concern or sympathy is certainly gratifying for the patient who then feels heard, but little is gained in terms of promoting direct or verbal communication. A response that ignores or minimizes the behavior increases the patient’s sense of being alone and unheard. A response of disgust, frustration, or anger (especially when the self-harming behavior is in violation of a therapeutic “safety contract”) inevitably provokes shame and a confirmation of the patient’s perceived defectiveness, and sets into motion the abuse-related scenario of patients feeling shamed that they have been bad and deserve to be punished.

Perhaps the best response in these situations is one that is modulated in terms of expressed emotion and conveys concern and interest along with a gentle confrontation concerning the dysfunctional aspects of the behavior: “I can see that you have been in a great deal of pain, and I would like to learn more about your cutting and what leads to it. I am sorry that you have not found another way to let me or other people know about your pain, and that you have had to continue to do something that interferes with your ability to grow and heal.” Responding in a matter-of-fact, calm, but serious manner with gentle confrontation about the need to change is essential in transforming the self-harming behavior into a more adaptive solution, such as interpersonal communication and developing a sense of mastery. The therapist also needs to assess the dangerousness of the self-cutting, both in terms of suicide potential (unusual) and physical well-being. Even in the absence of suicidal intent, blood loss, serious scarring, and the potential for serious infection may mandate referral to a physician for ongoing monitoring and treatment.

Given the addictive quality of self-cutting, it is not surprising that the most effective treatment uses an addictions model. In this model, self-harmful behavior should not be regarded moralistically, but as a maladaptive effort at coping that has negative consequences. As in other addictions, there is a wide range of severity. At one extreme, there are patients who are so drawn to the behavior that they are at risk for seriously harming themselves. I remember several patients who had cut themselves so badly that they developed life-threatening cellulitis from the nonhealing wounds. Another patient, once she began to cut, felt strong impulses to cut more and more deeply. For such patients, total abstinence from cutting is required. However, for most patients, it is important to make the distinction between establishing safety and extinguishing self-harm. For many patients, the cutting has no serious medical implications, and it may be permissible for them to hold on to a reduced level of self-harming behavior until they have developed or restored basic abilities to engage productively with others. However, establishing an alliance around the progressive goal of stopping self-harm is essential. As in the treatment of other addictive behaviors, slips and relapses are common, and a sustained commitment to the ultimate goal of abstinence is the most important part of successful treatment. Emphasis must be placed on the patient to supply the primary motivation to control the behavior, although it must be acknowledged that the patient will require considerable support. As noted by Himber (1994):

Establishing an alliance around safety proceeds hand-in-hand with the development of understanding and communication. Although stopping self-cutting is a final goal of treatment, there are useful intermediate steps. If the patient cannot agree to stop cutting, can she identify and agree to goals which will help her recover? Some patients may disavow the seriousness of their behavior or the shame and fear associated with it, insisting that “it’s no big deal,” not suicidal, and not worth paying attention to. This can set the stage for a struggle between the patient and the therapist. In such struggles, the patient projects her distress and anxiety about self-harmful behavior onto the therapist, and then both attacks and devalues the therapist’s interventions. As the patient acts less and less concerned about cutting the therapist may become more and more alarmed and the struggle can escalate. It is important to keep the focus on the patient’s responsibility for her own safety and to name her attempts to disavow her own distress. (pp. 629–630)

Clinicians must be extremely careful not to take on one side of this ambivalence (the “good” side), which allows the patient to actually feel less conflicted about the self-harmful behaviors. Clinicians should provide expert advice and empathic support, but must make it clear that patients must carry the primary responsibility for their own behaviors, for ambivalence about the behaviors, and for changing the behaviors. The following case illustrates some of the dilemmas and the negotiations concerning the treatment of repetitive self-harm:

Barbara, a 35-year-old mother of two young children, was admitted to the hospital for severe depression and suicidal ideation. She reported a 20-year history of repetitive self-cutting, and although she had no major medical problems related to this behavior, both of her forearms were crisscrossed with hundreds of small scars and more recent wounds. Despite several years of therapy, Barbara was making little progress, which she attributed to both a sense of hopelessness about her own condition and to passivity on the part of her outpatient therapist: “She just listens and doesn’t actually do anything.” In regards to her self-cutting, she reported that she cut for a variety of reasons, but mostly when she felt intense feelings such as despair, anger, or aloneness. The cutting replaced these feelings with numbness.

Barbara’s outpatient therapist knew about the cutting and had actually tried a number of interventions to make it stop. Several safety contracts had been established, but despite Barbara’s superficial compliance, she continued to cut secretly and somewhat defiantly: “I know she wants me to stop, but it’s my body and she doesn’t understand how much I need it.” Barbara’s hospital therapist asked about details of the cutting and the circumstances under which it occurred. She also underscored both the adaptive role of the cutting and its impact on Barbara’s life: “I know that cutting has been a kind of friend to you over the years in helping you cope with intolerable feelings and circumstances. However, you should realize that if you can’t stop the cutting, you will not be able to find more adaptive ways to express your feelings and move on in your treatment. Only you can decide when you are ready to stop cutting. Rather than placing the responsibility on your outpatient therapist to ‘make’ you stop cutting, I think you should remember that the cutting makes you feel ashamed and out-of-control at times, and has interfered with your treatment.”

After considerable discussion, Barbara agreed to try and find ways to stop the self-cutting. She used several grounding techniques to try and control dysphoric dissociative states and followed through with a plan to try to talk to others when she had the impulse to cut. She also developed new techniques of controlling her impulses—for example, rubbing her forearms with an ice cube that produced a numbing feeling that was similar to the sensation of cutting and somehow made it less necessary to do so. Finally, Barbara devised a unique solution. Using a craft kit of wooden beads, she painted the name of each of her sons on two large beads, which she then fashioned into bracelets, one for each arm. Subsequently, when she would find herself looking at her arms for a place to cut, she would see the bracelets and recall that she had made a commitment to herself and her family to try and stabilize her life. This proved very effective and she was able to stop cutting—for the first time in decades. However, two weeks after discharge from the hospital, the outpatient therapist noticed fresh scars on her arms. Barbara shamefully admitted, “I guess I’ve been forgetting to wear the bracelets.” Barbara and her therapist were then able to discuss Barbara’s essential role in controlling the self-cutting, and were able to devise a new strategy for addressing this issue in the context of her treatment.

THE MANAGEMENT OF SUICIDE RISK

The risk of suicide is a very real threat with many patients with complex PTSD. A heightened level of suicidal behaviors has been correlated with childhood trauma (Afifi et al., 2008; Nelson et al., 2002; Sarchiapone et al., 2009; Ystgaard, Hestetun, Loeb, & Mehlum, 2004), PTSD (Amir, Kaplan, Efroni, & Kotler, 1999; Ben-Yaacov & Amir, 2004; Kotler, Iancu, Efroni, & Amir, 2001; Sareen et al., 2007; Sareen, Houlahan, Cox, & Asmundson, 2005), and dissociative disorders (Foote, Smolin, Neft, & Lipschitz, 2008; Putnam et al., 1986; Ross & Norton, 1989). The specter of suicide is frequently omnipresent in the early treatment of severely traumatized patients. Many patients who have survived extensive early abuse have made suicide gestures or attempts, and nearly all such patients chronically contemplate suicide as a potential relief from their intolerable daily experiences.

The management of true suicide risk should be relatively straightforward. First, truly suicidal impulses and behavior must be distinguished from the parasuicidal behaviors involved in self-cutting or other self-harming behaviors. Second, clinicians must insist that the threat (or implied threat) of suicide not be used as a form of communication or negotiation. Third, therapists and patients must agree—in advance—that the real possibility of suicide is a crisis situation, and that any and all interventions can and should be used. Fourth, although both therapists and patients together may help determine the risk of suicide, therapists have the ultimate responsibility for acting to preserve patients’ lives and well-being. These principles are central to managing chronic suicidal threat and necessary for the sanity of both patients and therapists. They cannot be compromised, and clear limits must be set concerning any violation of these principles.

Interpersonal conflict and struggle are often inherent features of the therapeutic relationship. It is a far safer therapeutic strategy to set clear limits concerning the principles about suicide from the outset, and to permit the inevitable conflict and negotiation to occur in other less lethal areas. I am indebted to my colleague and co-teacher in workshops for treating complex dissociative disorders, Audrey Wagner, PhD, for her clarity concerning the goals of therapy. As she clearly reminds our workshop attendees, therapy should be about improving the quality of life, not about deciding whether to live or die—an observation that has helped innumerable clinicians in their work. Agreement concerning this principle must be a prerequisite for starting or continuing therapy. Without such an agreement, treatment may well be unnecessarily prolonged, mired in endless negotiations about the possibility of suicide, or may even become therapeutically untenable with little hope for a positive outcome, with a greater likelihood of stalemate or even death through completed suicide.

The difference between suicidal and parasuicidal behavior is determined best by direct discussions with patients regarding the motivations and goals of their behavior. Patients are often able to be quite clear that there is no suicidal intent in certain self-harming activities. However, there are often areas of ambiguity, such as patients who hurt themselves in ways that might or might not be lethal, or in behavior that is not intended to be suicidal but might well result in serious injury or death (e.g., repeatedly driving while intoxicated). Because of the extreme consequences of this kind of ambivalent behavior, therapists should clearly err on the side of acting to safeguard patients’ well-being if there is any substantial question of personal safety.

Patients’ hints or threats about suicide can be a form of communication or negotiation. Statements such as “I’m not sure I can keep myself safe” are often a disguised way of asking, “Do you recognize that I am in pain and feel desperate?” or “What will you do for me if I don’t hurt myself?” Therapists should confront such implied communications directly and ask if the patient is trying to communicate the intent to commit suicide—or some other message. Because unresolved questions concerning suicide are likely to result in hospitalization or other unwelcome outcomes, the burden is on patients to try to clarify the underlying message in their statements. Frank and direct discussion about suicide is the best deterrent against self-endangering behavior. If patients and therapists are unable to engage in such direct discussion, suicidal behavior may even increase. For example, the patient who says, “I’m been thinking about killing myself” as a way of asking, “Do you care about me?” may actually feel impelled to act if the question is not clarified and the patient feels disappointed or upset by the therapist’s response.

Agreements that the patient will not attempt suicide, so-called safety contracts or safety agreements, can be very effective, particularly because many trauma patients have a rigid personal commitment of having to adhere to their promises (“I always keep my word”). However, from both a clinical and a medicolegal perspective, safety contracts do not substitute for the clinician’s judgment about the patient’s safety. For example, for a safety contract to be effective, the patient must have intact reality testing and—with all patients—there must be a sense of alliance between the patient and therapist. The presence of delusional beliefs may impel patients to make suicide attempts despite previous agreements not to do so, and in the absence of a basic alliance, patients may not feel bound by their contracts. Safety contracts must be interpreted in the total context of the patient’s clinical situation and should be reviewed regularly.

The best safety contracts are made face-to-face with direct eye contact and with therapists sensing a level of sincerity (although often with reluctance on the patient’s part) about the agreement. Safety contracts also have limitations. For example, it is almost impossible to devise a formal safety contract without loopholes, and patients may stick to the letter of the agreement but may find ways to violate the substance of the agreement (e.g., “I said I wouldn’t overdose, but I didn’t agree not to drive my car off the road” or “I agreed to be safe until our next appointment, but you canceled it and rescheduled it.”). Furthermore, safety contracts are usually time-limited, because few patients can agree to long-term or indefinite contracts not to attempt suicide. For the convenience of not having to renegotiate the contracts, it is advisable to ask for as long a period of time as possible, for example, a year. However, few patients are able to make such a prolonged commitment, and contracts for a few months or weeks are much more common. It is incumbent on the clinician to keep track of the end date of safety contracts. They must be renewed, and any failure to do so may well be seen by the patient as permission to engage in self-endangering behavior, as in this clinical illustration:

Ashley, an adolescent with a history of severe childhood abuse, had made several serious suicide attempts in her young life. She began working with a therapist, who helped her decrease her self-destructive behavior through a series of safety contracts that were established on a session-by-session basis. Ashley and her therapist took these contracts very seriously, including very detailed provisions in the contracts concerning not only the time period of the contracts but also various prohibitions against all sorts of self-harming and risk-taking behaviors. Following a therapy session approximately 18 months into the treatment, the therapist suddenly recalled that she had gotten an emergency telephone call near the end of the session and had neglected to renew the safety contract. After some thought, she decided that given the trust that had developed in the relationship and the precedence set by previous agreements, a continued safety contract was clearly implied, and she did not act further. Ashley, on the other hand, was acutely aware of the absence of the safety contract and was convinced that this was a clear message from her therapist that the therapist had finally gotten tired of her and wouldn’t mind if she killed herself. She took an overdose of all her medication and was subsequently admitted to a hospital after being found by her roommate.

It is hence crucial that patients be asked to adhere to the spirit rather than the letter of any safety contacts. Although safety contracts may be useful, establishing some kind of ongoing commitment by the patient to continue to struggle to stay alive is much more important. As with safety contracts, this commitment must be repeatedly discussed and reaffirmed.

As is the case with most self-harming behavior, traumatized patients have intense ambivalence about suicide. After all, those who unambivalently wish to die have unfortunately already suicided. Many abuse survivors have intense internal conflict about being alive. When patients are unable to tolerate the pain of their own intense conflicts, therapists may find themselves assuming one side of the ambivalent feelings—once again, usually the good or positive side. Unfortunately, this sometimes permits patients to be unambivalently negative about this complex issue. Therapists and patients may find themselves battling over the issues involving actual survival rather than recognizing them as the projections of the patient’s ambivalence and internal conflict:

In the early years of my psychiatric career, I began treating Deborah, a 36-year-old mother of two, who entered therapy with the goal of wanting to feel “less tortured.” She began to describe fragments of memory that suggested truly horrific physical, sexual, and emotional abuse in a highly chaotic family environment. As the therapy progressed, she became more and more aware of the extent of her abuse and more overwhelmed by feelings of depression, despair, and loneliness. Her suicidal ideation and self-destructive impulses increased. In therapy, Deborah claimed that she could no longer be responsible for her own personal safety and that I had to “hold the hope” for her. This resulted in many instances in which she would persuasively argue that her life had become a constant torment, and that I should understand and allow her to kill herself. I would then counter with reasons why she should live, including hopes for the future and the value of her life for herself and for others. Deborah rejected all of these arguments as false assertions. She even rejected the notion that her children would be devastated, arguing that they would be better off without her. I found myself becoming more and more anxious that she might suicide.

Finally, I was able to say: “I understand that you wish to die and that life is a torture for you. However, I think you may be oversimplifying the situation to yourself. I think you have very mixed feelings about living and dying. Although you desperately wish to die, you have a remaining small hope that life might get better. Although you know that I want you to live, it is much more important for you to know that you both want to live and to die. I cannot convince you to live, but I can help you sit with the very uncomfortable feelings about not knowing what to do.” Much to my surprise, Deborah acknowledged the validity of these observations, and the therapy then continued in a more stable manner.

Specifically concerning the issue of suicide, the therapist may need to temporarily assume responsibility for maintaining the patient’s safety, such as arranging hospitalization when the patient is unable to commit to safety. However, any such stance should be short-lived, because the therapy is untenable unless patients assume the burden of working through their own conflicts about living.

Making a commitment to stay alive is essential for maintaining a workable alliance and therapeutic relationship. This simple fact is too often overlooked by desperately tortured patients and their well-intentioned therapists. Patients often may be so filled with their own pain that they ignore the fact that they have a basic responsibility in any relationship including the therapeutic relationship: that they must be alive to participate in the relationship, and that this assumption is a prerequisite for expecting that anyone else will make a commitment to them. Therapists may be afraid to bring up this issue of the patient’s responsibility to remain alive because of the principle that therapists should not let any of their own feelings contaminate the therapy. However, even the therapeutic relationship depends on the most basic contract—that both parties agree to make a commitment to continue working together. Thus, another effective intervention is often the therapist confronting the patient’s abandonment of the relationship, for example:

“I know that you have many reasons to want to die. However, do you remember that you have often asked me to make a commitment to you? I am glad to do so for the foreseeable future, but it is only fair to ask that you do so too—by making some commitment to remaining alive. I have no wish to take away your ultimate control of the decision to live or die, but I do want to ask you to make a decision for now not to destroy our relationship.”

Emergency interventions are required in situations where patients’ lives are in danger. Too often, therapists feel they are not allowed to pursue critical options. Therapists should never agree to relinquish vital therapeutic interventions, for example, agreeing never to hospitalize the patient (“I’ll just be put into restraints and be retraumatized”), to always discuss all options beforehand (“I’ll never be able to trust you again”), or to never contact family members (“They’ll never let me forget it”). Although it is always clinically desirable to discuss matters with patients and to respect their wishes, a possible imminent suicide is an emergency situation that may require extraordinary measures. Such measures may be necessary to save a life, even at the cost of destroying an ongoing therapeutic relationship.

No matter how well-managed a therapy may be, there is always the possibility of broken contracts and attempted or even completed suicides. The burden of the living with the sequelae of horrific abuse may be more than some victims can tolerate. Fortunately, the number of completed suicides is quite small considering that self-harmful behavior, chronic suicidal impulses, and even suicide attempts are quite common in severely traumatized patients with complex PTSD. In some respects, patients’ ambivalence about living or dying is expressed in their use of suicide gestures such as medication overdoses rather than more lethal means such as self-inflicted gunshots or hanging.

In situations where there is a serious breach of the substance or spirit of agreements concerning safety (and the patient survives), the therapist needs to consider several options. First, is the therapist willing to continue the treatment? A chaotic and anxiety-provoking therapy places a considerable burden on the therapist, and therapists need to consider whether they are able and willing to continue. It is very important for therapists to be truly candid with themselves about this issue, as both the patient’s and therapist’s well-being depends on it. Too often, therapists convince themselves they can continue to treat difficult patients and then subtly act out their frustrations and anger much to the detriment of the treatment. Second, if therapists are willing and able to continue the treatment, they must determine what basic requirements must be met by the patient (e.g., agreements concerning safety, behavior, outside supports, shift in attitudes, etc.), and then ask the patient to meet these requirements in order to continue the therapy. A serious suicide attempt is a major breach of the therapeutic relationship, and it is then incumbent on the patient to demonstrate a willingness and ability to heal the rupture in order to continue the therapy.

REVICTIMIZATION2

One common failure of self-care results in the revictimization of childhood abuse survivors. I have observed a variety of behaviors in patients with traumatic backgrounds that range from seeming obliviousness to potential danger to repetitive reenactments of their abuse to chronic risk-taking that sometimes appears almost addictive in nature. These behaviors result from a variety of different and complex psychological processes that are tied to early abuse experiences and place many traumatized patients at considerable risk.

Shortly after developing an interest in understanding and treating patients with histories of childhood abuse, it seemed to me that there was an unusually high incidence of adult physical and sexual assaults in this patient population. In our study that was published in 1990 (Chu & Dill), we found that patients with a history of childhood sexual abuse were more than twice as likely to be victims of adult sexual assault than those with no sexual abuse history. Subsequent focused studies have confirmed that the rate of sexual revictimization is double for women who had been sexually abused in childhood compared to those without such histories (Gidycz, Coble, Latham, & Layman, 1993; Tjaden & Thoennes, 2000), and one large study of men showed a fivefold increase in the rate of adult sexual abuse if they had been sexually victimized in childhood (Desai, Arias, Thompson, & Basile, 2002).

In settings such as emergency rooms and crisis centers, adults with histories of childhood abuse have been shown more likely to be victims of multiple rapes and other kinds of revictimization (Briere & Runtz, 1987; Dutton, Burghardt, Perrin, Chrestman, & Halle, 1994; Follette et al., 1996). Even in psychotherapy, patients with a history of childhood sexual abuse are more likely to be the victims of therapists’ sexual misconduct (Kluft, 1989b, 1990a). Therapists who have sexually exploitative impulses or who are repeat sexual offenders pose a serious risk to all patients, but particularly to those who have been previously victimized (Schoener, Milgrom, Gonsiorek, Luepker, & Conroe, 1990). Finally, revictimization is not limited to sexual abuse (which has been more widely studied than other types of abuse). In our 1990 study (Chu & Dill), women who had been physically abused in childhood were dramatically more likely to be physically abused as adults, with an odds ratio of 17:1.

The underlying causes of revictimization are complex. In the case of repetitions of childhood victimization, there is the impetus for reenactment. By this, I do not mean to imply that the victim seeks subsequent harm (a version of perpetrators’ “explanations” that victims “asked for it”). Rather, early abuse sets into motion powerful underlying psychological forces that can consciously or unconsciously affect subsequent thinking and behavior. The repetition compulsion in relation to childhood trauma may be one of the key factors behind revictimization. In his discussion of the repetition compulsion, Freud (1920/1955) postulated the “need to restore an earlier state of things” and a need for the person to rework the original experience, specifically taking an active versus a previously passive role, as a way of gaining a sense of mastery over the experience. He also noted that repetitions of repressed experience allowed venting of affects associated with the experience, particularly sadism and hostility. These two last dynamic issues—the active mastery of prior passive unpleasant experiences and the expression of affects associated with past experiences—are important in understanding the role of the repetition compulsion in the revictimization of survivors of childhood abuse. The compulsion to repeat may involve persons taking active (although unconscious) measures to reenact prior traumatic events, as in the following case example.

Many years ago, I met Susie, a 27-year-old, single woman, with a childhood history of extreme physical and sexual abuse, who I began treating for chronic depression, emptiness, and self-destructive behavior. Frequently, when overwhelmed by her feelings (and often while somewhat intoxicated), she felt compelled to park along the side of major highways late at night, waiting to be “rescued.” I would often hear about such episodes in the early morning hours when I was called by the state highway patrol; somehow Susie would let them know I was her therapist. I was then in the position of being her rescuer. After one of these episodes, I brought up my concern that she could be hurt by pursuing such behaviors. Susie was unable to understand why I objected to her behavior, saying that she only wanted someone to pay attention to her and that she knew how to take care of herself. After one episode in which she was picked up and sexually assaulted by a law enforcement officer, she withheld this information from me, feeling angry that I would probably say, “I told you so.”

Perhaps the clearest examples of attempts at mastery through the repetition of early sexual trauma come from the reports that have linked prostitution with childhood sexual abuse. Studies of prostitutes have shown extremely high levels of childhood sexual abuse, and levels of both incest and rape that are far higher than in control groups of women (James & Meyerding, 1977; Silbert & Pines, 1981; Widom & Kuhns, 1996). Herman (1981) documented both promiscuity and victimization in women who had been sexually abused. It is in clinical situations that the elements of this type of repetition are clearly evident. One patient who frequently prostituted herself remarked, “When I do it, I’m in control. I can control them through sex.” Her contempt for the men who used her was evident, and she was only minimally aware of how she may have been exploited. In this situation, it is clear that there was an attempt to have active control of a previously passively experienced victimization, and that a great deal of the affect (contempt and hostility) associated with previous sexual abuse was expressed.

The repetition of past abusive experiences might result in favorable outcomes if persons were actually able to master past aversive experiences through reenactments. Unfortunately, these attempts usually seemed doomed. The inherent interpersonal betrayals of childhood abuse frequently lead adults to avoid supportive alliances. Hence, when they are confronted with overwhelming repetitions of past abuse, they have only their own resources to draw upon and are frequently again overwhelmed, retraumatized, and revictimized. Moreover, the venting of bitterness and anger often results in further disruption of the interpersonal ties, which might otherwise provide protection and support. In this way, the childhood interpersonal arena is recreated and reexperienced, leaving its victims unprotected and exploited, ultimately leading to isolation, helplessness, and despair.

Trauma-related symptomatology is another key factor related to revictimization. When overwhelming life events (or the feelings associated with them) are dissociated, individuals are not only compelled to repeat the events but may also experience additional posttraumatic syndromes that place them at risk (Chu, 1992b; Gold, Sinclair, & Balge, 1999; Sandberg, Lynn, & Green, 1994). As Kluft (1989b) noted:

They often have dissociative defenses that cloud their perceptions and leave them with a discontinuous experience of themselves and their mental contents. . . . Their defenses leave their sense of self and identity fragmented and experience becomes more compartmentalized than integrated. (p. 487)

Such persons, who are unable to bring their full experience to bear on a potentially dangerous situation, may act with less than their best judgment, leading to revictimization. The symptoms of chronic posttraumatic stress disorder, with the classic biphasic response of periods of intrusion alternating with periods of avoidance and numbing, are evident in many survivors of childhood abuse in their adult lives. During periods of intrusion, individuals have recurrent reexperiences of the traumatic events along with associated affect. Individuals who are actively reexperiencing abuse are unlikely to be revictimized; in fact, they may be hyperreactive even to circumstances that contain no real threat. However, during the numbing phase, when individuals avoid recalling their abuse, they have markedly constricted affect and are detached from others, placing them at higher risk for revictimization. Past traumatic events and the associated affects (including fear and anticipatory anxiety) are quite dissociated from conscious awareness. Thus, individuals may be in a quite threatening situation and be seemingly unaware of potential danger, as in the following example:

Nancy, a young woman who was in treatment for the sequelae of extensive childhood physical and sexual abuse, was accustomed to taking long walks through the woods around her home. She found these walks to be quite soothing and particularly helpful in allowing herself to block out painful memories of her childhood. One evening, while walking along a trail, Nancy found her path blocked by a young man riding a motorcycle and dressed in Army fatigues—apparently from a nearby Army base. With no qualms, she stopped and allowed herself to be engaged in conversation and accepted a ride on his motorcycle. She was shocked when he subsequently made sexual advances and raped her.

Dissociative symptoms and unavailability of normal anticipatory anxiety is most marked in patients with severe dissociative disorders. Their rigid compartmentalization of experience and identity places them at substantial risk for revictimization. Not only are traumatic experiences dissociated from consciousness, but many dysphoric affects (including anticipatory anxiety) are split off into separate self-states or alternate personalities, resulting in increased vulnerability of revictimization.

One other posttraumatic phenomenon is of note. The model of “inescapable shock” described by van der Kolk and others (van der Kolk et al., 1985; van der Kolk & Greenberg, 1987) is based on situations where the victim of trauma is helpless to prevent or escape from the aversive events. Inescapable shock leads to an impairment of the ability to learn how to escape from new aversive experiences. Thus, when persons with childhood abuse histories are faced with potentially threatening situations, they may feel extremely constricted in their choices and helpless to escape. Not only do they have difficulties in conceptualizing new ways to deal with traumatic circumstances, but they often feel overwhelmed by the return of feelings of helplessness associated with the original abuse that is triggered by the current trauma. This is often manifested in patients’ descriptions of going limp, freezing, or becoming automatically submissive in the presence of a powerful, threatening, and abusive person.

The absence of nurturing interpersonal attachments in childhood is another powerful factor in revictimization. Disturbances of attachment, particularly separation and disruption of early childhood nurturing relationships, leave individuals vulnerable to being overwhelmed both in childhood and later as adults (Bowlby, 1980; Rutter, 1987). Thus, children who are subjected to traumatic experiences within the context of inadequately protective social environments are at greatest risk for ongoing difficulties in relating to others (see Chapter 4). They are hence deprived of any model of healthy relationships and lack the support that is inherent in a social network of relationships. Clinical and research psychologists David Finkelhor, PhD, and Angela Browne, PhD (1985), summarize the relational effects of traumatic childhood abuse, citing betrayal as a major dynamic issue:

Sexual abuse victims suffer from grave disenchantment. In combination with this there may be an intense need to regain trust and security, manifested in the extreme dependency and clinging seen in especially young victims. This same need in adults may show up in impaired judgment about the safety of other people. (pp. 536–537)

For many trauma survivors, the assumptions and schemas associated with early abuse are perhaps the most powerful factors that predispose individuals to revictimization. Having existed in an environment where they were chronically physically or sexually abused, individuals may later accept a level of either actual or threatened physical or sexual assault. Individuals who have not previously been abused would not tolerate such situations, but for those who have been victimized such situations are part of their assumptive world; their adult revictimization is experienced as painfully familiar. Investigation of so-called traumatic bonding suggests that prolonged exposure to intermittent abuse predisposes persons to form powerful emotional bonds to abusers and later to others like them (Dutton & Painter, 1981). Thus, victims of early abuse may tolerate abusive adult relationships, caught in a repetitive scenario of abuse and dependency. For such persons, the choice may seem to be either remaining in a battering relationship or being doomed to an endless state of aloneness. For many persons who lack a basic sense of self-efficacy and self-sufficiency, the logical choice may be to opt for the security of a continuing relationship and to accept continuing interpersonal abuse as an unavoidable inherent drawback.

There are also particular difficulties with individuals who have a negative self-image. Individuals who have been subjected to abuse and victimization and those who have not received positive reinforcement and validation in childhood are likely to have extremely negative self-regard and to view themselves as powerless (Bagley & Ramsey, 1986; Carmen, Rieker, & Mills, 1984; Gelinas, 1983; Herman et al., 1986; Shapiro, 1987; Swanson & Biaggo, 1985). Feeling responsible for the abuse or neglect that they suffered and sometimes seeing themselves as loathsome and defective, they cannot conceive of situations in which they would be regarded with esteem and respect. Hence, it is hardly surprising that individuals who hate themselves often allow themselves to become involved in situations in which they are revictimized. The role of victim, although painful, is consistent with their self-image.

In patients with a history of childhood abuse and patterns of revictimization, specific psychotherapeutic stances should be taken. The traumatic antecedents of revictimization should be acknowledged, but if patients are currently at risk for physical or sexual violence, the therapist should be highly sensitive to the danger of dismantling the dissociative and posttraumatic defenses that they need to cope with their current life situation. Because of the powerful unconscious dynamic factors that predispose abuse survivors to revictimization, therapists have the responsibility to educate patients about their vulnerability and to point out potentially risky or dangerous behaviors in relationships. An emphasis on relational issues is particularly important, as a solid therapeutic relationship and an interpersonal support network may be the most effective way of helping patients avoid revictimization. Finally, every effort should be made to identify situations, internal emotional states, and triggers that are connected to revictimization and to be aware of important protective defenses such as anticipatory anxiety.

Although therapists must insist that patients take personal responsibility for their own safety, this is not to imply that patients are to blame for being revictimized. An understanding of how persons with histories of early abuse are intensely vulnerable to subsequent revictimization should only underscore the responsibility of perpetrators who intentionally inflict harm on others. Similarly, the availability of vulnerable individuals does not absolve predators, who often seem to search out those whom they can exploit. Although abuse survivors need to understand the mechanisms through which they may be exploited and to control any behaviors that leave them more vulnerable, they cannot be held responsible for the sadistic and often illegal actions of others. To blame childhood abuse survivors for their own vulnerability and for causing their own subsequent exploitation may be one final form of revictimization.

1 This section draws on the clinical research and practice of Judith Himber, PsyD, and portions were incorporated, as noted, from her article, “Blood Rituals: Self-Cutting in Female Psychiatric Patients” (Himber, 1994).

2 Portions of this section were adapted from the article, “The Revictimization of Adult Women with Histories of Childhood Abuse” (Chu, 1992b).