AFTER TRAUMA, HIDDEN OR OBVIOUS: POSSIBILITIES FOR TREATMENT.
Johanna Krout Tabin, Ph.D. ABPP
Note: These papers were presented at the Section V Panel, APA, New Orleans, LA, August, 2006. (They are also online as downloadable pdfs on the Section II link on the Division 39 home page .)
An important part of the mission of Section V is to keep abreast of innovation in psychoanalysis. The papers which follow offer ground-breaking applications of psychoanalytic understanding in trying to help victims of trauma. Marvin Hurvich contributes a theoretically grounded but clinically practical exploration of annihilation fantasies. Sharon Farber speaks in the same way to the use of cutting and other self-harming mechanisms. She shows the clinical importance of recognizing the adaptive function of such behaviors.
PSYCHIC TRAUMA, ANNIHILATION ANXIETIES AND PSYCHODYNAMIC TREATMENT
Marvin Hurvich, Ph.D. ABPP
PSYCHIC TRAUMA MARKERS
Key indicators of psychic trauma were delineated by Freud in 1920: a feeling of helplessness associated with sudden onset; surprise; an impact that is overwhelming; and obligatory repetition in the service of mastery. The subsequent literature includes many definitions of psychic trauma. Ferenczi (1933) added betrayal of trust, underscoring the importance of relational issues. An overall framework includes the components of a traumatic event, a traumatic process, and a traumatic effect, accompanied by painful affect. (Rangell, 1967, p 79).
A broad definition of psychic trauma was provided by Greenacre (1967): any conditions which seem definitely unfavorable, noxious, or dramatically injurious to the developing young individual" (p. 128). A narrower definition is that psychic trauma is associated with devastating and shattering experiences that result in internal disruption as a result of putting ego functioning and ego mediation out of action (A. Freud 1967, p. 242;), and may interfere with or threaten the integrity of the sense of self. (Pao?) A distinction has been made between a traumatic neurosis and a traumatic event (Mahony, 1984). In the former, most of the psychopathology is seen to result from the subject's inability to assimilate the traumatic experiences. In the latter, the major traumatic significance is based on the role of the traumatic event in activating psychopathological tendencies (p. 53). The current author adds that there are transitional phases between un-assimilability and the activation of latent psychopathological trends in the wake of traumatic experience. Both the traumatic neuroses and the traumatic event tend to arouse annihilation anxieties. The presence of annihilation anxieties may thus be seen to constitute trauma markers.
Psychic traumas can have organizing influences on the mental sphere, and play a dramatic role in shaping the further development of the individual. "The residues of the past and the content of the future tend to be formulated, constructed, and reconstructed in terms of that [traumatic] experience" (Dowling, 1986, p. 212).
Annihilation-survival fantasies comprise key psychic contents of trauma. Annihilation anxieties involve concerns over survival, self -preservation, and safety. Two central areas of concern are for the integrity of the sense of self and the intactness of the ego functions. Annihilation anxieties are triggered by survival threat; are found early but can be engendered throughout the life cycle; constitute a basic danger; are residuals of psychic trauma; have specifiable sub-dimensions; may occur in presymbolic form or be associated with fantasies in conflict and compromise formation; may arise with or without anticipation; may be accompanied by controlled or uncontrolled anxiety; are motives for defense; and may be associated with particularly recalcitrant resistances (Hurvich, 2003).
Annihilation anxieties can be specified on the level of clinical description and on the level of clinical generalization (Waelder, 1962). Examples from the level, of clinical generalization have been described as (a) fears of being overwhelmed, being unable to cope, and of losing control; (b) fears of merger, entrapment, or being devoured; (c) fears of disintegration of self or of identity, of emptiness, meaninglessness, or nothingness, or of humiliation-mortification; (d) fears of impingement, penetration, or mutilation; (e) fears of abandonment or need for support; and (f) apprehensions over survival, persecution, catastrophe (Hurvich, 2003).
Specific annihilation fantasies that are residuals of the traumatic experience often serve as components in the organizing function of psychic trauma for the given person, centering around individually configured meanings of being overwhelmed, unable to cope, invaded, merged, and imminently destroyed. Zetzel (1949/1970) observed that soldiers whose narcissistic defenses of invulnerability protected them from experiencing any fear prior to battle were the ones whose sense of safety in the world was compromised as a result of exposure to combat, which fragmented their specific fantasies of invulnerability.
Annihilation anxieties can be shown to play a significant role in all the major forms of severe psychopathology, conditions which are especially found to include traumatic events in the life history: panic, nightmares, phobias, borderline, narcissistic and psychotic conditions, dissociative states, perversions, and psychosomatic disorders (Hurvich, 2003a). Sharon Farber, a member of today's panel, has written convincingly about the relation between eating disorders and annihilation anxieties and eating disorders.
When annihilation fantasies are accompanied by markers characterizing the more pathological, maladaptive, and primitive pole (uncontrolled anxiety, disorganizing regression), the reaction is more likely to qualify as a traumatic response. Conversely, when the markers found along with annihilation content are on the more adaptive side (controlled anxiety, presence of reflective awareness, etc.), there is a greater likelihood that it is an anticipation of a traumatic situation. Time for recovery, and traumatic residuals, including the possibility of a traumatic neurosis or Post-Traumatic Stress Disorder are relevant here. Time of onset, be it infantile, childhood, adolescence or adulthood, is a key variable. Severe childhood trauma tends to result in a permanent expectation of a return of the traumatic state and dread of its return. A fear of emotional experience develops and this results in an impairment of affect tolerance (Krystal, 1989). Under debate is the contribution of psychic trauma to pathogenesis more generally, and how to distinguish pathological influences of trauma from other pathological effects. While his conception of psychic trauma changed as his theories evolved, Freud (1939) attributed a key role to psychic trauma in all symptom formation.
The expansion of trauma theory, and a first step toward an integration with the psychoanalytic theory of anxiety, involves the formulation that the experience of being overwhelmed, a signature of the traumatic moment, can also be anticipated and associated with controlled anxiety, and hence be included in the basic danger series (Hurvich, 2001, 2003a). Thus, issues related to being overwhelmed or annihilated (Freud, 1923, p. 57) may be part of a traumatic moment in present time, or may constitute a danger situation that is anticipated in future time: concerns about being overwhelmed may thus be either present, actual, or potential threat (Schur, 1953; Hurvich, 2003a&b).
Traumatic events are experiences processed by the subject as constituting a threat to psychic and/or physical survival. A basic assumption is that shock and strain trauma decrease a sense of safety, increase a sense of vulnerability in the world, and a heightened fear of imminent destruction--mortal terror. This threat is reflected in fantasies, conscious and/or unconscious, that have survival-annihilation content, and in defensive-restitutive fantasies and behaviors directed against the fantasies and the disruptive and sometimes intolerable affects associated with them. While the DSM-Kraeplinian approach emphasizes descriptive, observable, symptomatic manifestations of psychic trauma, the more recent PDM - Psychodynamic Diagnostic Manual, 2006-to be reported on this Saturday in a meeting to be chaired by Nancy McWilliams - additionally includes a focus on intrapsychic events and much more.
Annihilation-survival-related contents and anxieties involve terror, fright, and dread. They reflect residues of and intrapsychic reactions to traumatic experience. The ideational aspect entails a dynamic fantasy content that is found at varying levels of symbolization/mentalization, such as fears of being overwhelmed, unable to cope, merged, invaded, and losing or being negated in one's sense of self. Such fantasy contents, uniquely elaborated by each individual, and the defenses against them, extend and particularize the utility of the concept of psychic trauma. They are amenable to psychotherapeutic inquiry as are other psychic contents (Hurvich, 2003a). This schema has been used to construct measures to assess annihilation anxieties clinically (Hurvich, 1991, 2003a; Hurvich & Simha-Alpern,1997) and empirically (Hurvich, et.al., 1993; Levin & Hurvich, 1995; Benveniste et.al. 1998).
POSSIBILITIES FOR TREATMENT
Anna Freud (1936) pointed out that the general technical rule of analyzing the defenses did not have a favorable therapeutic result when the defense had been engendered as a result of the patient's fear of the strength of his drives. This technical caveat was a major basis for the clinical application of ego psychological principles to the theory of technique with more disturbed individuals, who regularly manifest traumatic residues and annihilation anxieties. Analyzing the defensive aspect of these patients' material tends to interfere with ego functioning and the maintenance of a coherent sense of self. Since the self tends to be an organizer of ego functioning, any therapeutic interventions which strengthen the coherence of the self will aid in improving the level of adaptive behavior. These include reflective (empathic) responses, other forms of support, some encouragement, providing of transitional objects, verbal and nonverbal refueling, and, sometimes, a degree of self-disclosure. These, in addition to the standard clinical procedures of clarification, interpretation, and reconstruction, further self-integration.
There are always a number of considerations relevant to the therapist-patient setting. For those who manifest high levels of annihilation anxieties and a traumatic history, an important issue involves the therapist protecting, maintaining, and enhancing the patient's sense of safety and comfort in the room. With such patients, timing and tact trump most other concerns, especially until a trusting relationship and a working alliance have been established. This is both difficult, and not always realizable. Due to the substantial and sometimes extreme sensitivity of such individuals to narcissistic injury, hostile or critical overtones and seductive or rejecting implications in the therapist's tone and message are especially toxic and counter-therapeutic.
For patients prone to panic experience, a supportive, calm, containing, and non-intrusive stance by the therapist helps the patient increase his tolerance for anxiety. Judicious, relatively ego-syntonic interpretations facilitate the patient's integration of cognitive and affective components of his experience.
From the interpretive side, it is often helpful to analyze and work through maladaptive ego functioning. "We have to show the patient, not only the many determinants of his anxiety, but also how and why a given situation gets out of hand and deteriorates into a traumatic situation. [Schur, 1971, p. 117] A relevant goal here is to facilitate the shift from uncontrolled to controlled anxiety.
A detailed knowledge of the clinical manifestations and implications of the major manifestations of annihilation anxieties is helpful. Such relevant phenomena as fears of being overwhelmed, merged, invaded, disorganized, in addition to excessive concerns over death, dying, bodily harm, and serious injury are also manifestations of excessive annihilation concerns, and it is therapeutically useful to underscore the annihilation meaning of such fears and to elicit associations when the patient is capable of such activity.
Relevant to all of this is that annihilation concerns of the patient, when these are extensive and strong, often trigger related issues in the therapist. One of the challenges of helping these difficult patients is the successful utilization, processing, and control of countertransference reactions. Since obligatory repetition is a major feature of psychic trauma (Freud, 1920), an especially challenging aspect of working with these patients is their strong, typically unconscious tendency to do to you what was done to them, to induce you to do to them what was done to them, and other variations of the Law of Talion (Hurvich, 2006). Winnicott's sage advice, to avoid retaliating against the patient, is more likely to be achievable when the therapist is able to process her or his countertransference reactions. An additional complicating factor here is that the patient's traumatic repetitions are typically accompanied by annihilation and death-related imagery/fantasies.
But the problem of annihilation anxiety-related countertransference reactions in the therapist are found in a broader range of therapeutic work with disturbed patients. The persecutory/malevolent transferential attitudes of psychotic and especially paranoid patients are frequently experienced by the therapist in the countertransference as threatening her or his psychic survival. As J. Wallerstein (1997) has written, "The central countertransference of the clinician, namely, the fear of annihilation, provides the key to the primitive psychological roots of the transference and illuminates the highly disturbed psychological functioning of the patient. For the clinician is not reacting with the kind of anxiety that is aroused in a relationship with a neurotic patient, but with a much greater, far more primitive fear of personal and professional annihilation." There is a basis to conclude that underlying traumatic residues play a role in the background of many seriously disturbed patients who do not meet the criteria for traumatic neurosis or PTSD (Hurvich, Knafo 2004).
BIBLIOGRAPHY
Dowling, S. (1986). Discussion of the various contributions. In Rothstein, 1986, op cit., pp. 205-217. Rothstein, ed. The Reconstruction of Trauma. Madison, CT: International Universities Press.
Ferenczi, S. (1933/1968) Confusion of tongues between adults and the child: The language of tenderness and of passion.Contemporary Psychoanalysis, 24: 196-206.
Freud, A. (1936). The Ego and the Mechanisms of Defense.
Freud, S. (1920). Beyond the pleasure principle SE
Greenacre, P. (1967). The influence of psychic trauma on genetic patterns. In S. Furst, ed., Psychic Trauma, pp. 108- 153. New York: Basic Books.
Hurvich, M. (2002). A Proposed Expansion of the Danger Series: Annihilation as Present or Potential Threat. Edmund Weil Memorial Lecture April 21, 2002
Hurvich, M (2004). Psychic Trauma and Fears of Annihilation. In D. Knafo, ed.: Living with Terror, Working with Trauma: A Clinician's Handbook. Jason Aronson: NJ.
Hurvich, M. (2006). The law of talion, the golden rule, and self-esteem regulation. Fall Colloquium, LIU, Brooklyn.
Rangell, L. (1967). The metapsychology of psychic trauma. In A Rothstein, ed. (1986) The Reconstruction of Trauma: Its significance in Clinical Work, pp. 51-84. Madison, Conn.: International Universities Press.
Waelder, R. (1962). Psychoanalysis, Scientific Method, and Philosophy. J. Amer. Psychoanal. Assn., 10:617-637
Wallerstein, J. (1997). Transference and countertransference in clinical interventions with divorcing families In M. Solomon & J. Siegel, eds. Countertransference in couples therapy, New York: Norton.
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THE INNER PREDATOR:
TRAUMA AND DISSOCIATION IN BODILY SELF-HARM
Sharon K. Farber, Ph.D., B.C.D.
People who live with self-mutilation (scratching, picking at, burning, or cutting the self), disordered eating (binging, purging, self-starvation), or compulsive body piercing, tattooing usually cling to it ferociously, and have little ability to reflect about how and why they live this way. To be really helpful to these patients, we must engage them in wondering about just what self-harm does for them, how it evolved in their lives, and what they will need in order to relinquish it (Farber, 1995, 1997, 2000, 2003; Farber, Jackson, Tabin and Bachar in press). These questions are the subject of this presentation.
These acts are generated out of dissociative experiences. In every act of self-harm there is more than one participant and more than one self-state. There is the dissociated part of the self being abused and another dissociated part doing the abusing. Dissociation makes possible the extraordinary feat of being the victim and the victimizer all at the same time.
There is a growing psychoanalytic interest in dissociation as basic to human mental functioning, and a view of the mind as a configuration of shifting, nonlinear states of consciousness, shaped not only by repression and intrapsychic conflict but also by trauma. Dissociation is a precious psychic survival tool that arises from the need to separate and compartmentalize aspects of traumatic experience while maintaining the attachment, to those who have neglected or abused them (Howell, 2005; Bromberg, 1998). Human responses to trauma involve physiological and behavioral hyperarousal, along with numbing, dissociative responses (Herman, 1992). When confronted with a life-threatening situation at a very young age, human beings, like the other animals, may react as if they were frozen, immobilized, paralyzed (Marks, 1994). Like the other animals, humans also exhibit radical changes in eating behavior and may become self-injurious (Epling and Pierce, 1996; Farber, 1995, 2000; Favazza, 1996).
Trauma not only separates cognition from affect (the customary psychological definition of dissociation), but also psyche from soma. Many patients have chronic physical symptoms that are actually dissociative in nature, because events that should have been processed mentally have been dissociated and experienced instead as somatic events ({Nijenhuis and van der Hart; Nijenhuis, 2004; Sacksteder, 1989a, 1989b). Because trauma dissociates thought from affect and mind from body, the body may repeat and relive that which the mind wants to forget.
When the body weeps tears of blood, we need to wonder what terrible sorrows cannot be spoken. When food that had tasted good suddenly feels like poison and has to be purged from the body, we should wonder what traumatic experiences exist that cannot be contained, metabolized, and integrated. ...The body speaks of that which cannot be said in words, of secrets, lies, and trust that has been broken (Farber 2000).
The split between psyche and soma starts to form in infancy, when the mother's lack of relatedness to the infant's soma and developing psyche, reflected in how she cares for and holds the infant, leads to the development of the infant's own lack of relatedness to his soma and psyche. The capacity to develop mental representations of the body and its contents is thwarted, and thus the unity of the mind and the body does not develop.
This view of the split between psyche and soma was basic to nineteenth-century views on hysteria, particularly by Pierre Janet, (1907), the French neurologist and psychiatrist, and Charcot, but was not basic to Freud's view. Janet (1859-1947) was the most important clinical investigator of dissociative states who studied the "mysterious leap from the mind to the body" (Deutsch, 1959), known then as conversion hysteria, the process by which repudiated mental content is transformed into physical symptoms. Freud recognized that the dramatic somatic symptoms of hysteria were induced by psychological trauma ({Freud, 1910) but subsequently dismissed the phenomenon of dissociation that Josef Breuer , his associate, believed was at the root of hysteria ({Breuer, 1895). The result in psychoanalysis is an emphasis on repression at the expense of dissociation. "Part of our work as analysts facilitates the restoration of links between dissociated aspects of self so that the conditions for intrapsychic conflict and its resolution can develop (Bromberg 1998. p. 13)."
Dissociation has been called "the escape when there is no escape ({Putnam, 1992, p.104)." Self-harm allows the individual to adapt to the most horrific of circumstances without becoming psychotic and without killing himself or someone else, and in that way serves an invaluable defensive function. But it is far more than a defense, and more than a symptom. It is the behavioral component of a part of the self with a set of needs, feelings, and perceptions that have been dissociated from the patient's total self-experience. It meets the needs of a part of the self that is at odds with the patient's ordinary experience of herself. It both expresses and defends against unrecognized archaic needs and feelings. It numbs painful affects and protects the patient from fears of annihilation and disintegration. Often the patient experiences this part of herself as foreign, alien, as "not me" (Bromberg 1998) because it is self-destructive and out-of-control. "It is like there is a monster or a demon in me urging me to stuff myself and make myself throw up." Or, there is an external seductively caring voice urging her, "Go on, sweetheart. Do it. Just a little cut will make you feel so much better. You know it will."
Despite her view of the self-harm as negative and crazy, this secret part of the self is precious, and so anyone who tries to take it away from her will be met with ferocious resistance, and sometimes even more violent and dangerous symptoms. We need to understand the nature of the attachment to self-harm if we want to keep these patients from developing careers as mental patients, going from therapist to therapist, hospital to hospital.
Attachment theory helps us understand how human beings can become so attached to pain and, suffering that they cannot imagine living without it. If we examine how self-harm evolves as a survival tool, this will tell us something about the treatment of patients who harm themselves. Darwin's theory of natural selection tells us that when survival is threatened, one can "kill or be killed", "eat or be eaten ". One can be the predator or one can be the prey. To be the predator is to be powerful; to be the prey is to be annihilated.
Each species in the animal kingdom has its own biologically based attachment system that attaches its offspring to its caretaker and caretaker to its offspring in order to protect the newborn from predators in the environment (Bowlby, 1969). The caretaker must have a deep attachment to the child to insure his biological survival, and to provide the sense of security needed for the development of self-regulatory functioning, such as eating, sleeping, heart rate, breathing, body temperature, growth hormones (Hofer, 1995). A secure attachment helps the child to develop a basic sense of trust and to tolerate separations. The attachment ensures that the child survives and thrives in other future attachments as well.
When those who are meant to protect the child are neglectful or unattuned, the child comes to feel unprotected, in his real environment or in his imagination, from those who might harm him, and can experience an intolerable anxiety about being annihilated, as Marvin Hurvich (2003, 2006) has thoroughly described. This annihilation anxiety engraves a pathway in his brain, creating a template upon which all subsequent anxiety-provoking situations are patterned (Farber 2000). When those who are meant to protect the child come to harm him instead, this creates a deep and confusing attachment in which the child becomes powerfully attached to the parent he fears will annihilate him, and powerfully attached to pain and suffering.
The object becomes split into good and bad object representations that allow him to maintain his attachment to both the good aspects of the object and to the bad, as if they were two separate people. Despite the shift from passive prey to active predator, the predator-to-prey object relationship is repeated and the attachment to pain and suffering is repeated by means of presymbolic wordless physical traumatic reenactments in behavior, in relationships to others and to ones own body, as I will describe.
These individuals articulate through their bodies what may be biologically based primal and universal urges that remain relatively unarticulated in the rest of us. Robert Stoller (1991) asked "How common are the little sadomasochisms of everyday life, covert but observable: the skin pinching, cuticle tearing, gum picking, colonic treatments, deep massage, hairpulling, dreamy-self-and-other-stimulations (p.23)."
Self-Regulation and Symptom Substitution
The primary function of self-harm is to regulate both the self and relatedness to others. The individual turns to self-harm in order to circumvent the need for human relatedness, and to release tension by terminating dysphoric moods, affect states, and states of consciousness.
Although the remarkably high comorbidity between disordered eating and self-injury had been documented in numerous studies, there was no explanation as to how and why they were linked together. This question became the subject of my dissertation study (Farber 1995), and became the adventure of a lifetime. I found that these behaviors actually serve as a form of self-medication (Khantzian, 1985). Both bulimic behavior and self-mutilation were found to be extremely potent forms of self-medication, of approximately equal potency (Farber 1995). When a patient gives up one behavior before the ego is ready to relinquish it, as often happens when a patient stops the behavior to please the therapist or gain discharge from the psychiatric hospital, another self-harm symptom of more or less equal potency will crop up in instead (Farber 1995).
Here is an example from my practice (Farber 2000). Dina, age 23, was one of numerous children from a large chaotic family. Two sisters remember being beaten by their father although Dina has no memory of this. For years Dina experienced depression, drinking binges, promiscuity, bulimia, compulsive shopping and shoplifting. Shortly after her first shop-lifting arrest, she recognized that her life was out of control and was hospitalized voluntarily. While in the hospital she Prozac was prescribed and she began attending daily Alcoholics Anonymous meetings. When she was discharged and resumed her treatment with me, she no longer drank or engaged in bulimic behavior. However, she began to feel the impulse to cut herself. And while driving over a bridge, to drive over the railing. When I asked what the cutting would do for her, she said she felt like a balloon, so full and tight; popping it open would release the tension. Further exploration revealed that when she was around ten, her sister teased her about a large brown mole on the back of her thigh, saying that it looked like a piece of shit stuck there. Dina then took a paring knife and cut the mole away. Years later, while looking in the mirror as she applied her makeup, she became transfixed by the crease in her eyelid. She picked up a razor blade and in a depersonalized state drew it slowly across the eyelid crease, watching in excited fascination as drops of blood appeared and dripped down her cheek.
Psychic Functions served by self-harm
These patients tend to be alexithymic, unable to identify emotions or use words expressively (Cochrane, Brewerton, Wilson, and Hodges 1993; Farber 1995, 1997, 2000, 2005; Farber, Jackson et al, in press; Nemiah, Freyberger and Sifneos, 1976; Taylor, Bagby, and Parker, 1991; Taylor and Bagby, 2005). Not surprisingly, alexithymia has been found to be associated with dissociative tendencies (Clayton, 2004 ; Grabe, Rainermann, Spitzer, Gänsicke, and Freyberger, 2000; { Sayar and Kose, 2003; Taylor, and Bagby 2005; Tutkun, Savas, Zoroglu, Esgi, Herken, and Tiryaki, 2004; { Wise, Mann, and Sheridan,2000). Phobic about experiencing emotion, they dissociate and harm themselves instead, which essentially is an attack on language itself and on the process of creating meaning. These acts of self-harm are very creative attempts to serve certain psychic functions, such as self soothing, defining and differentiating inner and outer body boundaries, bodily expression of emotions, and psychophysiological reenactments of past trauma. There is not time to discuss all of them so I'll limit myself to self soothing and psychophysiological reenactments of past trauma.
Self-Soothing
The individual turns to self-harm in much the same way a toddler may turn to his transitional object, usually a favorite stuffed animal or old blanket, when feeling lonely and anxious, thus comforting himself with the illusion that he is being held and comforted by his mother (Winnicott, 1953). This transitional object is a "not me" object, not part of his body. The binge-purger or self-mutilator seizes upon the symptomatic behavior, immersing herself in the comfort it provides. It does calm her for a brief time, releasing serotonin into her system, but it fails as a transitional phenomenon. It does not promote separation-individuation processes ({Mahler, Pine and Bergmann, 1975). It fails to further the capacity for symbol formation. It functions instead as an addiction or a fetish, shoring up a defective sense of self for the brief time that the shoring up lasts, until it is time to do it again, and again, more severely and more frequently. It is like the alcoholic developing a tolerance for the effect of alcohol, progressing to drinking greater volume and with greater frequency. The self-harm episodes may become more severe and more frequent. When even the escalated form of the behavior fails to do what it is supposed to do, another self-medicating behavior that is even more severe may be added to the repertoire. Thus, after even the most severe bulimic behavior no longer is strong enough self-medication, self-mutilating behavior may well be needed to supplement it.
Bodily Reenactments of Past Trauma
The body becomes susceptible to a heightened somatic stimulation in general or in the part of the body that was abused or injured (Terr, 1990, 1994), what is often called body memory. For example, many sexual abuse survivors complain of chronic pelvic pain for which no organic basis can be found. The body memory can be a cue to the therapist of dissociated experience related to that part of the body.
The addiction to self-harm behaviors often represents a compulsion to repeatedly reenact severe childhood trauma on the body (Farber, 1995; van der Kolk, 1988, 1989). For example, in the self-harming behavior in a survivor of sexual abuse, we might see a dissociated reenactment of the trauma she experienced. In the reenactment, she is in control and is active, in a vain attempt to master the trauma. In a depersonalized frenzy in which she identifies with the hateful abuser, she shoves food into her mouth as others shoved a penis, fingers, or other objects into her body. Then as the identification quickly shifts to an identification with her abused self, she vomits the food out to rid her body of those things that were inserted by force. Or she may penetrate her flesh with a razor blade, lit cigarette, or fingernails, as her abuser penetrated her. As she watches liquid oozing from the wound, she feels pleased that the vile stuff that had been inside her, (semen, the hateful parts of herself) is being expelled, leaving her clean and pure. She also has the pleasure of discharging rage and violence onto the abuser. She is both the abuser and the one being abused. She is the sadist and the masochist. She is a cool observer of her own self-abuse, like the parent who was present but failed to protect her. In the self-harming act she is all these, oscillating crazily from self to bad object to good object and back again, traumatically attached to both the affects and her abuser.
Similarly, the individual who was traumatized by intrusive and painful medical or surgical procedures may repeat the trauma by sticking himself or others with needles, and/or getting others to stick him with needles. It was striking in my study that quite a few of the subjects who reported a history of childhood medical trauma and severe self-mutilation became intensive care or emergency room nurses. The women with this history also reported having acquired professional tattooes and piercings significantly more than those without this history. In fact, two of them earned their livelihood as professional tattoo artists and body piercers.
Transferential Reenactments of Past Trauma
Enactments in the relationship with therapist tend to be around these same themes as in the bodily reenactments, reflecting the childhood relational patterns that have become internalized as dissociated parts of her self experience ({Davies and Frawley, 1994 ; Farber 1997; Miller, 1994). These manifestations, most pronounced in survivors of sexual abuse, can alternate in a dizzying sequence in which the patient tries on various dramatic roles and assigns corresponding roles to the therapist. The patient may cast the therapist in the role of her abuser while clinging to her role as victim, may then cast the therapist in the role of the parent who failed to protect her while demonstrating her need for protection, then will cast the therapist in the role of the helpless victim while she traumatizes the therapist as she had been traumatized, and may cast the therapist in the role of seducer while clinging to her role as the seduced. As you would expect, intense counter-transference feelings tend to be evoked, and therapists should not expect themselves to maintain neutrality. What is more important is that the relationship be vital and authentic.
When dissociation is a major component of the patient's defensive operations against annihilation anxiety, this can actually induce a parallel dissociative process in the therapist (Bromberg 1998), evoked by the therapist's own annihilation anxiety (Hurvich, 2003, 2006). By means of dissociation and the powerful process of projective identification, the patient projects these dissociated aspects of himself into the therapist, causing him to lose his ability to think, contain, and reflect upon the patient's experience, thus annihilating the therapist's mind. This is when the most destructive enactments in the treatment are likely to occur, created by both patient and therapist. The therapist is in danger of retaliating mindlessly against the patient, which can destroy the treatment. If this occurs, and if the therapist can genuinely acknowledge his role, and apologize for it, this allows the patient to begin to acknowledge his own role, and the treatment can be saved.
When the therapist can help the patient to decode the enactment, either through understanding what it communicates via his own countertransference responses or through understanding the enactment on the body, then what had been dissociated can become integrated into the self, to be thought about and reflected upon. Thus, these dissociative defenses are permeable enough to serve as a bridge to a more satisfying object relationship and to growth in the therapeutic relationship.
The Remarkable Power of Self-Harm
The attack upon the self has what may seem like magical power. If a period of depersonalization becomes painfully lonely, as may well happen when accompanied by the feeling that the rest of the world is not real, inflicting pain upon the self can terminate the dissociation. When hyperarousal lasts too long and is painful, inflicting pain upon the self can terminate the hyperarousal. When the raging depression is too much to bear, inflicting pain upon the self can terminate that too. That is why people who inflict harm on themselves often say it makes them feel better.
Kim, a young woman who had been sexually abused in childhood by her father, was no longer his victim but nonetheless reenacted the attacks. Cutting herself was a way of pre-empting his attack as well as triumphing over it. She wrote the following in The Cutting Edge, a newsletter for women who live with self-inflicted violence:
Tonight I've done everything to distract myself from thoughts of cutting. . . I feel angry and I'm not very good at that feeling. They say that behind anger is always fear. So I ask myself: "What are you afraid of?" Well, what do you think?! I'm afraid my father will jump right through my skin and scare the silence right out of me. When I put down this pen, who'll get me first? My daddy or me? I'd rather get there first. This belongs to me! cut, cut, cut (Kim, 1993 470 }, pp.3-4.)
A Multi-Phased Approach to Treatment
The Shakespearean injunction to "give sorrow words" is the key task of psychotherapy with all patients. With patients who cannot use words about their inner life, and whose behavior puts them at such great risk, much preparatory work must be done before they can become able to put words to their sorrow and trauma. Treatment must be a phase-oriented process, roughly divided into three phases with considerable overlap: 1) safety, stabilization and trust; 2) trauma work; and the third, mourning, resolution, reconsolidation, and reconnection (Farber 2000, 2004). Treatment is usually a long, hard road with many detours, regressions, plateaus, enactments, and negative therapeutic reactions, in which progress may be followed by a regressive move backward.
The cardinal rule in working with these patients is safety first, meaning both their physical safety as well emotional safety in the relationship with the therapist. The development of a safe and secure attachment to the therapist is what helps the patient relinquish the attachment to pain and suffering. It is the significant interactions between patient and therapist that ultimately lead to structural psychic change, and so it is these interactions that are emphasized from the beginning.
Before the patient can come to care for himself, he must feel cared for and know that his well-being is paramount in the therapist's mind. The therapist's real presence, reliability, punctuality, attentiveness, empathy-all the elements of support-- are in the forefront for the patient. In the early stages and at times of unusual vulnerability, the therapist must make himself unusually available, to be used as a transitional object, by phone or for emergency sessions. As the relationship develops, the patient becomes more receptive to learning ways to regulate anxiety states on his own.
All defenses must be treated respectfully and cautiously, even when those defenses are potentially life-threatening symptoms. Because the expression of emotions, especially anger, is so concrete, impulsive, and destructive, these patients cannot tolerate analysis of defense; in fact it can evoke more anxiety and more self-harm behavior. They can benefit greatly, however, from ego psychological techniques of ego building and strengthening (Blanck and Blanck 1974), as well as cognitive-behavioral tools for affect tolerance and regulation, such as distraction, postponing the self-harm behavior. When they cannot speak of their emotions, I have found that helping them to write down their thoughts and feelings in the therapist's presence during a session is a very powerful intervention. It can promote freer associations, help them identify and tolerate affect states, and provides containment for their impulses, and promotes more reflective thinking (Farber 2005).
The therapist needs to make himself unusually available, inviting the patient to call at critical times for soothing, even in off-hours or the therapist's vacation, thus functioning as a transitional object. These experiences are extremely potent, and can become mutative, corrective emotional experiences that lead to structural change in the personality. They can also prepare patients to acquire tools for self-soothing and affect regulation from the therapist. Because these patients often turn to self-harm to make their dissociated selves come alive or to calm themselves, bodily techniques that stimulate circulation (exercise, cold showers, touching the skin with an ice cube), will make the body feel alive, or techniques that promote relaxation (exercise, yoga, deep breathing, warm baths) will be invaluable.
Premature exploration of trauma may cause symptoms to worsen, but focusing on eliminating symptoms can do the same. Symptom management, however, is an essential part of the treatment, and is determined according to an assessment of the self-harm behavior along several axes, which suggest points for immediate intervention. The therapist should evaluate: the potential lethality of the behavior, the frequency or repetitiveness, chronicity, the directness of the harm, the extent to which the behaviors are compulsive, impulsive or both, the extent to which the behavior is ego-alien or ego-syntonic, the level of consciousness that accompanies the act, the degree to which the intent is suicidal, sadistic, or masochistic, and the multiple psychic functions served by the behavior (Farber 2000).
The first axis, the lethality of the self-harm behavior, is most critical. The therapist should engage the patient in trying to make his self-harm behavior less dangerous, so that it is safe for him to be treated on an outpatient basis. The therapist will have to rely on his powers of observation, the information he gets from the patient and/or family, which may or may not be reliable, and quite possibly, medical monitoring. To assess the lethality of the behavior, the clinician will need to know how severe and out of control it is. The rapidity of weight loss, the severity of purging (number of purging strategies and frequency of purging), the severity of self-mutilation, and alcohol or drug-related medical damage are indicators of severity. For example, episodes of bingeing and purging twice a week is less dangerous than seven or eight episodes a day in which each binge is followed by several purges; superficial controlled cutting is less dangerous than deep jagged cuts.
When the patient becomes sufficiently stable, the work of deconditioning traumatic memories and responses can begin, which further stabilizes the patient. When the therapist can help the patient restore the links between dissociated aspects of the self, the patient begins to integrate the traumatic experiences and redirects the rage which had been directed at his body. As ego functioning becomes more able to sustain the demands made by a more intensive treatment, the work can shift, to psychoanalytic psychotherapy or psychoanalysis.
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My interactive case study on this subject is available online at www.PsyBC.com.
Sharon Klayman Farber, Ph.D., B.C.D.
Sharon_farber@psychoanalysis.net
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