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Mental Health Topics Trauma & Recovery By the way, what have you got to say to the suggestion that the whole of my brand-new theory of the primary origins of hysteria is already familiar and has been published a hundred times over, though several centuries ago? Do you remember my always saying that the medieval theory of possession, that held by ecclesiastical courts, was identical with our theory of a foreign body and the splitting of consciousness? But why did the devil who took possession of the poor victims invariably commit misconduct with them, and in such horrible ways? Why were the confessions extracted under torture so very like what my patients tell me under psychological treatment?The answer to this question comes from those fortunate survivors who have found a way to take control of their own recovery and thus have become the subjects of their own quest for truth rather than the objects of inquisition. The author and incest survivor Sylvia Fraser recounts her journey of discovery: "I have more convulsions as my body acts out other scenarios, sometimes springing from nightmares, leaving my throat ulcerated and my stomach nauseated. So powerful are these contractions that sometimes I feel as if I were struggling for breath against a slimy lichen clinging to my chest, invoking thoughts of the incubus who, in medieval folklore, raped sleeping women who then gave birth to demons.... In a more superstitious society, I might have been diagnosed as a child possessed by the devil. What, in fact, I had been possessed by was daddy's forked instrument--the devil in man." In earlier times, Fraser notes, she might well have been condemned as a witch. In Freud's time she would have been diagnosed as a classic hysteric. Today she would be diagnosed with multiple personality disorder. She reports numerous psychiatric symptoms, which include hysterical seizures and psychogenic amnesia beginning in childhood, anorexia and promiscuity in adolescence, sexual dysfunction, disturbed intimate relationships, depression, and murderous suicidality in adult life. In her wide array of symptoms, her fragmented personality, her severe impairments and extraordinary strengths, Fraser typifies the experience of survivors. With her remarkable creative gifts, she is able to reconstruct the story of a self formed under the burden of repeated, inescapable abuse, and to trace with clarity the pathways of development from victim to psychiatric patient, and from patient to survivor. THE ABUSIVE ENVIRONMENT Chronic childhood abuse takes place in a familial climate of pervasive terror, in which ordinary caretaking relationships have been profoundly disrupted. Survivors describe a characteristic pattern of totalitarian control, enforced by means of violence and death threats, capricious enforcement of petty rules, intermittent rewards, and destruction of all competing relationships through isolation, secrecy, and betrayal. Even more than adults, children who develop in this climate of domination develop pathological attachments to those who abuse and neglect them, attachments that they will strive to maintain even at the sacrifice of their own welfare, their own reality, or their lives. The omnipresent fear of death is recalled in the testimony of numerous survivors. Sometimes the child is silenced by violence or by a direct threat of murder; more often survivors report threats that resistance or disclosure will result in the death of someone else in the family: a sibling, the nonoffending parent, or the perpetrator. Violence or murder threats may also be directed against pets; many survivors describe being forced to witness the sadistic abuse of animals. Two survivors describe the violence they endured: I saw my father kicking the dog across the room. That dog was my world. I went and cuddled the dog. He was very angry. There was a lot of yelling.In addition to the fear of violence, survivors consistently report an overwhelming sense of helplessness. In the abusive family environment, the exercise of parental power is arbitrary, capricious, and absolute. Rules are erratic, inconsistent, or patently unfair. Survivors frequently recall that what frightened them most was the unpredictable nature of the violence. Unable to find any way to avert the abuse, they learn to adopt a position of complete surrender. Two survivors describe how they tried to cope with the violence: Every time I tried to figure out a system to deal with her, the rules would change. I'd get hit almost every day with a brush or a studded belt. As she was beating--I used to be in the corner with my knees up--her face changed. It wasn't like she was hitting me any more--like she was hitting someone else. When she was calm I'd show her the big purple welts and she'd say "Where'd that come from?" While most survivors of childhood abuse emphasize the chaotic and unpredictable enforcement of rules, some describe a highly organized pattern of punishment and coercion. These survivors often report punishments similar to those in political prisons. Many describe intrusive control of bodily functions, such as forced feeding, starvation, use of enemas, sleep deprivation, or prolonged exposure to heat or cold. Others describe actually being imprisoned: tied up or locked in closets or basements. In the most extreme cases, abuse may become predictable because it is organized according to ritual, as in some pornography or prostitution rings or in clandestine religious cults. Asked whether she considered the rules usually fair, one survivor replied: "We never thought of rules as fair or unfair, we just tried to follow them. There were so many of them it was hard keeping up. In retrospect I guess they were too strict, too nitpicking. Some of them were pretty bizarre. You could be punished for smirking, for disrespect, for the expression on your face." DOUBLETHINK I would do it by unfocusing my eyes. I called it unreality. First I lost depth perception; everything looked flat, and everything felt cold. I felt like a tiny infant. Then my body would float into space like a balloon."Under the most extreme conditions of early, severe, and prolonged abuse, some children, perhaps those already endowed with strong capacities for trance states, begin to form separated personality fragments with their own names, psychological functions, and sequestered memories. Dissociation thus becomes not merely a defensive adaptation but the fundamental principle of personality organization. The genesis of personality fragments, or alters, in situations of massive childhood trauma has been verified in numerous investigations." The alters make it possible for the child victim to cope resourcefully with the abuse while keeping both the abuse and her coping strategies outside of ordinary awareness. Fraser describes the birth of an alter personality during oral rape by her father. I gag. I'm smothering. Help me! I scrunch my eyes so I can't see. My daddy is pulling my body over him like mommy pulls a holey sock over a darning egg. Filthy filthy don't ever let me catch you shame shame filthy daddy won't love me love me dirty filthy love him hate him fear don't ever let me catch you dirty dirty love hate guilt shame fear fear fear fear fear fear... .A DOUBLE SELF Not all abused children have the ability to alter reality through dissociation. And even those who do have this ability cannot rely upon it all the time. When it is impossible to avoid the reality of the abuse, the child must construct some system of meaning that justifies it. Inevitably the child concludes that her innate badness is the cause. The child seizes upon this explanation early and clings to it tenaciously, for it enables her to preserve a sense of meaning, hope, and power. If she is bad, then her parents are good. If she is bad, then she can try to be good. If, somehow, she has brought this fate upon herself, then somehow she has the power to change it. If she has driven her parents to mistreat her, then, if only she tries hard enough, she may some day earn their forgiveness and finally win the protection and care she so desperately needs. Self-blame is congruent with the normal forms of thought of early childhood, in which the self is taken as the reference point for all events. It is congruent with the thought processes of traumatized people of all ages, who search for faults in their own behavior in an effort to make sense out of what has happened to them. In the environment of chronic abuse, however, neither time nor experience provide any corrective for this tendency toward self-blame; rather, it is continually reinforced. The abused child's sense of inner badness may be directly confirmed by parental scapegoating. Survivors frequently describe being blamed, not only for their parents' violence or sexual misconduct, but also for numerous other family misfortunes. Family legends may include stories of the harm the child caused by being born or the disgrace for which she appears to be destined. A survivor describes her scapegoat role: "I was named after my mother. She had to get married because she got pregnant with me. She ran away when I was two. My father's parents raised me. I never saw a picture of her, but they told me I looked just like her and I'd probably turn out to be a slut and a tramp just like her. When my dad started raping me, he said, `You've been asking for this for a long time and now you're going to get it." Feelings of rage and murderous revenge fantasies are normal responses to abusive treatment. Like abused adults, abused children are often rageful and sometimes aggressive. They often lack verbal and social skills for resolving conflict, and they approach problems with the expectation of hostile attack. The abused child's predictable difficulties in modulating anger further strengthen her conviction of inner badness. Each hostile encounter convinces her that she is indeed a hateful person. If, as is common, she tends to displace her anger far from its dangerous source and to discharge it unfairly on those who did not provoke it, her selfcondemnation is aggravated still further. Participation in forbidden sexual activity also confirms the abused child's sense of badness. Any gratification that the child is able to glean from the exploitative situation becomes proof in her mind that she instigated and bears full responsibility for the abuse. If she ever experienced sexual pleasure, enjoyed the abuser's special attention, bargained for favors, or used the sexual relationship to gain privileges, these sins are adduced as evidence of her innate wickedness. Finally, the abused child's sense of inner badness is compounded by her enforced complicity in crimes against others. Children often resist becoming accomplices. They may even strike elaborate bargains with their abusers, sacrificing themselves in an attempt to protect others. These bargains inevitably fail, for no child has the power or the ability to carry out the protective role of an adult. At some point, the child may devise a way to escape her abuser, knowing that he will find another victim. She may keep silent when she witnesses the abuse of another child. Or she may even be drawn into participating in the victimization of other children. In organized sexual exploitation, full initiation of the child into the cult or sex ring requires participation in the abuse of others." A survivor describes how she was forced to take part in the abuse of a younger child: "I kind of know what my grandfather did. He would tie us up, me and my cousins, and he'd want us to take his--you know--in our mouths. The worst time of all was when we ganged up on my little brother and made him do it too." The child entrapped in this kind of horror develops the belief that she is somehow responsible for the crimes of her abusers. Simply by virtue of her existence on earth, she believes that she has driven the most powerful people in her world to do terrible things. Surely, then, her nature must be thoroughly evil. The language of the self becomes a language of abomination. Survivors routinely describe themselves as outside the compact of ordinary human relations, as supernatural creatures or nonhuman life forms. They think of themselves as witches, vampires, whores, dogs, rats, or snakes." Some use the imagery of excrement or filth to describe their inner sense of self. In the words of an incest survivor. "I am filled with black slime. If I open my mouth it will pour out. I think of myself as the sewer silt that a snake would breed upon." By developing a contaminated, stigmatized identity, the child victim takes the evil of the abuser into herself and thereby preserves her primary attachments to her parents. Because the inner sense of badness preserves a relationship, it is not readily given up even after the abuse has stopped; rather, it becomes a stable part of the child's personality structure. Protective workers who intervene in discovered cases of abuse routinely assure child victims that they are not at fault. Just as routinely, the children refuse to be absolved of blame. Similarly, adult survivors who have escaped from the abusive situation continue to view themselves with contempt and to take upon themselves the shame and guilt of their abusers. The profound sense of inner badness becomes the core around which the abused child's identity is formed, and it persists into adult life. This malignant sense of inner badness is often camouflaged by the abused child's persistent attempts to be good. In the effort to placate her abusers, the child victim often becomes a superb performer. She attempts to do whatever is required of her. She may become an empathic caretaker for her parents, an efficient housekeeper, an academic achiever, a model of social conformity. She brings to all these tasks a perfectionist zeal, driven by the desperate need to find favor in her parents' eyes. In adult life, this prematurely forced competence may lead to considerable occupational success. None of her achievements in the world redound to her credit, however, for she usually perceives her performing self as inauthentic and false. Rather, the appreciation of others simply confirms her conviction that no one can truly know her and that, if her secret and true self were recognized, she would be shunned and reviled. If the abused child is able to salvage a more positive identity, it often involves the extremes of self-sacrifice. Abused children sometimes interpret their victimization within a religious framework of divine purpose. They embrace the identity of the saint chosen for martyrdom as a way of preserving a sense of value. Eleanore Hill, an incest survivor, describes her stereotypical role as the virgin chosen for sacrifice, a role that gave her an identity and a feeling of specialness: "In the family myth I am the one to play the `beauty and the sympathetic one.' The one who had to hold [my father] together. In primitive tribes, young virgins are sacrificed to angry male gods. In families it is the same." These contradictory identities, a debased and an exalted self, cannot integrate. The abused child cannot develop a cohesive self-image with moderate virtues and tolerable faults. In the abusive environment, moderation and tolerance are unknown. Rather, the victim's self-representations remain rigid, exaggerated, and split. In the most extreme situations, these disparate self-representations form the nidus of dissociated alter personalities. Similar failures of integration occur in the child's inner representations of others. In her desperate attempts to preserve her faith in her parents, the child victim develops highly idealized images of at least one parent. Sometimes the child attempts to preserve a bond with the nonoffending parent. She excuses or rationalizes the failure of protection by attributing it to her own unworthiness. More commonly, the child idealizes the abusive parent and displaces all her rage onto the nonoffending parent. She may in fact feel more strongly attached to the abuser, who demonstrates a perverse interest in her, than in the nonoffending parent, whom she perceives as indifferent. The abuser may also foster this idealization by indoctrinating the child victim and other family members in his own paranoid or grandiose belief system. Hill describes the godlike image of her abusive father held by her entire extended family: "The man of the hour, our hero, the one with the talent, intelligence, charisma. Our genius. Everyone here defers to him. No one would dare to cross him. It was the law laid down at his birth. Nothing can change it. Whatever he does, he reigns as the chosen one, the favorite." Such glorified images of the parents cannot, however, be reliably sustained. They deliberately leave out too much information. The real experience of abusive or neglectful parents cannot be integrated with these idealized fragments. Thus, the child victim's inner representations of her primary caretakers, like her images of herself, remain contradictory and split. The abused child is unable to form inner representations of a safe, consistent caretaker. This in turn prevents the development of normal capacities for emotional self-regulation. The fragmentary, idealized images that the child is able to form cannot be evoked to fulfill the task of emotional soothing. They are too meager, too incomplete, and too prone to transform without warning into images of terror. In the course of normal development, a child achieves a secure sense of autonomy by forming inner representations of trustworthy and dependable caretakers, representations that can be evoked mentally in moments of distress. Adult prisoners rely heavily on these internalized images to preserve their sense of independence. In a climate of chronic childhood abuse, these inner representations cannot form in the first place; they are repeatedly, violently, shattered by traumatic experience. Unable to develop an inner sense of safety, the abused child remains more dependent than other children on external sources of comfort and solace. Unable to develop a secure sense of independence, the abused child continues to seek desperately and indiscriminately for someone to depend upon. The result is the paradox, observed repeatedly in abused children, that while they quickly become attached to strangers, they also cling tenaciously to the very parents who mistreat them. Thus, under conditions of chronic childhood abuse, fragmentation becomes the central principle of personality organization. Fragmentation in consciousness prevents the ordinary integration of knowledge, memory, emotional states, and bodily experience. Fragmentation in the inner representations of the self prevents the integration of identity. Fragmentation in the inner representations of others prevents the development of a reliable sense of independence within connection. This complex psychopathology has been observed since the time of Freud and Janet. In 1933 Sandor Ferenczi described the "atomization" of the abused child's personality and recognized its adaptive function in preserving hope and relationship: "In the traumatic trance the child succeeds in maintaining the previous situation of tenderness."' Half a century later another psychoanalyst, Leonard Shengold, described the "mind-fragmenting operations" elaborated by abused children in order to preserve "the delusion of good parents." He noted the "establishment of isolated divisions of the mind in which contradictory images of the self and of the parents are never permitted to coalesce," in a process of "vertical splitting." The sociologist Patricia Rieker and the psychiatrist Elaine Carmen describe the central pathology in victimized children as a "disordered and fragmented identity deriving from accommodations to the judgments of others." ATTACKS ON THE BODY These deformations in consciousness, individuation, and identity serve the purpose of preserving hope and relationship, but they leave other major adaptive tasks unsolved or even compound the difficulty of these tasks. Though the child has rationalized the abuse or banished it from her mind, she continues to register its effects in her body. The normal regulation of bodily states is disrupted by chronic hyperarousal. Bodily self-regulation is further complicated in the abusive environment because the child's body is at the disposal of the abuser. Normal biological cycles of sleep and wakefulness, feeding, and elimination may be chaotically disrupted or minutely overcontrolled. Bedtime may be a time of heightened terror rather than a time of comfort and affection, and the rituals of bedtime may be distorted in the service of sexually arousing the adult rather than quieting the child. Mealtimes may similarly be times of extreme tension rather than times of comfort and pleasure. The mealtime memories of survivors are filled with accounts of terrified silences, forced feeding followed by vomiting, or violent tantrums and throwing of food. Unable to regulate basic biological functions in a safe, consistent, and comforting manner, many survivors develop chronic sleep disturbances, eating disorders, gastrointestinal complaints, and numerous other bodily distress symptoms. The normal regulation of emotional states is similarly disrupted by traumatic experiences that repeatedly evoke terror, rage, and grief. These emotions ultimately coalesce in a dreadful feeling that psychiatrists call "dysphoria" and patients find almost impossible to describe. It is a state of confusion, agitation, emptiness, and utter aloneness. In the words of one survivor, "Sometimes 'I feel like a dark bundle of confusion. But that's a step forward. At times I don't even know that much." The emotional state of the chronically abused child ranges from a baseline of unease, through intermediate states of anxiety and dysphoria, to extremes of panic, fury, and despair. Not surprisingly, a great many survivors develop chronic anxiety and depression which persist into adult life. The extensive recourse to dissociative defenses may end up aggravating the abused child's dysphoric emotional state, for the dissociative process sometimes goes too far. Instead of producing a protective feeling of detachment, it may lead to a sense of complete disconnection from others and disintegration of the self. The psychoanalyst Gerald Adler names this intolerable feeling "annihilation panic. Hill describes the state in these terms: "I am icy cold inside and my surfaces are without integument, as if I am flowing and spilling and not held together any more. Fear grips me and I lose the sensation of being present. I am gone."" This emotional state, usually evoked in response to perceived threats of abandonment, cannot be terminated by ordinary means of self-soothing. Abused children discover at some point that the feeling can be most effectively terminated by a major jolt to the body. The most dramatic method of achieving this result is through the deliberate infliction of injury. The connection between childhood abuse and self-mutilating behavior is by now well documented. Repetitive self-injury and other paroxysmal forms of attack on the body seem to develop most commonly in those victims whose abuse began early in childhood . Survivors who self-mutilate consistently describe a profound dissociative state preceding the act. Depersonalization, derealization, and anesthesia are accompanied by a feeling of unbearable agitation and a compulsion to attack the body. The initial injuries often produce no pain at all. The mutilation continues until it produces a powerful feeling of calm and relief; physical pain is much preferable to the emotional pain that it replaces. As one survivor explains: "I do it to prove I exist." Contrary to common belief, victims of childhood abuse rarely resort to self-injury to "manipulate" other people, or even to communicate distress. Many survivors report that they developed the compulsion to self-mutilate quite early, often before puberty, and practiced it in secret for many years. They are frequently ashamed and disgusted by their behavior and go to great lengths to hide it. Self-injury is also frequently mistaken for a suicidal gesture. Many survivors of childhood abuse do indeed attempt suicide. There is a clear distinction, however, between repetitive self-injury and suicide attempts. Self-injury is intended not to kill but rather to relieve unbearable emotional pain, and many survivors regard it, paradoxically, as a form of self-preservation. Self-injury is perhaps the most spectacular of the pathological soothing mechanisms, but it is only one among many. Abused children generally discover at some point in their development that they can produce major, though temporary, alterations in their affective state by voluntarily inducing autonomic crises or extreme autonomic arousal. Purging and vomiting, compulsive sexual behavior, compulsive risk taking or exposure to danger, and the use of psychoactive drugs become the vehicles by which abused children attempt to regulate their internal emotional states. Through these devices, abused children attempt to obliterate their chronic dysphoria and to simulate, however briefly, an internal state of well-being and comfort that cannot otherwise be achieved. These selfdestructive symptoms are often well established in abused children even before adolescence, and they become much more prominent in the adolescent years. These three major forms of adaptation--the elaboration of dissociative defenses, the development of a fragmented identity, and the pathological regulation of emotional states--permit the child to survive in an environment of chronic abuse. Further, they generally allow the child victim to preserve the appearance of normality which is of such importance to the abusive family. The child's distress symptoms are generally well hidden. Altered states of consciousness, memory lapses, and other dissociative symptoms are not generally recognized. The formation of a malignant negative identity is generally disguised by the socially conforming "false self." Psychosomatic symptoms are rarely traced to their source. And self-destructive behavior carried out in secret generally goes unnoticed. Though some child or adolescent victims may call attention to themselves through aggressive or delinquent behavior, most are able successfully to conceal the extent of their psychological difficulties. Most abused children reach adulthood with their secrets intact. THE CHILD GROWN UP Many abused children cling to the hope that growing up will bring escape and freedom. But the personality formed in an environment of coercive control is not well adapted to adult life. The survivor is left with fundamental problems in basic trust, autonomy, and initiative. She approaches the tasks of early adulthood--establishing independence and intimacy--burdened by major impairments in self-care, in cognition and memory, in identity, and in the capacity to form stable relationships. She is still a prisoner of her childhood; attempting to create a new life, she reencounters the trauma. The author Richard Rhodes, a survivor of severe childhood abuse, describes how the trauma reappears in his work: "Each of my books felt different to write. Each tells a different story.... Yet I see that they're all repetitions. Each focuses on one or several men of character who confront violence, resist it, and discover beyond its inhumanity a narrow margin of hope. Repetition is the mute language of the abused child. I'm not surprised to find it expressed in the structure of my work at wavelengths too long to be articulated, like the resonances of a temple drum that aren't heard so much as felt in the heart's cavity." The survivor's intimate relationships are driven by the hunger for protection and care and are haunted by the fear of abandonment or exploitation. In a quest for rescue, she may seek out powerful authority figures who seem to offer the promise of a special caretaking relationship. By idealizing the person to whom she becomes attached, she attempts to keep at bay the constant fear of being either dominated or betrayed. Inevitably, however, the chosen person fails to live up to her fantastic expectations. When disappointed, she may furiously denigrate the same person whom she so recently adored. Ordinary interpersonal conflicts may provoke intense anxiety, depression, or rage. In the mind of the survivor, even minor slights evoke past experiences of callous neglect, and minor hurts evoke past experiences of deliberate cruelty. These distortions are not easily corrected by experience, since the survivor tends to lack the verbal and social skills for resolving conflict. Thus the survivor develops a pattern of intense, unstable relationships, repeatedly enacting dramas of rescue, injustice, and betrayal. Almost inevitably, the survivor has great difficulty protecting herself in the context of intimate relationships. Her desperate longing for nurturance and care makes it difficult to establish safe and appropriate boundaries with others. Her tendency to denigrate herself and to idealize those to whom she becomes attached further clouds her judgment. Her empathic attunement to the wishes of others and her automatic, often unconscious habits of obedience also make her vulnerable to anyone in a position of power or authority. Her dissociative defensive style makes it difficult for her to form conscious and accurate assessments of danger. And her wish to relive the dangerous situation and make it come out right may lead her into reenactments of the abuse. For all of these reasons, the adult survivor is at great risk of repeated victimization in adult life. The data on this point are compelling, at least with respect to women. The risk of rape, sexual harassment, or battering, though high for all women, is approximately doubled for survivors of childhood sexual abuse. In Diana Russell's study of women who had been incestuously abused in childhood, two-thirds were subsequently raped .36 Thus the child victim, now grown, seems fated to relive her traumatic experiences not only in memory but also in daily life. A survivor reflects on the unrelenting violence in her life: "It almost becomes like a selffulfilling prophecy--you start to expect violence, to equate violence with love at an early age. I got raped six times, while I was running away from home, or hitchhiking or drinking. It kind of all combined to make me an easy target. It was devastating. The crazy thing about it is at first I felt sure [the rapists] would kill me, because if they let me live, how would they get away with it? Finally I realized they had nothing to worry about; nothing would be ever done because I had `asked for it.' " The phenomenon of repeated victimization, indisputably real, calls for great care in interpretation. For too long psychiatric opinion has simply reflected the crude social judgment that survivors "ask for" abuse. The earlier concepts of masochism and the more recent formulations of addiction to trauma imply that the victims seek and derive gratification from repeated abuse. This is rarely true. Some survivors do report sexual arousal or pleasure in abusive situations; in these cases early scenes of abuse may be frankly eroticized and compulsively reenacted. Even then, however, there is a clear distinction between the wanted and unwanted aspects of the experience, as one survivor explains: "I like physical abuse to myself, if I pay someone to do it. It can be a high. But I like to be in control. I went through a period in my drinking where I would go to a bar and pick up the dirtiest, scuzziest man I could find and have sex with him. I would humiliate myself. I don't do that any more." More commonly, repeated abuse is not actively sought but rather is passively experienced as a dreaded but unavoidable fate and is accepted as the inevitable price of relationship. Many survivors have such profound deficiencies in self-protection that they can barely imagine themselves in a position of agency or choice. The idea of saying no to the emotional demands of a parent, spouse, lover, or authority figure may be practically inconceivable. Thus, it is not uncommon to find adult survivors who continue to minister to the wishes and needs of those who once abused them and who continue to permit major intrusions without boundaries or limits. Adult survivors may nurse their abusers in illness, defend them in adversity, and even, in extreme cases, continue to submit to their sexual demands. An incest survivor describes how she continued to take care of her abuser even as an adult: "My father got caught later on. He raped his girlfriend's daughter, and she pressed charges against him. When she threw him out, he had nowhere to go, so I took him in to live with me. I prayed he wouldn't go to jail." A well-learned dissociative coping style also leads survivors to ignore or minimize social cues that would ordinarily alert them to danger. One survivor describes how she repeatedly found herself in vulnerable situations: "I really didn't know but I did know things. I would find these older, fatherly men, and first thing I knew.... Once I got involved with an old mean in a fleabag hotel where I was living--just the prostitutes, the alcoholics, and me. I would clean for him and grew to love him. Then one day there he was lying in bed. He said the doctor didn't want him to see prostitutes and would I help him out and give him a hand job. I didn't know what he was talking about but he showed me. I did it. Then I felt guilty. I didn't get mad until much later. Survivors of childhood abuse are far more likely to be victimized or to harm themselves than to victimize other people. It is surprising, in fact, that survivors do not more often become perpetrators of abuse. Perhaps because of their deeply inculcated self-loathing, survivors seem most disposed to direct their aggression at themselves. While suicide attempts and self-mutilation are strongly correlated with childhood abuse, the link between childhood abuse and adult antisocial behavior is relatively weak . A study of over 900 psychiatric patients found that while suicidality was strongly related to a history of childhood abuse, homicidality was not. Although the majority of victims do not become perpetrators, clearly there is a minority who do. Trauma appears to amplify the common gender stereotypes: men with histories of childhood abuse are more likely to take out their aggressions on others, while women are more likely to be victimized by others or to injure themselves. A community study of 200 young men noted that those who had been physically abused in childhood were more likely than others to acknowledge having threatened to hurt someone, having hit someone in a fight, and having engaged in illegal acts. A small minority of survivors, usually male, embrace the role of the perpetrator and literally reenact their childhood experiences. The proportion of survivors that follow this path is not known, but a rough estimate can be extrapolated from a follow-up study of children who had been exploited in sex rings. About 20 percent of these children defended the perpetrator, minimized or rationalized the exploitation, and adopted an antisocial stance. One survivor of severe childhood abuse describes how he became aggressive toward others: "When I was about thirteen or fourteen, I decided I'd had enough. I started fighting back. I got really rough. One time a girl was picking on me and I beat the shit out of her. I started carrying a gun. That's how I got caught and sent away--for an unlicensed gun. Once a kid starts fighting back and becomes a delinquent, he reaches the point of no return. People should find out what the hell is going on in the family before the kid ruins his whole life. Investigate! Don't lock the kid up!" In the most extreme cases, survivors of childhood abuse may attack their own children or may fail to protect them. Contrary to the popular notion of a "generational cycle of abuse," however, the great majority of survivors neither abuse nor neglect their children . Many survivors are terribly afraid that their children will suffer a fate similar to their own, and they go to great lengths to prevent this from happening. For the sake of their children, survivors are often able to mobilize caring and protective capacities that they have never been able to extend to themselves. In a study of mothers with multiple personality disorder, the psychiatrist Philip Coons observed: "I have generally been impressed by the positive, constructive and caring attitude that many mothers with multiple personality disorder have toward their children. They were abused as children and strive to protect their children against similar misfortunes." As survivors attempt to negotiate adult relationships, the psychological defenses formed in childhood become increasingly maladaptive. Doublethink and a double self are ingenious childhood adaptations to a familial climate of coercive control, but they are worse than useless in a climate of freedom and adult responsibility. They prevent the development of mutual, intimate relationships or an integrated identity. As the survivor struggles with the tasks of adult life, the legacy of her childhood becomes increasingly burdensome. Eventually, often in the third or fourth decade of life, the defensive structure may begin to break down. Often the precipitant is a change in the equilibrium of close relationships: the failure of a marriage, the birth of a child, the illness or death of a parent. The facade can hold no longer, and the underlying fragmentation becomes manifest. When and if a breakdown occurs, it can take symptomatic forms that mimic virtually every category of psychiatric disorder. Survivors fear that they are going insane or that they will have to die. Fraser describes the terror and danger of coming face to face as an adult with the secrets of her childhood: Did I truly wish to open the Pandora's box under my father's bed? How would I feel to discover that the prize, after four decades of tracing clues and solving riddles, was the knowledge that my father had sexually abused me? Could I reconcile myself without bitterness to the amount of my life's energy that had gone into the cover-up of a crime? ... In the second stage of recovery, the survivor tells the story of the trauma. She tells it completely, in depth and in detail. This work of reconstruction actually transforms the traumatic memory, so that it can be integrated into the survivor's life story. Janet described normal memory as "the action of telling a story." Traumatic memory, by contrast, is wordless and static. The survivor's initial account of the event may be repetitious, stereotyped, and emotionless. One observer describes the trauma story in its untransformed state as a "prenarrative." It does not develop or progress in time, and it does not reveal the storyteller's feelings or interpretation of events. Another therapist describes traumatic memory as a series of still snapshots or a silent movie; the role of therapy is to provide the music and words. When Stephanie first told her story, her therapist was horrified by the sheer brutality of the rape, which had gone on for over two hours. To Stephanie, however, the worst part of the ordeal had occurred after the assault was over, when the rapists pressured her to say that it was the "best sex she ever had." Numbly and automatically, she had obeyed. She then felt ashamed and disgusted with herself. Both patient and therapist must develop tolerance for some degree of uncertainty, even regarding the basic facts of the story. In the course of reconstruction, the story may change as missing pieces are recovered. This is particularly true in situations where the patient has experienced significant gaps in memory. Thus, both patient and therapist must accept the fact that they do not have complete knowledge, and they must learn to live with ambiguity while exploring at a tolerable pace. After gradually disclosing his involvement in a pedophilic sex ring, Paul suddenly announced that he had fabricated the entire story. He threatened to quit therapy immediately unless the therapist professed to believe that he had been lying all along. Up until this moment, of course, he had wanted the therapist to believe he was telling the truth. The therapist admitted that she was puzzled by this turn of events. She added: "I wasn't there when you were a child, so I can't pretend to know what happened. I do know that it is important to understand your story fully, and we don't understand it yet. I think we should keep an open mind until we do." Paul grudgingly accepted this premise. In the course of the next year of therapy, it became clear that his recantation was a last-ditch attempt to maintain his loyalty to his abusers.Therapists, too, sometimes fall prey to the desire for certainty. Zealous conviction can all too easily replace an open, inquiring attitude. In the past, this desire for certainty generally led therapists to discount or minimize their patients' traumatic experiences. Though this may still be the therapist's most frequent type of error, the recent rediscovery of psychological trauma has led to errors of the opposite kind. Therapists have been known to tell patients, merely on the basis of a suggestive history or "symptom profile," that they definitely have had a traumatic experience. Some therapists even seem to specialize in "diagnosing" a particular type of traumatic event, such as ritual abuse. Any expression of doubt can be dismissed as "denial." In some cases patients with only vague, nonspecific symptoms have been informed after a single consultation that they have undoubtedly been the victims of a Satanic cult. The therapist has to remember that she is not a fact-finder and that the reconstruction of the trauma story is not a criminal investigation. Her role is to be an openminded, compassionate witness, not a detective. Because the truth is so difficult to face, survivors often vacillate in reconstructing their stories. Denial of reality makes them feel crazy, but acceptance of the full reality seems beyond what any human being can bear. The survivor's ambivalence about truth-telling is also reflected in conflicting therapeutic approaches to the trauma story. Janet sometimes attempted in his work with hysterical patients to erase traumatic memories or even to alter their content with the aid of hypnosis." Similarly, the early "abreactive" treatment of combat veterans attempted essentially to get rid of traumatic memories. This image of catharsis, or exorcism, is also an implicit fantasy in many traumatized people who seek treatment. It is understandable for both patient and therapist to wish for a magic transformation, a purging of the evil of the trauma. Psychotherapy, however, does not get rid of the trauma. The goal of recounting the trauma story is integration, not exorcism. In the process of reconstruction, the trauma story does undergo a transformation, but only in the sense of becoming more present and more real. The fundamental premise of the psychotherapeutic work is a belief in the restorative power of truth-telling. In the telling, the trauma story becomes a testimony. Inger Agger and Soren Jensen, in their work with refugee survivors of political persecution, note the universality of testimony as a ritual of healing. Testimony has both a private dimension, which is confessional and spiritual, and a public aspect, which is political and judicial. The use of the word testimony links both meanings, giving a new and larger dimension to the patient's individual experience. Richard Mollica describes the transformed trauma story as simply a "new story," which is "no longer about shame and humiliation" but rather "about dignity and virtue." Through their storytelling, his refugee patients "regain the world they have lost."" TRANSFORMING TRAUMATIC MEMORY Therapeutic techniques for transforming the trauma story have developed independently for many different populations of traumatized people. Two highly evolved techniques are the use of "direct exposure" or "flooding" in the treatment of combat veterans and the use of formalized "testimony" in the treatment of survivors of torture. The flooding technique is part of an intensive program, developed within the Veterans' Administration, for treating post-traumatic stress disorder. It is a behavioral therapy designed to overcome the terror of the traumatic event by exposing the patient to a controlled reliving experience. In preparation for the flooding, sessions, the patient is taught how to manage anxiety by using relaxation techniques and by visualizing soothing imagery. The patient and therapist then carefully prepare a written "script," describing the traumatic event in detail. This script includes the four elements of context, fact, emotion, and meaning. If there were several traumatic events, a separate script is developed for each one. When the scripts are completed, the patient chooses the sequence for their presentation in the flooding sessions themselves, progressing from the easiest to the most difficult. In a flooding session, the patient narrates a script aloud to the therapist, in the present tense, while the therapist encourages him to express his feelings as fully as possible. This treatment is repeated weekly for an average of twelve to fourteen sessions. The majority of patients undergo treatment as outpatients, but some require hospitalization because of the severity of their symptoms during treatment. This technique shares many features with the testimony method for treating survivors of political torture. The testimony method was first reported by two Chilean psychologists, who published their findings under pseudonyms in order to protect their own security. The central project of the treatment is to create a detailed, extensive record of the patient's traumatic experiences. First, therapy sessions are recorded and a verbatim transcript of the patient's narrative is prepared. The patient and therapist then revise the document together. During revision, the patient is able to assemble the fragmented recollections into a coherent testimony. "Paradoxically," the psychologists observe, "the testimony is the very confession that had been sought by the torturers ... but through testimony, confession becomes denunciation rather than betrayal ." In Denmark, Agger and Jensen further refined this technique. In their method, the final written testimony is read aloud, and the therapy is concluded with a formal "delivery ritual," during which the document is signed by the patient as plaintiff and by the therapist as witness. An average of 12-20 weekly sessions is needed to complete a testimony." The social and political components of the testimony method of treatment are far more explicit and developed than in the more narrowly behavioral flooding. This should not be surprising, since the testimony method developed within organizations committed to human rights activism, whereas the flooding method developed within an institution of the United States government. What is surprising is the degree of congruence in these techniques. Both models require an active collaboration of patient and therapist to construct a fully detailed, written trauma narrative. Both treat this narrative with formality and solemnity. And both use the structure of the narrative to foster an intense reliving experience within the context of a safe relationship. The therapeutic effects are also similar. Reporting on 39 treatment cases, the Chilean psychologists noted substantial relief of post-traumatic symptoms in the great majority of survivors of torture or mock execution. Their method was specifically effective for the aftereffects of terror. It did not offer much solace to patients, such as the relatives of missing or "disappeared" persons, who were suffering from unresolved grief but not from post-traumatic stress disorder. The outcome of the flooding treatment with combat veterans gives even clearer evidence for the effectiveness of this technique. Patients who completed the treatment reported dramatic reductions in the intrusive and hyperarousal symptoms of post-traumatic stress disorder. They suffered fewer nightmares and flashbacks, and they experienced a general improvement in anxiety, depression, concentration problems, and psychosomatic symptoms. Moreover, six months after completing the flooding treatment, patients reported lasting improvement in their intrusive and hyperarousal symptoms. The effects of the flooding treatment were specific for each traumatic event. Desensitizing one memory did not carry over to others; each had to be approached separately, and all had to be addressed in order to achieve the fullest relief of symptoms. It appears, then, that the "action of telling a story" in the safety of a protected relationship can actually produce a change in the abnormal processing of the traumatic memory. With this transformation of memory comes relief of many of the major symptoms of post-traumatic stress disorder. The physioneurosis induced by terror can apparently be reversed through the use of words. These intensive therapeutic techniques, however, have limitations. While intrusive and hyperarousal symptoms appear to improve after flooding, the constrictive symptoms of numbing and social withdrawal do not change, and marital, social, and work problems do not necessarily improve. By itself, reconstructing the trauma does not address the social or relational dimension of the traumatic experience. It is a necessary part of the recovery process, but it is not sufficient. Unless the relational aspect of the trauma is also addressed, even the limited goal of relieving intrusive symptoms may remain out of reach. The patient may be reluctant to give up symptoms such as nightmares or flashbacks, because they have acquired important meaning. The symptoms may be a symbolic means of keeping faith with a lost person, a substitute for mourning, or an expression of unresolved guilt. In the absence of a socially meaningful form of testimony, many traumatized people choose to keep their symptoms. In the words of the war poet Wilfred Owen: "I confess I bring on what few war dreams I now have, entirely by willingly considering war of an evening. I have my duty to perform towards War." Piecing together the trauma story becomes a more complicated project with survivors of prolonged, repeated abuse. Techniques that are effective for approaching circumscribed traumatic events may not be adequate for chronic abuse, particularly for survivors who have major gaps in memory. The time required to reconstruct a complete story is usually far longer than 12-20 sessions. The patient may be tempted to resort to all sorts of powerful treatments, both conventional and unconventional, in order to hasten the process. Large-group marathons or inpatient "package" programs frequently attract survivors with the unrealistic promise that a "blitz" approach will effect a cure. Programs that promote the rapid uncovering of traumatic memories without providing an adequate context for integration are therapeutically irresponsible and potentially dangerous, for they leave the patient without the resources to cope with the memories uncovered. Breaking through the barriers of amnesia is not in fact the difficult part of reconstruction, for any number of techniques will usually work. The hard part of this task is to come face-to-face with the horrors on the other side of the amnesiac barrier and to integrate these experiences into a fully developed life narrative. This slow, painstaking, often frustrating process resembles putting together a difficult picture puzzle. First the outlines are assembled, and then each new piece of information has to be examined from many different angles to see how it fits into the whole. A hundred years ago Freud used this same image of solving a puzzle to describe the uncovering of early sexual trauma. The reward for patience is the occasional breakthrough moment when a number of pieces suddenly fall into place and a new part of the picture becomes clear. The simplest technique for the recovery of new memories is the careful exploration of memories the patient already has. Most of the time this plain, workaday approach is sufficient. As the patient experiences the full emotional impact of facts she already knows, new recollections usually emerge spontaneously, as in the case of Denise, a 32-year-old incest survivor: Denise entered treatment tormented by doubt about whether she had been abused by her father. She had a strong "body feeling" that this was the case but claimed to have no clear memories. She thought hypnosis would be needed to recover memories. The therapist asked Denise to describe her current relationship with her father. In fact, Denise was dreading an upcoming family gathering, because she knew her father would get boisterously drunk, subject everyone at the party to lewd remarks, and fondle all the women. She felt she could not complain, since the family consideredThe patient's present, daily experience is usually rich in clues to dissociated past memories. The observance of holidays and special occasions often affords an entry into past associations. In addition to following the ordinary clues of daily life, the patient may explore the past by viewing photographs, constructing a family tree, or visiting the site of childhood experiences. Post-traumatic symptoms such as flashbacks or nightmares are also valuable access routes to memory. Sharon Simone describes how a flashback triggered by sexual intercourse offered a clue to her forgotten childhood history of incest: "I was having sex with my husband, and I had come to a place in the middle of it where I felt like I was three years old. I was very sad, and he was doing the sex, and I remember looking around the room and thinking, `Emily' (who's my therapist), "please come and get me out from under this man.' I knew `this man' wasn't my husband, but I didn't yet say 'Dad.'" In the majority of cases, an adequate narrative can be constructed without resort to formal induction of altered states of consciousness. Occasionally, however, major amnesiac gaps in the story remain even after careful and painstaking exploration. At these times, the judicious use of powerful techniques such as hypnotherapy is warranted. The resolution of traumatic memories through hypnosis, however, requires a high degree of skill. Each venture into uncovering work must be preceded by careful preparation and followed by an adequate period for integration. The patient learns to use trance for soothing and relaxation first, moving on to uncovering work only after much anticipation, planning, and practice. Shirley Moore, a psychiatric nurse and hypnotherapist, describes her approach to hypnotic uncovering work with traumatized people: We might use an age regression technique like holding a ribbon or a rope that goes to the past. For some survivors you can't use ropes. There are a lot of standard techniques that you have to change the language for. Another technique that works well for a lot of people is imagining they are watching a portable TV. When we use this, they become accustomed to having a "safe" channel, and that's always where we tune in first. The working channel is a VCR channel. It has a tape that covers the traumatic experience, and we can use it in slow-motion, we can fast-forward it, we can reverse-it. They also know how to use the volume control to modulate the intensity of their feelings. Some people like to just dream. They'll be in their protected place and have a dream about the trauma. These are all hypnotic projective techniques.In addition to hypnosis, many other techniques can be used to produce an altered state of consciousness in which dissociated traumatic memories are more readily accessible. These range from social methods, such as intensive group therapy or psychodrama, to biological methods, such as the use of sodium amytal. In skilled hands, any of these methods can be effective. Whatever the technique, the same basic rules apply: the locus of control remains with the patient, and the timing, pacing, and design of the sessions must be carefully planned so that the uncovering technique is integrated into the architecture of the psychotherapy. This careful structuring applies even to the design of the uncovering session itself. Richard Kluft, who works with patients with multiple personality disorder, expresses this principle as the "rule of thirds." If "dirty work" is to be done, it should begin within the first third of the session; otherwise it should be postponed. Intense exploration is done in the second third of the session, while the last third is set aside to allow the patient to reorient and calm herself. For survivors of prolonged, repeated trauma, it is not practical to approach each memory as a separate entity. There are simply too many incidents, and often similar memories have blurred together. Usually, however, a few distinct and particularly meaningful incidents stand out. Reconstruction of the trauma narrative is often based heavily upon these paradigmatic incidents, with the understanding that one episode stands for many. Letting one incident stand for many is an effective technique for creating new understanding and meaning. However, it probably does not work well for physiological desensitization. While behavioral techniques such as flooding have proved to be effective for alleviating the intense reactions to memories of single traumatic events, the same techniques are much less effective for prolonged, repeated, traumatic experiences. This contrast is apparent in a patient, reported on by the psychiatrist Arieh Shalev, who sought treatment after an automobile accident for the symptoms of simple post-traumatic stress disorder. She also had a history of repeated abuse in childhood. A standard behavioral treatment successfully resolved her symptoms related to the auto accident. However, the same approach did little to alleviate the patient's feelings about her childhood victimization, for which prolonged psychotherapy was required . The physiological changes suffered by chronically traumatized people are often extensive. People who have been subjected to repeated abuse in childhood may be prevented from developing normal sleep, eating, or endocrine cycles and may develop extensive somatic symptoms and abnormal pain perception. It is likely, therefore, that some chronically abused people will continue to suffer a degree of physiological disturbance even after full reconstruction of the trauma narrative. These survivors may need to devote separate attention to their physiological symptoms. Systematic reconditioning or long-term use of medication may sometimes be necessary. This area of treatment is still almost entirely experimental. MOURNING TRAUMATIC LOSS Trauma inevitably brings loss. Even those who are lucky enough to escape physically unscathed still lose the internal psychological structures of a self securely attached to others. Those who are physically harmed lose in addition their sense of bodily integrity. And those who lose important people in their lives face a new void in their relationships with friends, family, or community. Traumatic losses rupture the ordinary sequence of generations and defy the ordinary social conventions of bereavement. The telling of the trauma story thus inevitably plunges the survivor into profound grief. Since so many of the losses are invisible or unrecognized, the customary rituals of mourning provide little consolation. The descent into mourning is at once the most necessary and the most dreaded task of this stage of recovery. Patients often fear that the task is insurmountable, that once they allow themselves to start grieving, they will never stop. Danieli quotes a 74-year-old widow who survived the Nazi Holocaust: "Even if it takes one year to mourn each loss, and even if I live to be 107 [and mourn all members of my family], what do I do about the rest of the six million?" The survivor frequently resists mourning, not only out of fear but also out of pride. She may consciously refuse to grieve as a way of denying victory to the perpetrator. In this case it is important to reframe the patient's mourning as an act of courage rather than humiliation. To the extent that the patient is unable to grieve, she is cut off from a part of herself and robbed of an important part of her healing. Reclaiming the ability to feel the full range of emotions, including grief, must be understood as an act of resistance rather than submission to the perpetrator's intent. Only through mourning everything that she has lost can the patient discover her indestructible inner life. A survivor of severe childhood abuse describes how she came to feel grief for the first time: By the time I was fifteen I had had it. I was a cold, flip little bitch. I had survived just fine without comfort or affection; it didn't bother me. No one could get me to cry. If my mothers threw me out, I would just curl up and go to sleep in a trunk in the hallway. Even when that woman beat me, no way was she going to make me cry. I never cried when my husband beat me. He'd knock me down and I'd get up for more. It's a wonder I didn't get killed. I've cried more in therapy than in my whole life. I never trusted anyone enough to let them see me cry. Not even you, till the last couple of months. There, I've said it! That's the statement of the year!Since mourning is so difficult, resistance to mourning is probably the most common cause of stagnation in the second stage of recovery. Resistance to mourning can take on numerous disguises. Most frequently it appears as a fantasy of magical resolution through revenge, forgiveness, or compensation. The revenge fantasy is often a mirror image of the traumatic memory, in which the roles of perpetrator and victim are reversed. It often has the same grotesque, frozen, and wordless quality as the traumatic memory itself. The revenge fantasy is one form of the wish for catharsis. The victim imagines that she can get rid of the terror, shame, and pain of the trauma by retaliating against the perpetrator. The desire for revenge also arises out of the experience of complete helplessness. In her humiliated fury, the victim -imagines that revenge is the only way to restore her own sense of power. She may also imagine that this is the only way to force the perpetrator to acknowledge the harm he has done her. Though the traumatized person imagines that revenge will bring relief, repetitive revenge fantasies actually increase her torment. Violent, graphic revenge fantasies may be as arousing, frightening, and intrusive as images of the original trauma. They exacerbate the victim's feelings of horror and degrade her image of herself. They make her feel like a monster. They are also highly frustrating, since revenge can never change or compensate for the harm that was done. People who actually commit acts of revenge, such as combat veterans who commit atrocities, do not succeed in getting rid of their post-traumatic symptoms; rather, they seem to suffer the most severe and intractable disturbances. During the process of mourning, the survivor must come to terms with the impossibility of getting even. As she vents her rage in safety, her helpless fury gradually changes into a more powerful and satisfying form of anger. righteous indignation. This transformation allows the survivor to free herself from the prison of the revenge fantasy, in which she is alone with the perpetrator. It offers her a way to regain a sense of power without becoming a criminal herself. Giving up the fantasy of revenge does not mean giving up the quest for justice; on the contrary, it begins the process of joining with others to hold the perpetrator accountable for his crimes. Revolted by the fantasy of revenge, some survivors attempt to bypass their outrage altogether through a fantasy of forgiveness. This fantasy, like its polar opposite, is an attempt at empowerment. The survivor imagines that she can transcend her rage and erase the impact of the trauma through a willed, defiant act of love. But it is not possible to exorcise the trauma, through 'either hatred or love. Like revenge, the fantasy of forgiveness often becomes a cruel torture, because it remains out of reach for most ordinary human beings. Folk wisdom recognizes that to forgive is divine. And even divine forgiveness, in most religious systems, is not unconditional. True forgiveness cannot be granted until the perpetrator has sought and earned it through confession, repentance, and restitution. Genuine contrition in a perpetrator is a rare miracle. Fortunately, the survivor does not need to wait for it. Her healing depends on the discovery of restorative love in her own life; it does not require that this love be extended to the perpetrator. Once the survivor has mourned the traumatic event, she may be surprised to discover how uninteresting the perpetrator has become to her and how little concern she feels for his fate. She may even feel sorrow and compassion for him, but this disengaged feeling is not the same as forgiveness. The fantasy of compensation, like the fantasies of revenge and forgiveness, often becomes a formidable impediment to mourning. Part of the problem is the very legitimacy of the desire for compensation. Because an injustice has been done to her, the survivor naturally feels entitled to some form of compensation. The quest for fair compensation is often an important part of recovery. However, it also presents a potential trap. Prolonged, fruitless struggles to wrest compensation from the perpetrator or from others may represent a defense against facing the full reality of what was lost. Mourning is the only way to give due honor to loss; there is no adequate compensation. The fantasy of compensation is often fueled by the desire for a victory over the perpetrator that erases the humiliation of the trauma. When the compensation fantasy is explored in detail, it usually includes psychological components that mean more to the patient than any material gain. The compensation may represent an acknowledgment of harm, an apology, or a public humiliation of the perpetrator. Though the fantasy is about empowerment, in reality the struggle for compensation ties the patient's fate to that of the perpetrator and holds her recovery hostage to his whims. Paradoxically, the patient may liberate herself from the perpetrator when she renounces the hope of getting any compensation from him. As grieving progresses, the patient comes to envision a more social, general, and abstract process of restitution, which permits her to pursue her just claims without ceding any power over her present life to the perpetrator. The case of Lynn, a 28-year-old incest survivor, illustrates how a compensation fantasy stalled the progress of recovery: Lynn entered psychotherapy with a history of numerous hospitalizations for suicide attempts, relentless self-mutilation, and anorexia. Her symptoms stabilized after a connection was made between her self-destructive behavior and a history of abuse in childhood. After two years of steady improvement, however, she seemed to get "stuck." She began calling in sick at work, canceling therapy appointments, withdrawing from friends, and staying in bed during the day.A variant of the compensation fantasy seeks redress not from the perpetrator but from real or symbolic bystanders. The demand for compensation may be placed upon society as a whole or upon one person in particular. The demand may appear to be entirely economic, such as a claim for disability, but inevitably it includes important psychological components as well. In the course of psychotherapy, the patient may focus her demands for compensation on the therapist. She may come to resent the limits and responsibilities of the therapy contract, and she may insist upon some form of special dispensation. Underlying these demands is the fantasy that only the boundless love of the therapist, or some other magical personage, can undo the damage of the trauma. The case of Olivia, a 36-year-old survivor of severe childhood abuse, reveals how a fantasy of compensation took the form of a demand for physical contact: During psychotherapy Olivia began to uncover horrible memories. She insisted that she could not endure her feelings unless she could sit on her therapist's lap and be cuddled like a child. When the therapist refused, on the grounds that touching would confuse the boundaries of their working relationship, Olivia became enraged. She accused the therapist of withholding the one thing that would make her well. At this impasse the therapist suggested a consultation. Unfortunately, therapists sometimes collude with their patients' unrealistic fantasies of restitution. It is flattering to be invested with grandiose healing powers and only too tempting to seek a magical cure in the laying on of hands. Once this boundary is crossed, however, the therapist cannot maintain a disinterested therapeutic stance, and it is foolhardy to imagine that she can. Boundary violations ultimately lead to exploitation of the patient, even when they are initially undertaken in good faith. Renee, a 40-year-old divorced woman, sought therapy after escaping from a twenty-year marriage to a man who had repetitively beaten her in front of their children. In therapy she was able to grieve the loss of her marriage, but she became profoundly depressed when she recognized how the years of violence had affected her adolescent sons. The boys had themselves become aggressive and openly defied her. The patient was unable to set any limits with them because she felt that she deserved their contempt. In her own estimation she had failed in her role as a parent, and now it was too late to undo the damage.In this case it was insufficient to point out to the patient that she herself was a victim and that her husband was- entirely to blame for the battering. As long as she saw herself only as a victim, she felt helpless to take charge of the situation. Acknowledging her own responsibility toward her children opened the way to the assumption of power and control. The action of atonement allowed this woman to reassert the authority of her parental role. Survivors of chronic childhood trauma face the task of grieving not only for what was lost but also for what was never theirs to lose. The childhood that was stolen from them is irreplaceable. They must mourn the loss of the foundation of basic trust, the belief in a good parent. As they come to recognize that they were not responsible for their fate, they confront the existential despair that they could not face in childhood. Leonard Shengold poses the central question at this stage of mourning. "Without the inner picture of caring parents, how can one survive? ... Every soul-murder victim will be wracked by the question `Is there life without father and mother?' " The confrontation with despair brings with it, at least transiently, an increased risk of suicide. In contrast to the impulsive self-destructiveness of the first stage of recovery, the patient's suicidality during this second stage may evolve from a calm, flat, apparently rational decision to reject a world where such horrors are possible. Patients may engage in sterile philosophical discussions about their right to choose suicide. It is imperative to get beyond this intellectual defense and to engage the feelings and fantasies that fuel the patient's despair. Commonly the patient has the fantasy that she is already among the dead, because her capacity for love. has been destroyed. What sustains the patient through this descent into despair is the smallest evidence of an ability to form loving connections. Clues to the undestroyed capacity for love can often be found through the evocation of soothing imagery. Almost invariably it is possible to find some image of attachment that has been salvaged from the wreckage. One positive memory of a caring, comforting person may be a lifeline during the descent into mourning. The patient's own capacity to feel compassion for animals or children, even at a distance, may be the fragile beginning of compassion for herself. The reward of mourning is realized as the survivor sheds her evil, stigmatized identity and dares to hope for new relationships in which she no longer has anything to hide. The restorative power of mourning and the extraordinary human capacity for renewal after even the most profound loss is evident in the treatment of Mrs. K, a survivor of the Nazi Holocaust: The turning point in Mrs. K's treatment came when she "confessed" that she had been married and had given birth to a baby in the ghetto whom she "gave to the Nazis." Her guilt, shame, and feeling "filthy" were exacerbated when she was warned after liberation by "well-meaning people" that if she told her new fiance, he would never marry her. The baby, whom she bore and kept alive for two and a half years under the most horrendously inhuman conditions, was torn from her arms and murdered when his whimper alerted the Nazi officer that he was hidden under her coat ...The second stage of recovery has a timeless quality that is frightening. The reconstruction of the trauma requires immersion in a past experience of frozen time; the descent into mourning feels like a surrender to tears that are endless. Patients often ask how long this painful process will last. There is no fixed answer to the question, only the assurance that the process cannot be bypassed or hurried. It will almost surely take longer than the patient wishes, but it will not go on forever. After many repetitions, the moment comes when the telling of the trauma story no longer arouses quite such intense feeling. It has become a part of the survivor's experience, but only one part of it. The story is a memory like other memories, and it begins to fade as other memories do. Her grief, too, begins to lose its vividness. It occurs to the survivor that perhaps the trauma is not the most important, or even the most interesting, part of her life story. At first these thoughts may seem almost heretical. The survivor may wonder how she can possibly give due respect to the horror she has endured if she no longer devotes her life to remembrance and mourning. And yet she finds her attention wandering back to ordinary life. She need not worry. She will never forget. She will think of the trauma every day as long as she lives. She will grieve every day. But the time comes when the trauma no longer commands the central place in her life. The rape survivor Sohaila Abdulali recalls a surprising moment in the midst of addressing a class on rape awareness: "Someone asked what's the worst thing about being raped. Suddenly I looked at them all and said, the thing I hate the most about it is that it's boring. And they all looked very shocked and I said, don't get me wrong. It was a terrible thing. I'm not saying it was boring that it happened, it's just that it's been years and I'm not interested in it any more. It's very interesting the first 50 times or the first 500 times when you have the same phobias and fears. Now I can't get so worked up any more." The reconstruction of the trauma is never entirely completed; new conflicts and challenges at each new stage of the lifecycle will inevitably reawaken the trauma and bring some new aspect of the experience to light. The major work of the second stage is accomplished, however, when the patient reclaims her own history and feels renewed hope and energy for engagement with life. Time starts to move again. When the "action of telling a story" has come to its conclusion, the traumatic experience truly belongs to the past. At this point, the survivor faces the tasks of rebuilding her life in the present and pursuing her aspirations for the future.
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