Victims of Violence: Aspects of the "Victim-to-Patient" Process in Women* REBEKA MOSCARELLO, M.D.!

This paper is an overview of aspects of the victim-to-patient process which reflects the interrelationship between mental health and mental disorder, particularly of women who suffer the sexual assault, sexual abuse, or wife assault. Knowledge ofthe psychologicalprocesses and symptoms aids diagnosis, modifies treatment and the process of recovery following acts of violence.

unwanted vaginal penetration in their lifetime (2). Ten percent of women will be physically abused in a relationship (3). Recent studies of psychiatric inpatients (4-7) and outpatients (8-11) reveal a higher than expected rates of abuse, ranging from 53% in a 1984 study (4) to 83.1% in a 1990 Canadian study (7) of a general hospital and a large psychiatric hospital. In a report of an outpatient clinic, Herman et al (10) found a history of childhood trauma in 81% of cases (11 subjects); a rate of 62% (12 subjects) was reported by Surrey, Swett, Michaels and Levine (11). These percentages are higher than those found in the general population, suggesting that there is a relationship between sexual violence and mental illness. Multiple personality disorder, borderline personality disorder, somatoform disorder and post-traumatic stress disorder are common diagnoses among women. The association between abuse and addictive behaviour (12,13) and prostitution (14, 15) is being investigated. A survey of patients receiving psychotherapy revealed that few of them reported sexual violation and that therapists rarely ask about it (16). Shame may prevent patients from reporting this abuse.

T

he psychological trauma which results from sexual abuse, sexual assault, and wife assault is currently being addressed by mental health professionals and the general public. This paper focuses on the psychological trauma of sexual violation as a contributor to the victim-patient process. Damage to the self, subsequent to the violent acts of sexual abuse, sexual assault and wife assault, seems to be central to the ensuing psychological processes and symptoms. For women, damage to, or fracturing of, the self caused by these psychological traumas is intensified by aspects of their feminine development. Basic to all considerations is the conceptualization of acts of sexual violation (sexual abuse, sexual assault by a stranger or aquaintance, and wife assault) as acts of aggression and power executed through the sexual and physical assault.

Self

This paper will begin with current data on the prevalence of violence against women, a simple definition of the self, an outline of some ideas about feminine development that intensify the psychological trauma of violence and some components of the post-traumatic stress response that damage the self.

The concept of the self is complex. Using Kohut's (17) definition, in the broad sense the self is "the centre of the individual's psychological universe." It is what "I" refers to when we say, "I feel such-and-such; I think this-and-this; and I do so-and-so." Profound damage to the self, the "I", is closely connected to the psychological processes which follow the major psychological trauma caused by non consensual sexual trauma (18-21).

Prevalence

Feminine Development

According to Canadian reports, 33% of women will experience unwanted sexual contact by the age of 18 (1),20% of adult women will experience sexual assault and six percent

All types of sexual violation attack the concept of the self, in both women and men, For women, some aspects of feminine development intensify their psychological response to acts of violence, for example, their sense of attachment and connection to others, their difficulty in acknowledging and expressing anger, and their low status in society. Women's sense of self and self-worth develops in relation to others. For women, attachment - a sense of connection to others and the fostering of mutual development - is an important component of the self (22). Acts of violence fracture attachment bonds (23); there are subsequent feelings of disconnection, abandonment and isolation from others, and the self suffers.

*Manuscript received December 1990, revised December 1991. lCoordinator, Psychiatric/Mental Health Outpatient Clinics, Department of Psychiatry, Women's College Hospital; Assistant Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario. Address reprints requests to: Dr. Rebeka Moscarello, Women's College Hospital, 76 Grenville Street, Toronto, Ontario M5S 182

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Women perceive the acknowledgement and expression of anger as unfeminine and destructive to relationships, and acts of violence evoke intense anger and rage. Experiencing these reactions to violence is damaging to the self (24). In addition, women's difficulty in managing anger (18,25,26) compounds trauma to the self. Both women and children are devalued and disadvantaged in our society (27). Devaluation leads to a lack of confidence in one's self, and the fragmentation of the self and the person's identity. Women therefore have a greater reliance on the opinion of others. Acts of violence add to the feeling of being devalued, further damaging the self and fragmenting the individual's identity. The opinion of others becomes more important than the individual's opinions of him or herself as self-worth and self-esteem plummet. All of the above combine to change the meaning of abuse so that the victim assumes responsibility for the violation. "Everyone told me that if I had not worked overtime and not gone to the parking lot at 8 pm, I would not have been raped."

The Post-Traumatic Stress Response The post-traumatic stress response (PTSR) is an attempt to make sense of a traumatic experience. Intense fear, terror and helplessness are experienced during sexual violation and the PTSR is initiated (28). In fact, the devastating effect of helplessness upon the psyche has been described as psychic death (29). Attempts to regain control, and fear of loss of control dominate the victim's life. Three basic assumptions, which are taken for granted by the average person, are the belief in personal invulnerability, in the world as meaningful and comprehensible and in the sense of self-worth (30). After sexual violation, one's assumptions are drastically altered. The person feels vulnerable and unsafe. Symptoms of anxiety and fear of a repeat assault stem from the heightened sense of vulnerability. Some of the fears are being alone, going out after dark, reading or hearing about community or world violence, and a fear of men. Most people believe that the world is meaningful and comprehensible. However, after sexual violation, trust in other people and in society in general is lost. It becomes difficult for woman to establish trusting relationships, particularly with men, and to be intimate emotionally or physically. Most people have an average sense of self-esteem and selfworth. However, after sexual violation, latent negative selfimages are activated and the self is viewed as weak, helpless, out of control and unable to protect the individual (31). "I must be bad or this would not have happened to me" (32). Loss of self-esteem and self-worth is profound. In summary, the victim is left with a sense of VUlnerability and helplessness in an unpredictable, unjust, untrustworthy world that no longer makes sense. The basis for the development of depressive symptoms is formed.

Threats to Ego Function Ego function is threatened by sexual violation and the shock of the violation is associated with regression of the ego. However, initial denial and dissociation protect some ego function. The range of symptoms related to dissociation is being acknowledged (33). Intense anger, rage and aggressive drives are evoked by sexual violation. Fear of loss of control and murderous impulses damage the self. These feelings are frequently expressed as, "I am no better than the perpetrator." Irritability and uncontrolled outbursts of anger are present. The phasic nature of symptoms associated with the PTSR include intrusion (with painful re-experiencing) of unbidden thoughts, feelings and memories, followed by the defense of numbing and avoidance. Symptoms cifhyperarousal manifest themselves as impaired mood regulation, disordered sleep, hypervigilance, being hyperalert and physiological symptoms of anxiety. When working through the traumatic event, the person initially blocks out much of the meaning (denial of the psychological trauma) and gradually doses or psychologically regulates the amount of meaning that is admitted to consciousness. Painful aspects of the abuse are briefly considered, followed by a phase of constriction of feeling and focus. After working it through, there is a gradual decrease in severity and frequency of intrusive and avoidance phases, and the resumption of a normal level of arousal. As the trauma is integrated, a new equilibrium is established in the world where violence has been experienced (34) (see Figure 1). If the trauma is not worked through successfully, posttraumatic stress disorder results (35). This diagnosis requires at least one re-experiencing criterion, three avoidance/numbing criteria and two hyperarousal criteria, to coexist for 30 days. The onset of symptoms may be immediate or be delayed for months or years. It is important for psychiatrists and the justice system to recognize delayed onset. Recent sexual violation may trigger unresolved conflicts, particularly previous sexual violation.

Shame, Self-Blame and Guilt Shame is a painful, complex emotion that makes us want to hide. The intimate connection between sexual violation, VIOLENCE: INTRA PSYCHIC RESPONSES PsyChic trauma 01 violence:

ccnuacrcrs deeply held beliels

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• outcry

about sell and the world

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Traumatic stress Response

cerense: exlreme gap between anerec Image of sell and the world.

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Inlegralionof aHeredselland beliels aboullhe world.

0

.. Oh no It eannol be true.

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.. Nothing has changed ."

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Completion

.. I will go on living."

Figure 1. aspects of the "victim-to patient" process in women (intrapsychicresponses).

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VICfIMS OF VIOLENCE

shame and psychological sequelae is now being recognized in the literature (36-39). Shame is linked to the early development of the self. Shame is experienced as early as three months of age (36), and between six and 12 months is connected with genital excitement and sexuality. Nathanson (37) notes that all sexual behaviour "is ringed around by shame." Shame follows a moment of exposure of aspects of the self which are particularly sensitive, vulnerable and intimate. Pride, the reciprocal of shame, includes the emotions of joy, interest, excitement and enjoyment. Pride and shame form an axis related to the development of the self. Lewis (38) states that if humanity is based on an ethical system that includes human sociability, then the transgression of attachment bonds evokes shame. Kaufman suggests that shame is triggered by anything that breaks the "interpersonal bridge," such as betrayal, treachery or abandonment. Other examples are ridicule, contempt, humilation and cruelty. Intrapsychically, the experience of hurt, anger, failure and helplessness evoke shame. During sexual violation, all of the above occur when the most vulnerable, private aspects of a woman, her self, her body and her sexuality are exposed. The painful shame"experienced traumatizes her sense of self and her femininity, gender identity and sexuality. Self-blame frequently follows a violent act; it is viewed as a defense against shame (38) and self-criticism which compounds low self-esteem. Adding to the victim's self-blame are the perceptions that she used poor judgement in the case of stranger or acquaintance rape and ignored anticipatory fears. The need for society to blame the victim in order to retain its own illusion of invulnerability also contibutes to self blame. If a vestige of self-blame remains, the victim of sexual assault may feel that she can regain the illusion of invulnerability by changing her behaviour, and by being more careful or more assertive. For others, self-blame is compounded by "changing the meaning of abuse." For these women, remaining in the abusive situation seems reasonable. Shame and guilt are often confused, and both have their origin in lost bonds of connection and affection. Lewis (38) feels that shame operates beneath guilt: "shame is about the self; guilt is about action." Shame can be experienced as humiliation, mortification, embarrassment, self-consciousness, chagrin, shyness, and feelings of ridiculousness. Guilt may be felt as responsibility, obligation, fault and blame. Changing the Meaning of Abuse In changing the meaning of the abuse suffered, the victim gives up her sense of reality that the violation occurred, and accepts the assailant's untruths that the violation did not occur, that it was the victim's fault, and that it was for her good. For the victim, this process is lifesaving and prevents abandonment. Reiker and Carmen (26), in their classic paper, discuss three defensive strategies: 1. denying the abuse; 2. altering their affective response to the abuse; and 3. changing the meaning of the abuse. For women who have suffered sexual abuse, the process of denial begins with a lack ofconfirmation

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of the abuse by the victim's family and society, which adds to the victim's confusion. She must adjust to a world in which abusive behaviour is accepted and her truth, not accepted. Miller (40) states that the alternative to remaining alone and isolated with the truth is to lose all knowledge of it. The confusion is more intense for girls and women who have been trained since childhood to be obedient and suppress their own feelings in order to maintain the cohesion of the family. "Do not tell. I will go to jail. It will kill your mother." Accommodation follows, during which the reality of the victimization is altered. For example, "This is not happening to me" becomes "This is happening to me, but it is not important," to "This did not happen to me." The victim alters her thoughts, feelings, and behaviour about the victimization (transformation) to meet the expectations of her family and society. Information about the abuse is excluded from the victim's consciousness. Through repression, dissociation and denial, the abuse is denied and the self is damaged. Bowlby (41) has written about the remarkable ability of children to conform to parental wishes by excluding, redefining or distorting events to which the child has been a witness. Altered affective responses to the abuse occurs when the abuser both hurts and helps the victim. Ambivalence may be intolerable for the victim of sexual abuse who depends on the abuser for comfort, protection and survival. Through distortion and suppression, the abuser is labelled as "good", while the victim labels her self as "bad". Because of this mind-splitting operation, anger is directed at the self. Defensive identification with the aggressor can also occur. The victim may find it difficult to be angry with the abuser and may feel less entitled to seek professional help. When the victim gives up the right to assign her own meaning to the abuse and accepts the family's or society's assertions that the abuse was deserved, the meaning of abuse is changed. The victim may attempt to make sense out of the abusive behaviour and occasionally may view the abuse as an attempt at discipline. This view has been reported by Amsterdam and colleagues (42), who found that adolescents who were severely injured by their parents felt that they deserved the punishment. Very young children simply assume that any punishment means they have been bad (43,44). Adult survivors of sexual abuse often have no memories of their abuse, and therefore do not find a direct connection between their symptoms and the trauma. They may experience somatic sensations such as body memories; affect states, including fears, anxiety, irritability; behavioural reenactments, which may include prostitution or acting out; and dissociative states, such as periods of amnesia, or multiple personality disorder. Abused wives and victims of date rape also distort the meaning of the abuse. The abuse they suffered is in some ways similar to that experienced by survivors of child sexual abuse; they were sexually violated by a person in a position of trust - husband, acquaintance, date or parent. Denial of the abuse may occur when the abusing partner and/or date refuses to acknowledge the imposed violation. Thoughts and feelings about the reality of the abuse may be altered to assume impersonal motivation such as,"he assaulted me be-

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cause of stress in his life," i.e., stress from family, school, work, alcohol use or mental illness, etc. In time, the abused wife comes to believe that she is at fault. Had she been a "better" wife and supported her partner, he would not have had to abuse her. The victim of date rape may feel that she was at fault, that she said or did the "wrong thing." She may question her ability to judge and trust others, devastating her self-confidence. The victim of assault by a stranger may follow a similar path of disconfirmation and transformation to self-blame, and accepting responsibility for the sexual assault. Although she may feel entitled to be believed, tell others, seek help, and report the assault to the police (45), shame frequently prevents her from doing so. The long term sequelae are depression, anxiety, fears and phobias, impaired sexual adjustment and impaired quality of life such as not feeling entitled to that which life has to offer (for example, education). Self-esteem, self-worth and self-confidence are shattered.

Summary In summary, for women who are victims of sexual violation, damage is caused to the self, self-esteem, and self-value through the experience of intense fear, helplessness, loss of one's assumptive world, activation of negative self-schema, post-traumatic stress symptoms, shame (for some), the meaning of abuse is changed, set within particular facets of feminine development. Victims experience low self-esteem, self-hatred, affective instability, poor control of aggressive impulses, disturbed interpersonal relationships compounded by an inability to trust and difficulty protecting themselves. The psychological strategies that once ensured survival (denial, dissociation, identification with the aggressor, suppression, repression and distortion) may now form the core of the survivor's psychological illness (26). A trauma spectrum of disorders may result (45), which may be conceptualized as adaptation to abuse. The sexual violation extends from chronic severe sexual abuse to more circumscribed violation and may contribute to the etiology of multiple personality disorder, borderline personality disorder, post-traumatic stress disorder, some forms of somatoform disorders, panic and anxiety disorders. Depression, phobias, difficulty in intimacy, sexual adjustment, and social adjustment are sequelae yet to be investigated. Acknowledgement The author wishes to thank Dr. Edna Magder for her helpful comments.

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4. Carmen EH, Reiker R, Mills T. Victims of violence and psychiatric illness. Am J Psychiatry 1984; 3: 378-383. 5. Jacobson A, Richardson B. Assault experiences of 100 psychiatric in-patients: evidence of the need for routine inquiry. Am J Psychiatry 1987; 7: 908-913. 6. Bryer JB, Bernadette AW, Miller JB, et al. Childhood sexual and physical abuse as factor in adult psychiatric illness. Am J Psychiatry 1987; 144: 1426-1430. 7. Firsten T. An exploration of the role of physical and sexual abuse for psychiatric institutionalized women. Toronto ON: Ontario Women's Directorate, 1990. 8. Putnam FW, Gurott JJ, Silberman EK. The clinical phenomenology of multiple personality disorder: review of 100 recent cases. J Clin Psychiatry 1987; 47: 285-293. 9. Morrison J. Childhood sexual histories of women with somatization disorder: review of 100 recent cases. J Clin' Psychiatry 1987; 47: 285-293. 10. Herman JL, Perry JC, van der Kolk BA. Childhood trauma in borderline personality disorder. Am J Psychiatry 1989; 146: 490-495. 11. Surrey J, Swett C, Michaels A, et al. Reported history of physical and sexual abuse and severity of symptomatology in women psychiatric out-patients. Am J Orthopsychiatry 1990; 60: 412-417. 12. Root MPP. Treatment failures: the role of sexual victimization in women's addictive behaviors. Am J Orthopsychiatry 1989; 59: 542-549. 13. Groeneveld J, Shain M. Drug use among victims of physical and sexual abuse: a preliminary report. Addiction Research Foundation July, 1989. 14. James J, Meyerding J. Early sexual experience and prostitution. Am J Psychiatry 1977; 134: 1381-1385. 15. Silbert MH, Pines AM. Sexual abuse as an antecedent to prostitution. Child Abuse Negl 1981; 5: 407-411. 16. Gelinas D. The persisting negative effects of incest. Psychiatry 1983; 46: 312-332. 17. Kohut H. The restoration of the self. New York: International Universities Press, 1977: 311. 18. Burgess AW, Holmstrom LL. Rape: victims of crisis. Bowie MA: Robert J. Brody Co., 1974. 19. Hilberman E. Overview: the "wife beater's wife" reconsidered. Am J Psychiatry 1980; 137: 1336-1347. 20. Symonds N. The rape victim: psychological patterns of response. Am J Psychoanall976; 36: 27-34. 21. Herman JL. Father-daughter incest. Cambridge MA: Harvard University Press, 1981. 22. Miller JB. Toward a new psychology of women, second edition, Boston MA: Beacon Press, 1986. 23. Kaufman G. Shame: the power of caring, revised edition. Boston MA: Schenkman, 1985. 24. Bibring E. The mechanism of depression. In: Greenacre P, ed. Affective disorders. New York: Intemational Universities Press, 1953: 13-48. 25. Ellis EM. A review of empirical rape research: victim reactions and response to treatment. Clin Psychol Rev 1983; 3: 473-490. 26. Rieker PP, Carmen EH. The victim-to-patient process: the disconfirmation and transformation of abuse. Am J Orthopsychiatry 1986; 56: 360-370. 27. Notman MT. Depression in women: psychoanalytic concepts. Psychiatr Clin North Am 1989; 12: 221-230. 28. Horowitz MJ. Stress response syndromes, second edition. New York: Jason Aronson Inc., 1986. 29. Krystal H. Psychoanalytic views on human emotional damages. In: van der Kolk BA, ed. Post-traumatic stress disorder: psy-

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Resume Cet article decrit le processus par lequella victime devient patient, ce qui reflete la relation entre la sante mentale et les desordres psychiatriques, surtout chez les femmes qui sont victimes d' abus sexuel ou de violence conjugale. Une connaissance des processus psychologiques et des symptomes facilite le diagnostic et modifie le traitement et la recuperation des victimes de violence.

Victims of violence: aspects of the "victim-to-patient" process in women.

This paper is an overview of aspects of the victim-to-patient process which reflects the interrelationship between mental health and mental disorder, ...
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