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DVD - Interventions for Cutters Substituting Self Control for Self Mutilation  
Cutters continuing education social worker CEUs

Section 22
Is Cutting Always a Sign of PTSD?

CEU Question 22 | CEU Test | Table of Contents | Self-Mutilation
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

Most recently, as the mental health system and the public have become aware of the prevalence of childhood physical and sexual abuse and neglect, TRS (Trauma Reenactment Syndrome) women have been given the label of Post-Traumatic Stress Disorder (PTSD). Originally developed as a diagnosis for war veterans and survivors of natural disasters and violent crimes, PTSD describes a cluster of responses to traumatic events. Using this diagnosis implies that the problem does not originate within the individual’s personality, but rather that an external event has created lasting but not incurable symptoms or reactions. The PTSD diagnosis is now extended to survivors of child abuse, as well as to women who have been battered or raped.
In Trauma and Recovery (1992), Judith Herman describes trauma in this way:

“Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life. Unlike commonplace misfortunes, traumatic events generally involve threats to life or bodily integrity, or a close personal encounter with violence or death. They confront human beings with the extremities of helplessness and terror and evoke the responses of catastrophe.” (p33)

The TRS woman’s experience of both childhood trauma and the current trauma of self-injuring is accurately represented in this description. Herman and others who specialize in the study and treatment of trauma have provided a valuable map for understanding the suffering of women who were previously misdiagnosed and whose treatment suffered as a consequence.

The PTSD diagnosis identifies the genesis of the damage to the patient rather than describing the patient. This is an important distinction. When a TRS client is given a label such as borderline or alcoholic, a set of expectations is established in the minds of everyone who interacts with her. Especially with a label such as borderline or chronic depression, she may not be given the opportunity to be seen as a whole person or a person who is capable of change. But when a client is given the diagnosis of PTSD, she is seen as having undergone a severe trauma, and her symptoms or problems in living are recognized as having resulted from trauma. Compare “I am a bulimic” or “she is a borderline” with “I am recovering from PTSD” or “she is in therapy because of PTSD.” Clearly there is a difference in how the whole person is portrayed. PTSD implies that there is more to her than the part that is represented by the trauma history.

Because of this major shift in awareness, not only in the professional world but in the media as well, many women with trauma histories are receiving more useful and empowering treatment than previously. While their particular symptoms may still be of concern, they are also offered the opportunity to explore their traumatic childhoods through psychotherapy and various kinds of healing groups. The PTSD-diagnosed woman works toward recovery by concentrating on the trauma itself: remembering, reliving, and then, when the trauma has been ventilated, reworking her self-image and her relationships. The recognition of PTSD as a major diagnosis, and its more sympathetic and holistic treatment protocol, represents a giant step toward recovery for TRS women.

Unfortunately, even the PTSD approach to treatment of the TRS woman is likely to be problematic. While the PTSD diagnosis is preferable to Borderline Personality Disorder, for example, it still does not adequately distinguish between those trauma victims who do not harm their bodies and those women who manifest their history of trauma through self-injury. It also does not describe the TRS woman’s complex levels of behaving, thinking, and feeling as they are translated into relationships, especially as those relationships pertain to treatment. Furthermore, the scope of PTSD is too limited. The types of trauma that point to a PTSD diagnosis are generally understood to include childhood sexual abuse, adult rape, battle trauma, and natural disasters. This definition does not include such childhood traumas as physical abuse, severe neglect, or invasive caretaking of the more benignly motivated sort. Because clients with these types of traumas are omitted from the PTSD population, many women who hurt themselves are still left without an appropriate diagnosis.

Another increasingly problematic aspect of the PTSD label is that it tends to be overused and too generalized, somewhat like the term “codependence.” The degrees of childhood trauma are difficult to measure and thus many different experiences may be covered by the catchall term PTSD. References to adult experiences of trauma may be even more careless and thus confusing or disturbing. For example, the rape victim has a very different experience of. her own security and personal power in the world than does the exhausted graduate student who says she is experiencing “trauma” when she gets negative feedback on an important term paper.

Although the PTSD diagnosis is a step forward, it is still necessary to distinguish between all survivors of childhood trauma and that subgroup among them who are TRS women. The complexity of what has happened to create the pattern of self-destructive behavior is not adequately contained in most diagnoses or treatments of PTSD. In treatment, for instance, simply disclosing the details of the trauma or even reexperiencing it through flashbacks, supportive therapy, or group sharing is not enough. June, for example, could produce her recitation of childhood neglect memories, religiously attend twelve-step meetings, and successfully abstain from drinking. Yet she was far from feeling whole or capable of achieving success in interpersonal interactions.

When TRS women disclose their trauma histories, they are often bewildered that they do not feel substantially healthier. It is maddening for many of them to recognize that the process of disclosure may actually exacerbate their symptoms, as well as make them feel more alone and more out of control. This creates a cycle of feeling betrayed by those who were supposedly going to rescue or stand by them. In addition, they feel an escalation of self-blame because they assume it must be their fault that telling about the abuse did not lead to a healthier, more open experience of living.

One aspect of PTSD treatment that can increase the TRS woman’s loneliness and rage about feeling different is the tendency to frame the story of childhood abuse in polarized terms. The abuser, referred to as “the offender” or “the perpetrator,” is cast as the villain of the story. He (or she, in cases of maternal incest) is portrayed as all bad, often as evil. The nonprotecting mother is also cast in a bad role, blamed not for the abuse per se but for failing to be an adequate, nurturing mother. Then there is the child herself, the victim, blameless and powerless. Discussions in the popular press and on talk shows generally take this oversimplified position, and groups for survivors often adopt this victim/villain frame for telling stories. Even in individual psychotherapy, the therapist may coerce this point of view as the only correct description.

When the survivor is coached to tell or understand her story this way, she feels shaken. Because she has internalized these complex primary relationships, she is filled with confusion and shame. If she completely renounces her love or loyalty in relation to either the abusive or nonprotecting parent, she may feel as if she is renouncing and even hating a part of herself. If there is no space for her to question and explore this web of complexity, she shuts down, or blames herself, or increases her experience of fragmentation.

Responding to the distress of feeling different, unseen, and misunderstood, the TRS woman often escalates the frequency or seriousness of her symptom. She is blocked from integrating her understanding of the symptom with her trauma history because those who focus on the symptom may want her to stop probing and hurting herself by exploring her childhood; this treatment approach is telling her to stop thinking about the past and to learn to contain her dysfunctional behavior. In short, the PTSD treatment approach urges her to remember the trauma, but not to rework it in a way that might lead to lasting recovery. It is no wonder that many TRS women become increasingly hopeless about themselves, despite the possibilities for healing offered by the advent of the PTSD treatment movement.

Approaches to trauma treatment continue to become more varied and more sophisticated. Judith Herman (1992) has introduced a new diagnosis, complex PTSD, which makes important distinctions between adult-onset or one-time-occurrence trauma and trauma such as child sexual abuse that is sustained over a prolonged period, is perpetrated by someone in a caretaker role in the child’s life, and tends to be more damaging. This kind of differentiation allows for a broader scope of treatment requirements. Many therapists and researchers continue to explore the complex responses of the survivor to her childhood trauma experiences; Bessel van der Kolk (1987), Judith Herman (1992), Lisa McCann and Laurie Pearlman (1990), Shanti Shapiro and George Dominiak (1992), Ronnie Janoff-Bulman (1992), and Denise Gelinas (1993) are all experts in the trauma treatment field who recognize that the therapy needs of the child abuse survivor are far more complex than simply recovering and reworking the trauma memories. Many theorists and practitioners of more general psychotherapy also recognize that there are more complex ways to work with trauma survivors than the oversimplified “remembering/catharsis/confronting/rebuilding” formula for PTSD treatment. Still, there is an absence of focus on the specific needs of the TRS woman in the literature to date.
- Miller, Dusty; Women who Hurt Themselves: A Book of Hope and Understanding; Basic Books: Massachusetts; 1994

Patient Self-Management Support Programs: An Evaluation

- Pearson, Marjorie, Patient Self-Management Support Programs: An Evaluation, RAND Health Santa Monica, CA, AHRQ Publication No. 08-0011 November 2007

Personal Reflection Exercise #8
The preceding section contained information about the connection between PTSD and TRS. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 22
According to the author, what is meant by “complex PTSD”? Record the letter of the correct answer the CEU Test.

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