According to the literature, the long-term effects of childhood sexual abuse include depression, anxiety, suicidality, revictimization, substance abuse and other addictions, low self-esteem, and difficulties with interpersonal relationships (1,2,3,4). About half of all men and two-thirds of all women in drug treatment centers report past sexual or physical abuse (1). Herman (5) outlined three stages in recovery from trauma: stabilization and safety, remembrance and mourning, and reconnection. According to Herman, getting clean and sober is associated with the first stage, although movement through the stages is not necessarily linear. The patient described in this article needed an integrated treatment approach that aimed to help her understand the interrelationship between substance abuse and traumatization (6).
Ms. H is a 37-year-old married woman who was sexually abused between the ages of ten and 13 years by an older brother. She developed severe adult-onset posttraumatic stress disorder (PTSD) as a result of an altercation with her boss at the age of 33. Until the onset of PTSD, Ms. H had lived a restricted lifestyle. She had self-medicated with alcohol and over-the-counter drugs to avoid confrontation with feelings and memories of her past sexual abuse, to keep depressive affect and anxiety under control, and to maintain her ability to function in her marriage, especially to have sex. She had sought extensive medical attention for many somatic complaints but had not used mental health or drug treatment services.
For many months after her breakdown, Ms. H felt that she was living in a "bad dream." She was overwhelmed by memories and feelings from her childhood sexual abuse and felt victimized by them. She felt desperate, ashamed, helpless, and abandoned by everyone. She "just wanted to die" and was sure that she would die, just as she had felt during her sexual abuse at age ten. Ms. H tried to gain control over her pain by using extremely high amounts of nonprescription sleeping pills and alcohol. She needed repeated emergency hospitalizations because of seemingly psychotic symptoms—visual and auditory hallucinations, loss of bladder control, and gait paralysis, which turned out to be the result of toxic drug levels.
For the first couple of years of treatment, Ms. H was obsessed with getting alcohol and pills. Her cravings, tolerance, and withdrawal symptoms led to the ever-increasing use and theft of alcohol and sedatives. Her substance abuse, which started as a coping mechanism for latent and then acute PTSD and functioned as an expression of her suicidality, became a full-blown addiction that satisfied DSM-IV criteria for alcohol and sedative dependence with physiological dependence.
Ms. H's intense hopelessness and suicidality and her out-of-control substance abuse induced hopelessness, despair, and anger among her clinicians. Two psychiatrists, one male and one female, whom Ms. H was seeing in conjunction with me, stopped seeing Ms. H after she overdosed repeatedly on the medications they had prescribed. Ms. H was on the no-admit list of two psychiatric hospitals. She felt rejected, but she also expected rejection and believed that she deserved it—it had been the story of her life.
As her second outpatient therapist, on several occasions I felt that my relationship with Ms. H was on the brink of collapse. I felt hopeless after she made yet another serious suicide attempt, when I had thought she would feel enough of an alliance to call me beforehand. It was difficult to keep believing in myself when Ms. H was considered untreatable by several of my colleagues. At times I felt intense anger toward Ms. H, and it took a lot of effort to regain a nonjudgmental attitude. I came to understand my countertransference anger as an attempt to ward off my own feelings of shame and hopelessness about this treatment.
Addressing self-destructive behavior
For the first two years, I focused on building a positive relationship with Ms. H and addressed her denial of her suicidality and out-of-control substance abuse. I realized that Ms. H was convinced that no one really cared and that no one could understand her pain. She had a need to act out her despair and pain over and over again so that I could "really understand." I reassured her that her despair, hopelessness, and pain were understandable responses to her past and present traumatization and that I was not going to reject her for "being bad"—that is, for feeling hopeless or failing to reach the goals of treatment contracts. As I was able to bear these feelings and not get drawn into them—at least not for a long period—Ms. H gradually became able to bear them herself.
We came to understand that the denial, despair, shame, and helplessness that Ms. H felt in the context of her substance abuse were emotions that she felt at the time of her sexual abuse. Once she had gained the perspective that these feelings originated in the past, Ms. H began to be motivated to actively work on her substance abuse and her suicidal feelings. She began to attend a hospital outpatient dual diagnosis group that reinforced the idea that her two illnesses were interrelated. To attend Alcoholics Anonymous or Narcotics Anonymous meetings would have been counterindicated at that point (7).
Connection between sexual abuse and substance abuse
Ms. H's attempts to stop the sexual abuse by her brother had been futile. Now that she had come to a point at which she wanted to take control of her substance abuse and her suicidal feelings, she realized that she again felt helpless and hopeless. She felt that her out-of-control affect and her substance abuse had become her perpetrators. She now felt great shame about being unable to keep herself safe and stop the substance abuse. Her shame in turn fueled greater substance abuse and made her want to hide its full extent.
As Ms. H told me more of the details of the sexual abuse, she became aware that she felt that the substance abuse was a "dirty secret" that she had to hide from everybody, including me at times. I helped her see that the trauma was now being played out in her own mind. She had identified with the perpetrator and now, just as her brother had done when he sexually abused her, she abused herself—with substances. Her frequent rejection of help functioned paradoxically to maintain her traumatic belief—her sense that "nobody is really there to help me." It gradually dawned on Ms. H that she was traumatizing herself now with the thought that she was "bad" and deserved to die.
Gaining self-empathy, trust, and sobriety
Because of her history, Ms. H expected disappointment, betrayal, and abandonment from her caregivers. Consequently, she acted to bring about rejection but at the same time secretly hoped for a different outcome. She had a remarkable skill for drawing me into her denial of self-abuse. I had to be hypervigilant not to miss signs of renewed substance abuse. If I did not detect it somehow, Ms. H felt abandoned by me.
Slowly Ms. H became able to face the pain of her self-abuse. She slowly began to believe that she was "good enough" and did not deserve to be treated by herself in an abusive manner. My observation that she was abusing herself had to be conveyed to her with the utmost tact and at a time when she was able to recognize it herself. Only then did she not interpret the situation as me blaming her—as another victimization of her—but as my attempt to help her gain control over this harmful behavior.
By the end of Ms. H's third year of treatment, her self-destructive impulses were much less intense. She began to honor our contracts to not drink or take drugs. She struggled with her cravings but could now talk about them instead of acting on them. Gradually, with many relapses, she was able to resist them. She began to grieve the loss of her coping mechanism and started to feel sad for the traumatized child in her. She emerged from this depression as a much stronger person who valued herself again and had regained trust in other people's caring for her.
Ms. H returned to work with greater confidence and initiative than before. In her relationships with her husband and her friends she was able to feel a deeper mutuality and a more genuine love, which is also a defining characteristic of Herman's (5) third stage in recovery from trauma—that is, reconnection.
Dissociation of traumatic affect and memories are the hallmark of trauma, usually accompanied by further defensive efforts to keep dissociation in place so that the person can continue to function. Ms. H had had a withdrawn lifestyle and used substances to keep her trauma under cover.
The therapeutic process of recovery involved a gradual undoing of the dissociated feelings and memories in the context of an increasingly safe therapeutic relationship. At the beginning of her treatment, Ms. H was overwhelmed by the trauma of substance dependence and the traumatic feelings from her childhood sexual abuse—helplessness, denial, fear, shame, and guilt. With the help of her therapist, she slowly became conscious of her feelings and able to experience them, which caused her to feel worse during the first couple of years. However, gradually, as her feelings and memories were no longer dissociated, she gained more and more control over them.
Simultaneously, with the help and support of her therapist, who was able to put her feelings in perspective for her, Ms. H understood that her substance abuse and feelings of helplessness, shame, and guilt were the result of her original unresolved traumatic experience and not evidence that she was a bad, weak, or helpless person. A reduction in shame and guilt brings about an increase in self-esteem. Ms. H started to feel, for the first time in her life, that she deserved to recover. With greater confidence that her therapist believed in her and was going to survive with her the inevitable traumatic enactments, she became able to identify with the therapist's therapeutic optimism.
Dr. Teusch is a psychoanalyst with the Psychoanalytic Society and Institute and an instructor in psychology with the department of psychiatry of Boston University School of Medicine. Send correspondence to her at 129 Mt. Auburn Street, Cambridge, Massachusetts 02138.