Aphrodite Matsakis, Ph.D.
Licensed Counseling Psychologist








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GROWING STRONGER #6
The Many Types of Guilt

Aphrodite Matsakis, Ph.D.

 

Guilt matters. Guilt must always matter.

Unless guilt matters the whole world is

Meaningless

Archibald Mac Leish 1972

What is Guilt? Guilt is an English word which originally meant debt. The New American Dictionary (1996) defines guilt as the “fact or state of having committed an offense or crime” or a “conscious violation of moral or penal law.” Guilt is a very uncomfortable feeling which stems from doing something (or thinking about doing something) which goes against your personal moral standards. It also involves the fear that because you did, or thought about doing, something unacceptable, that you will be punished, rejected, or disapproved of.

In Freud's view, guilt was pain generated by the superego or conscience in order to change a person's behavior. One of the best definitions of guilt is offered by psychologist Dr. E. Kubany who defines guilt as a negative feeling state which is triggered by the belief that one should have thought, felt, or acted differently.

Is Guilt Old-Fashioned ? As stated in the previous issue Guilt #1 , pop psychology

Pop psychology would have us believe that feeling guilty is old fashioned, a relic from the past, and that by adopting the proper attitude, all guilt feelings can be made to easily disappear. This belief makes some people feel guilty for feeling guilty. In my experience as a therapist, as in my own life, I've found that, old-fashioned or not, guilt troubles many people and deeply so. Furthermore, guilt is often an underlying cause of procrastination, indecision, depression, anxiety, indecision, overeating, alcoholism, drug and sex addictions, and self-defeating behaviors, such as turning down job opportunities, sabotaging relationships, or cheating oneself in other ways.

Guilt Series: This newsletter is #2 in a fifteen part series on guilt. In Growing Stronger, Guile #1, the difference between rational and irrational guilt was explained. Rational guilt refers to actions, thoughts, and feelings over which you had some control; irrational guilt, to situations over which you had little control. The first step in dealing with guilt is to break it down into the various types of guilt. In this issue, we will look at infantile guilt, guilt from failing to meet social expectations, shadow guilt, religious guilt, true guilt (vs false guilt) and guilt from failing to meet social expectations. These kinds of guilt overlap, but it is still useful to try to divide up guilt into different categories because otherwise our guilt feelings will be overwhelming, and we will feel crushed by them, or we will feel overwhelmed and run from them.

INFANTILE GUILT

“All upbringing is a cultivation of the sense of guilt on an intensive scale,” writes Tournier ( 1977, 10 ). According to Freud (1996), guilt begins in our childhood when as infants and young children we are completely dependent on our parents and other adults for our well-being. Since our survival depends on pleasing our caretakers, when they scold or become angry with us, we fear that we will be abandoned or neglected. Along with that fundamental fear, comes guilt at not having pleased the parent or caretaker.

Freud used the term infantile guilt to describe guilt you felt as a child when you were reprimanded or rejected by your parents or other caretakers for not pleasing them. This type of guilt motivated you to change your behavior in order to avoid parental scolding or neglect. Through direct teaching as well as parental admonitions, you probably learned the morale and rules of your household and society. In Freudian terms, you internalized the parent's or caretaker's value system and expectations and automatically felt guilty when you violated parental or societal norms. Even when your parents or caretakers weren't around to scold you, you probably scolded yourself for disobeying their rules. For example studies of two year olds have shown that even when their mothers were not around, they called themselves “naughty” and “bad” for having violated a household rule (Aronfreed et. al. 1971 ).

Freud coined the term superego to refer to internalized parental and societal expectations and morals. He theorized that if people developed a healthy superego, as they became older, they would not require their parents or other adults to make them feel guilty for violating a family or societal rule or moral. Their superego would remind them of their transgressions and they could make themselves feel guilty all by ourselves.

Freud further postulated that as people grew older they could transfer their infantile guilt from their parents and caretakers to other authority figures, such as teachers, clergy persons, work supervisors or superiors, political figures or others with religious, political, economical, or vocational status or power. Hence even a sixty-year old man could feel guilty about not meeting the expectations of someone in an authority position, for example, his work supervisor. Psychologically, the man feels as if his supervisor has the power not only to harm his professional standing, but to obliterate him. This fear not only of being scolded or shamed in pubic by an authority figure for not meeting a certain standard but of being annihilated by that person stems back to infancy and childhood. At that time being judged as deficient in some way could have lead to being rejected and neglected, which could have lead to death itself. On another psychological level, parental, caretaker, or teacher rejection and condemnation can severely stunt or damage a child's self-esteem, since children rarely have sources of validation other than the adults who take care of them.

Infantile guilt involves fear of losing the esteem and love of other people (Tournier 1977, 89) and evokes a fear of physically dying or being psychologically obliterated as the result of displeasing others. An adult whose life is organized around avoiding the criticism of others, especially authority figures, can be seen as suffering from infantile guilt. In more popular terms, infantile guilt can be seen as “people-pleasing,” which refers to putting aside one's own needs and desires in order to give precedence to the needs and desires of others.

When infantile guilt, or fear of condemnation from others, guides people's lives, they may have difficulty recognizing their own needs or talents and discovering their own convictions. On the other hand, children who fail to develop a healthy superego may need constant supervision in order not to be destructive to themselves or others and can grow up to become criminals, socio-paths, and other menaces to society.

Infantile guilt can compound survivor guilt in instances where an individual's failure to obey or please an authority figure resulted in the death or injury of another. For example, Tyrone was raised to believe that children were supposed to obey their parents. In the military, he learned to obey commanding officers. However in one instance, Tyrone balked when his commanding officer ordered him to fire at a group of supposed enemy soldiers in the distance. Based on reliable sources, including information from other soldiers, Tyrone thought the soldiers were Americans not the enemy.

Tyrone refused to fire, only to discover the commanding officer had been right: the soldiers in the distance were indeed armed enemy troops. During the resulting firefight, some of Tyrone's comrades were killed. Tyrone's guilt for having stayed alive was compounded by his infantile guilt at disobeying an authority figure, his commanding officer.

GUILT DERIVED FROM FAILURE TO MEET PARENTAL EXPECTATIONS

Infantile guilt provides the basis for two other types of guilt, guilt at failing to meet specific parental expectations and guilt at failing to meet societal expectations.

As an adult, you may experience guilt feelings just because you fail to please an authority figure or a person who is emotionally or otherwise important to you (infantile guilt). But you might also feel guilty for not living up to the specific expectations placed upon us by your parents or caretakers. Hence if your father was a meticulous gardener and instilled in you the value of maintaining a garden of the highest quality, as an adult, you might feel guilty, when you allow the weeds to take over your garden. Somewhere in the back of your mind your father's voice (your superego) reminds you that you have failed to complete your gardening duties.

In some cases survivor guilt can be intensified by guilt for not having lived up to certain parental dictums or expectations. For example, Mr. Chan brought his son a motorcycle for his 21st birthday. Two weeks later, his son was in a motorcycle accident that lead to nine months of hospitalization and several surgeries. Mr. Chan blames himself for his son's pain because he bought his son the motorcycle in the first place.

However, Mr. Chan is also experiencing some infantile guilt because in purchasing his child an expensive gift like a motorcycle, he violated two of his father's admonitions. The first admonition was against “spoiling children” by not having them earn the money to purchase their own clothes and luxuries. The second was against spending money for luxury items under almost any circumstances. Mr. Chan's father firmly believed that every extra penny should be saved for the future and in his own life, he barely spent money on anything except necessities.

Everytime Mr. Chan went to see his son at the hospital, he could hear his father's voice saying, “Spending money on fancy cars and toys is foolishness. See, I told you so. I warned you that it was wrong to spend money on expensive items and luxuries. If you had saved your money for the future, like I taught you to do, this would have never happened.”

Camry, a military nurse, suffers from double guilt also. She was on the front lines nursing a wounded soldier when the enemy attacked again. A speeding bullet grazed her face and killed a soldier next to her. She then used the soldier's corpse as a shield against the continued fire. To this day, decades later, she feels she should have died with the soldier ( a form of survivor guilt).

But Camry also suffers from guilt for violating her father's repeated admonitions about respecting the dead. Her father had been a soldier during WW2. He had served under a general who insisted that his troops respect not only their own dead, but enemy dead. Soldiers under this general were harshy punished if they mutilated the bodies of the dead. Camry's father had instilled in all his children the value of consecrating the remains of the dead. As a result, Camry feels as if she betrayed her father and all that he stood for, when she used the corpse for protection.

Self-Assessment for Infantile Guilt and Guilt Stemming from Failure to Meet Parental Expectations

The purpose of this writing exercise is to help you bring out into the open the kinds of moral and other messages you were given during your formative years from the people who were responsible for your well-being and held your emotional and physical health in their hands. These persons may have been parents or other caretakers, and they could have included grandparents, aunts and uncles, and other significant persons who were directly involved in taking care of you and trying to teach you “right from wrong.”

Often people are not aware of why they are feeling guilty about a certain matter because they have not had the opportunity to examine early messages about how they “should” be or act or how “good” people “should be or act. This exercise will help you put into words the kind of values and actions you were expected to embody as a child. Later on, when you will be asked to describe the situation which caused you to experience survivor guilt, you will refer back to your responses to this exercise in order to see how your early leanings about guilt interact with your survivor guilt.

On a fresh piece of paper in your journal, write the heading, “Early Shoulds Messages.” Think of all the “shoulds” you learned about how you ought to be during the first twelve years of your life. On your paper, draw three columns. In the first column, list as many shoulds as you can remember. Include those shoulds you heard from your parents, neighbors, friends, family members, teachers, religious instructors, and the media.

In the second column, list the source of the should -- where you learned it or who taught it to you. In the third column, describe what happened to you when you did not live up to this particular should. For example, were you verbally chastised, rejected, hit or made to feel ashamed? Were you threatened with abandonment or some other punishment?

Look over your list of “shoulds” and notice if any of the “shoulds” contradict one another. For example, suppose your mother told you should stand up for yourself and fight with bullies in school, but your grandfather told you that fighting was a sin. Or perhaps one of your caretakers gave you a double message. For instance, suppose your grandfather told you that fighting was a sin but that letting oneself get beat up was a sign of being a “sissy” and a disgrace to the family.

On a fresh piece of paper, entitled, “Shoulds Contradictions,” once again draw three columns. In the first column, list as many discrepancies you found between what the various people who were important in your early life taught you about how to behave, think, or feel. In the second column, describe how you coped with the contradictory “shoulds” you heard growing up. In the third column, describe what happened to you as the result of how you coped with the contradictory shoulds.

For example, if your mother taught you to fight bullies and your grandfather taught you to turn the other cheek, perhaps you lied to your grandfather when you fought back or perhaps you lied to your mother when you walked away from fights. Another possibility is that you didn't tell either of them how you responded to bullies and tried to carry the burden of being threatened at school all by yourself. Did you need to lie, steal, pretend, run-away, hurt yourself, or hurt animals or others as a result of the contradictory messages? If so, please describe in detail.

It is important to identify the early ways you responded to such pressures in order to see if you are still using these coping methods to deal with guilt you are experiencing today, for example, survivor guilt.

GUILT DERIVED FROM FAILURE TO MEET SOCIETAL EXPECTATIONS

Your parents and caretakers aren't the only source of the demands to meet certain standards. Society places pressures on people also. Regardless of how independent anyone thinks he or she might be, almost anyone can be made to feel guilty for not living up to cultural expectations their culture places upon them.

For example, many women in Western culture feel guilty about not being slender enough, even if they grew up in homes that paid no particular attention to female body size. Because the culture tends to measure the worth of a man by the size of his bankaccount, men who are unemployed or who are burdened with financial hardships tend to experience guilt for not being financially successful. Even men who grew up in homes which valued spiritual matters over the acquisition of material goods can experience some level of guilt for not living up to the cultural expectation that, as men, they should have a job, a home, a car, and plenty of money in the bank.

Parents or caretakers can make people feel guilty for not living up to societal expectations, but their friends and associates can also play a role. “In everyday life ...we are continually soaked in this unhealthy atmosphere of ... criticism” (Tournier 1977, 15). Sometimes the criticism is “keen and outspoken, sometimes silent” but it is “not less painful for being so. We are all sensitive to it, even if we conceal the fact” (Tournier 1977, 13).

Guilt derived from failing to meet societal expectations complicates survivor guilt. For example, Maureen is overweight and feels guilty about not meeting societal expectations that she be slender. When her daughter was sexually abused by her husband's brother, Maureen experienced survivor guilt in that she wished she could have been abused in her daughter's place. “She was a young girl who had everything to look forward too. I'm an overweight middle aged woman. If someone had to be raped, it should have been me,” she sobbed in session.

Maureen's survivor guilt was exacerbated by her guilt about her weight. Even though her eating habits and body size had nothing to do with her daughter's molestation, in her mind, they did. Maureen confused the two guilts-- her guilt over her appearance and her survival guilt. She illogically concluded that her overeating and overweight somehow caused the rape of her daughter. She felt that if she had been thinner she might have married a different man, one who didn't have a brother who was a child molester.

Maureen's therapist pointed out that while it was true Maureen might have married a different man if she had been thinner, this would not have prevented her daughter from getting hurt. For example, Maureen might have married a man who was a child abuser himself or who had a nephew or father or friend who was a pedophile. Only if Maureen had witnessed her daughter being abused or in some other way had been aware that her daughter was being hurt and, instead of helping her daughter, chose to go to go food shopping or on a eating binge, then and only then could her eating problems be related to her daughter's rape. Furthermore, Maureen needed to remember that it was not she or her overeating, but a pedophile, who had violated her daughter.

Self-Assessment for Guilt from Failing to Meet Societal Expectations .

What do you feel society expects of you in terms of appearance, intimate relationships, family relationships, financial status, community obligations, or political involvement?

Try to identify at least three expectations in each category. For example, under intimate relationships, one might write: “I feel society expects me to be married and to enjoy spending my leisure time with my spouse. Society expects me to be sexually faithful to my spouse and to make my spouse happy. If my spouse is unhappy and wants to leave me, society says that means that I failed.”

Now review the expectations you have listed for each category and, on a separate page, describe how you feel or what you do when you feel you feel you have failed to meet these expectations.

CHILDHOOD OMNIPOTENT GUILT and SUPERMAN/SUPERWOMAN GUILT

Another form of guilt is childhood omnipotent guilt -- a well-documented tendency of young children to think that the world revolves around them and that they control everything that happens. Young children think that if they wish something it might come true. For example, when children become frustrated with a parent or sibling, they often think or say, I hate you -- I wish you were dead, which is a perfectly normal expression of aggression. But, if for some reason that parent or sibling subsequently becomes ill, dies or leaves the family, the child thinks that he or she caused this person to become ill, die, or leave.

This is called magical thinking, because hating one's parent, sibling, spouse or friend, or even wishing another person dead, does not cause these people harm unless the aggressive wish is acted upon.

No matter how old or how mature we may be, a part of us -- consciously or unconsciously -- may still be engaging in magical thinking or seeing ourselves as omnipotent. When someone we know commits suicide, the child in us may feel that our hostility killed that person because we sometimes harbored hostile feelings toward him or her.

But hating people doesn't kill them or make them sick. Our angry, hateful feelings and wishes in themselves cannot cause the physical death, suicide, illness or injury of another, with one important exception: if you severely or continually maltreated someone, and then that person committed suicide or acquired an illness or injury directly related to your treatment, some of your guilt may be appropriate. If not, some of the guilt you are experiencing may fall into the category of childhood omnipotent guilt.

In adolescence and adulthood, childhood omnipotent guilt can be transformed into a type of guilt called “superman or superwoman” guilt. In order to cope with a traumatic or extremely stressful situation, people can come to believe that have superhuman qualities. The more helpless and powerless people feel in a life or death situation, the greater the need for superhuman powers. One theory (Krystal 1971) is that during traumatic conditions, people tend to revert to childlike thinking, including the tendency towards childhood omnipotent guilt.

Kubany (1994) , Opp and Samon (1989), Parson (1986) and others have found that survivors of traumatic circumstances often experience guilt and feelings of failure for not knowing what no human being could have known and for not having abilities that are beyond human capability. Examples are medical staff who feel guity for not being able to save everyone, parents who feel guilty for not being able to protect their children from all illnesses and harm, soldiers who feel guilty for not having forseen all enemy assaults, and relatives of seriously ill persons who feel guilty for not knowing the outcome of certain medical procedures.

If you suffer from superman/superwoman guilt, then you are telling yourself, “‘I'm in charge of all the variables for lie and death' and “I knew things would happen before they did.'” (Opp and Samson 1989 p. 162).

Self-assessment for Childhood Omnipotent Guilt

1. Have you ever wished or desired the injury, illness, mistreatment or death of a friend or relative? List five instances where you made such wishes.

2. Did harm come to any of the five persons you wished to be harmed?

3. If harm did come to them, explain how your wishing the harm caused it to happen. Assume you are presenting the case to a jury of reasonable adults. What evidence could you present that would indicate that your wishing caused each of these individuals to be injured or die?

4. If you hadn't of wished harm on another, what is the probability that he or she might have come to harm any way or some other time?

5. Have you ever wished for positive things to happen to others? List five examples of times you have wished for others to enjoy life, good health, prosperity, or other forms of well-being or happiness. In which of these instances do you feel your wishing made these positive results occur? If you were presenting a case to a jury of reasonable adults, what evidence could you present that would indicate that a your wishing caused each of these persons to have an improved life?

6. Write three or four sentences about how childhood omnipotent guilt or superwoman/superman guilt has caused you to feel responsible for events by ascribing magical powers to yourself.

RELIGIOUS GUILT

Sin and guilt are the themes of many major religions. Many of us have been taught to feel guilty when we fail to adhere to the tenants of our faith or to expected forms of worship. Furthermore, some faiths, for example, Christianity and Judaism, espouse the notions of original sin and man's inherent guilt. According to Christian beliefs, all people are born evil, and are therefore guilty, unless they are redeemed through the faith.

Religious guilt is frequently present with survivor guilt. For example, it is not uncommon for soldiers to experience guilt about violating the religious code of “thou shalt not kill” by being warriors. Some domestic violence survivors, such as battered women and physically or sexually abused children, are coerced into committing cruel or sadistic acts towards other; into lying, stealing, or committing certain sexual acts (including prostitution); or into killing animals or people, as in cult abuse. People who are victimized in these ways can suffer from severe religious guilt, which is often at the core of their content survivor guilt.

In some cases, persons who have lost a loved one to suicide or homicide attribute the death of this loved one to their having violated a tenant of their faith. For example, Randy still suffers from survivor guilt over the suicide of his daughter some fifteen years ago. However his survivor guilt is compounded by his religious guilt for having an adulterous affair during his marriage. On some level, he feels that the death of his son is divine “payback” for violation of his marriage vows. Another example is Esther, whose teenage son was killed by a mugger. When Esther is honest with herself, she feels the mugging was a form of punishment for leaving the religion of her childhood and converting to another faith.

Another type of religious guilt is almost the exact opposite of the religious guilt described above. This guilt involves rejecting your previous religious and spiritual beliefs and traditions. Hence family members of children who have died as the result of illness, murder or suicide may have stopped believing in their God because their prayers for their child were not answered. People trapped in natural disasters, such as fires or floods, and persons trapped in man-made disasters, such as violent or abusive homes, may abandon their religious beliefs when the God of their understanding does not provide them the help and rescue that they need.

However, there can be guilt in abandoning or rejecting one's former religious or spiritual beliefs, especially if family members or significant others are critical of this change. Hence persons of a particular faith who come to reject the tenants of their faith as the result of a severe trauma or stress may feel guilty about not being able to truly believe what they used to believe or not being able or willing to attend services as they used to.

Exercise: Self-Assessment for Religious Guilt

The purpose of this exercise is to help you identify and understand your religious values. If you are a member of an organized religion, some of these values are available in written form or you may hear them articulated when you attend meetings of your religious group. Some of you may not be a member of an organized religious group, however you may have been raised in a certain religion, and even though you no longer formally adhere to that religion, some of the values may still be important to you or may still influence you. It is often the case that even though certain religious values have been rejected, they become part of the psyche, especially if others who are important to you still adhere to those values.

Some of you may have changed faiths or adopted spiritual values that are not unique to or particularly identified with any religious group. Regardless of the origin of your religious or spiritual values, it is important to be aware of these values because they can form the basis of guilt when you transgress those values.

Open up your journal and on a fresh piece of paper, write the heading “My Religious/Spiritual Values” at the top of the page. Then answer the following questions:

If you belonged to an organized religion as a child, what values were you taught? How did that religion define “right” and “wrong” or “good” and “evil”? You may need several pages to answer this question, or you may simply make a list the values of your religion.

Looking back over what you have written, ask yourself which of those values you truly believed in? All of them, some of them, none of them?

Were you ever scolded or chastised for not obeying one of the rules of the religion or for violating one of the religion's codes? What values or codes did you violate? At the time, how did you feel about being chastised? Did you feel guilty, or not? If you felt guilty, how guilty did you feel? Just a twinge of guilt? A moderate amount of guilt? Profound guilt?

Were you conflicted about your guilt? In other words, did a part of you feel guilty but another part of you feel justified or not guilty at all?

What happened when you felt guilty? Did your mood change? Did your attitude towards yourself or others change? Did your lifestyle or daily habits change? Did you become angrier or more destructive to yourself or others? Did the guilt result in any changes which you today, in retrospect, see as positive?

At the time, were you given means to make amends for your errors, were you punished in some manner, or both? How did you feel about being punished or making amends at the time?

How do you feel about being scolded or punished today, years later? If your religion provided a means of atonement, what is your opinion about the methods of your faith today? Did punishments or means of atonement help relieve any guilt you were experiencing in the past? Did the feeling of relief carry into the present?

If you have changed religions or adopted a different spiritual approach to life, what would you say are the values of your new spirituality or religious outlook? How do you feel when you violate one of these values? Is it part of your current spiritual or religious program to punish yourself in some way or make amends in some manner? If so, please describe in detail.

As the result of the stresses or traumas you have experienced, have you come to doubt some of the tenants of your faith and perhaps rejected your faith altogether? If this is the case, do you feel guilty about having moved away from your original faith? Write two or three sentences about any such feelings of guilt.

Do your close friends or family members accept your change in beliefs or withdrawal from your original faith? How does their response to your change affect your sense of guilt?

GUILT OF BEING V.S. GUILT OF DOING

Guilt can arise from violating a religious taboo or not living up to a moral code espoused by one's religion of choice, regardless of the particular religion. This type of guilt is called the guilt of doing. However some religions, for example those in the Judeo-Christian tradition, also foster another kind of guilt: the guilt of being.

The guilt of doing involves the sense that you can not live up to a certain religious or spiritual ideal because of something you did wrong or something you failed to do right. In contrast, the guilt of being refers to the sense that you can not live up to your religious and spiritual beliefs because of what you are -- a vulnerable, frail, and according to some faiths, by nature, a sinful human being.

In the Judeo-Christian tradition, the guilt of being derives from the notion of original sin. In other religions, for example, Islam, there is no parallel to the idea of original sin (Swanson 1995). While guilt of being can originate from religious ideas about the inherent sinfulness of being human, it can also arise from being the emotional scapegoat in a family or group. White supremacists make African-Americans, Asians, and other non-white people the scapegoats for their internal ills and problems in the world which they feel powerless to remake according to their own desires. Most hate-groups, regardless of who they hate, think that if they only eliminate a certain kind of person, then they will feel happy and peaceful inside and the world will be put in good order.

Hate groups blame their problems on the sheer existence of people of a different color, national origin, religion or sexual orientation. The guilt of the people who are different than one's self is the guilt of being alive. This is the guilt of being.

For example, it doesn't matter to a white supremacist what an African-American does or feels. He or she could be a brilliant doctor or a street thug. It's all the same to the white supremacists because, in the extremist mind, the African-American is a criminal that needs to be punished if not obliterated because he or she exists. Of course, if the African-American commits a crime or makes a mistake or somehow fails in being a modern day saint, then that adds fuel to the fire. But it isn't the cause of the fire.

In families, the same process of scapegoating can occur. Usually one child or family member is selected. However in some families, more than one person can be placed in the role of scapegoat. There can be so much emotional and verbal abuse of the family scapegoats, that they can easily begin to feel they should have never been born. This sense of guilt at being is even greater if those who are being emotionally scapegoated are also being physically or sexually abused.

Family scapegoat who become the objects of frequent or ongoing verbal or other forms of abuse need to develop coping strategies to survive, some of which may be dysfunctional. For example, abused persons with little support and no way out may start to drink, use drugs, overeat, lie, steal, or they have memory problems and make frequent mistakes. These behaviors then become the object of criticism by the other family members and the scapegoated person may criticize himself or herself as well. The self-criticisms and the criticisms of others lead to guilt of doing, which only reinforces the scapegoat's fundamental feeling of guilt of being.

Another important factor in such situations is the humiliation involved in being the recipient of verbal, physical or sexual abuse. The awareness that one is being used and that others have power over one's body, emotions, thoughts erodes the integrity, which can make one feel like a thing, not a person. This vulnerability to the verbal and other forms of attack to others can create a sense of powerlessness and worthlessness that can lead to a sense that one does not deserve to live and a feeling of guilt at simply being alive.

One woman writes: “I've been criticized from the day I was born. My mother told me she was ashamed to have such an ugly child. My dad wasn't happy with me either. I felt I shouldn't have been born and never existed. I felt guilty for being alive -- for breathing, eating, sleeping, having fun, working, anything. Even today I can feel guilty about anything I do, even going to church or doing good deeds, because I feel like I shouldn't have been born.

“To try to steal a little peace and happiness, I lied a lot about what I did and where I went. I stole money too, to feed my addiction. Of course the family caught me lying, stealing, and drinking, which only gave them more cause to hate me and criticize me. I couldn't argue with them because, of course, it was wrong to do those things. But even if I never told another lie and was the holiest person in the world, I would still be guilty in their eyes -- guilty for being me or for just being.”

“ I've cleaned up my act somewhat. No more drinking, stealing, lying. But I slip sometimes, and when I do, I'm scared that doing just one little wrong thing will cause my family to reject me. Then I'll be outcast. It's like they are all watching me, waiting for me to make a mistake. I know I'm exagerrating the feeling of being watched, but it's also true that they look, and judge me, more than they do others. I'm not imagining that they are looking and judging. They are. And they only see the bad, not the good. I can feel the negative energy coming towards me and it destroys me. I don't even have the energy to fight back. I shrivel up. Then that makes me feel guilty for taking up room on the world, guilty for just being alive.”

This woman also suffers from content survivor guilt, which is described in Chapter .

Self-Assessment for Guilt of Being

Use a fresh sheet in your journal and write “Guilt of Being” as the heading. Answer the following questions in your journal as completely as possible.

Have you ever feel guilty not for any particularly characteristic you have or for something you have done (or not done) but simply for being alive?

Describe the circumstances where you first began experiencing guilt of being in detail, being careful to remember pressures or stresses imposed by others. For example, when was the first time you had this feeling? Did the idea come from within you or from somewhere outside of yourself, for example, an organization, a book, a media presentation, or another person?

Did anyone ever tell you didn't deserve to be alive? Who? How often did that person invalidate your existence? Did you believe that person? If so, did you believe that person entirely or only partially? Did that person harm you in other ways, emotionally, physically, financially, or socially?

Did your guilt for being begin as part of a trauma or was it made stronger by being involved in a life-threatening experience? If you had never been involved in this trauma, do you think you'd feel guilty about being alive? If so, why? Did this feeling of guilt for being part of the teaching of a religious or spiritual group with which you were, or are, affiliated?

SHADOW GUILT

Related to religious guilt, but somewhat different, is shadow guilt. According to psychologist Carl Jung, the human personality has many parts. One part of our personality -- the person we present to the world -- is called “the persona.” The person has learned socially acceptable traits and knows how to modify certain instincts and desires in order to fit into society and not be punished for breaking societal rules.

Another part of the personality, however, is called the shadow. The shadow is the reservoir of many of our desires and feelings that we, or society, feel are unacceptable. Hence the shadow contains our lust, greed, vanity, aggressiveness, pettiness, selfishness, capacity for violence and evil and all those parts of that are “bad” and should definitely not be acted upon. Also contained in the shadow are qualities that are not considered “evil” but are socially undesirable, for example, vulnerability and emotionality in men and aggressiveness in women.

Some people are relatively unaware of their shadow. They don't even know it exists. If you ask the average person if he or she has ever lied, cheated, wanted to kill someone, or lusted for someone who was not their mate, most likely that person would say “no.” That might not be the actual truth, but to that person, most of the time, it is the truth because he or she is not aware of his or her shadow. It is too horrible to contemplate. The idea of being murderous or lustful is so unacceptable, the shadow is suppressed out of awareness.

However, according to Tournier (1977), even though our shadow is usually repressed and even if we do not act on the impulses and desires in the shadow, we are aware that we have secret desires and temptations which we, or others, judge to be immoral. Our awareness of our shadow, however vague, unclear or confused, breeds a sense of guilt. “In an existential sense....man feels guilt with regard to himself... because there are within him obscure forces, impulses, and inhibitions which neither his will nor his intelligence or his knowledge can master” (Tournier 1977, 48).

In addition, no matter how much we suppress our shadows, the primitive urges and feelings contained in it continue to emerge. They are very powerful.

One way to handle the shadow is to deny it exists, but to satisfy it by watching other people act as if motivated by their shadow. That's one reason why movies with lots of sex, killing and other socially unacceptable behavior are so popular -- people release their shadow urges by watching others act out those urges.

The average person wouldn't dream of robbing a bank, plotting a financial swindle, killing, raping, or wishing someone in their family dead. But people spend time and money to watch television programs and movies where such things are commonplace. In other words, one way to handle the shadow is to allow it to live vicariously through reading books or watching dramas where people act in ways we wouldn't dare for fear of being condemned by society. Another way is to admire people who act out or who are thought to act out their shadow. For example, a recent study concluded that voters “secretly” want presidents and elected officials to be adulterous and have sexual escapes (Morin 1998).

However, people who have been in stressful life circumstances leading to the death, injury, or debasement of others have often encountered the shadow not in movies or in distant political figures, but in real life. They may have seen people act out their shadows and may have been in situations where they were forced to act out their shadow or where their shadow urges were activated.

Anyone who has been the victim of sexual assault, war or other forms of violence has seen people who are acting out shadow urges. Anyone who has been exposed to injustices based on prejudice due to race, gender, sexual orientation, religion or disability and anyone who has grown up in a home where there is emotional or other types or where one or more family members suffer from an alcohol, drug, or food addiction has seen people whose shadow selves are damaging not only their own lives, but the lives of others. Those who have been forced to abuse another person, lie, steal, or cheat or go against their own moral standards in order to save their own lives or the lives of others were forced to act out parts of their shadow.

Even if you were not forced to betray your values during your stressful experiences, if you have ever felt vengeful or murderous towards those who hurt you or someone you loved, you have met your shadow. Having self-destructive thoughts is also a part of the shadow personality and persons coping with survivor guilt frequently have thoughts of suicide, self-mutilation, and self-abasement.

To go through a stressful life event and not encounter the shadow in oneself or another person is impossible. In fact, it is encountering the shadow in others and oneself that makes these types of life situations so stressful, if not traumatizing. Your experience has taught you the capacity of others for evil, deceit, or negligence. You have seen these qualities in others and, in one way or another, whether you have had to act on them or not, you may have seen them in yourself. If you are the survivor of a man-made trauma, you are probably acutely aware of the possibility of human evil. However, even those of you who have suffered as the result of the expected loss or illness of a love one, an unjust personal or job-related situation, or an act of nature may have been exposed to human error and malice.

Even if you have never acted on a shadow impulse, you may experience shadow guilt because when you are honest with yourself, you realize that no matter how hard you try you can not eliminate the shadow part from your being and because you sense that the shadow, although repressed, has the potential to erupt and cause havoc in our lives. The fantasies and desires of our shadow, whether they be of sloth, murder, greed, lust, or self-aggrandizement, “defy the censorship of our will. It is another self which is in us, which we cannot stifle, and which we fear will be discovered” (Tournier 1977, 47-48).

Self-Assessment for Shadow Guilt

On a fresh piece of paper in your journal, enter the heading “Shadow Guilt” and answer the following questions to the best of your ability. Since shadow guilt is related to religious guilt, some of your answers to the following questions may be similar to those for the questions on religious guilt.

1. Have you ever lusted for or had sexual fantasies about someone whom you were told you should not desire sexually?

2. Have you wanted more than your share of money, food, recognition, power, or some other commodity?

3. Have you ever wanted to act selfishly and think only of yourself?

4. Have you ever stolen anything or wanted to steal something?

5. Have you ever been petty or manipulative or thought about being petty or conniving?

6. Have you ever injured or killed or thought about injuring or killing another living being?

7. Have you ever injured or killed another living being and enjoyed the sense of power involved or fantasized about how enjoyable killing and maiming might be

8. Have you felt like lying or told a lie?

9. Have you ever thought about cutting or mutilating yourself or about killing yourself?

10. Have you ever injured yourself physically or attempted suicide?

Look over your responses to these questions, then answer the following question: Have you or do you feel guilty for answering “yes” to any of the questions above. Write two or three sentences about your experience of guilt for each of the questions you answered “yes” to above.

TRUE GUILT v.s.. FALSE GUILT

Infantile guilt, religious guilt, and the guilt resulting from failing to meet parental or societal expectations result from not measuring up to the expectations set by others. Psychologist Carl Jung and psychiatrist Paul Tournier (Tournier 1977) contrast these types of guilt, which label they label false guilt, with true guilt, or not meeting standards you have set for yourself. True guilt involves letting ourselves down, whether in the form of not taking care of ourselves, not developing our talents, allowing others to mistreat us, or not pursuing our personal dreams. False guilt derives from “fear of social judgement and the disapproval” of others ( Tournier 1977, 69), but true guilt derives from not being faithful to ourselves.

For example, Toni's husband insisted that she have her tubes tied when she was twenty-one years old. They already had two children. He didn't want any more children, but she did and she wanted to retain the capacity to have children. When she suggested a vasectomy, her husband refused. He pressured her until she relented. “I didn't want to do it. I felt I was too young to get my tubes tied. But my husband made me feel guilty about not doing what he wanted. I went along because I wanted to be a good wife,” explains Toni.

“Today I feel guilt towards myself for doing what he wanted instead of what was important to me. We separated soon after I got my tubes tied and many of the men I met wanted to marry a woman who could have a family. Of course, I couldn't have any more children, so it was hard for me to find a new life-partner. But even if I had remained married to my ex-husband, I would still be mad at myself today for not sticking up for what I wanted.”

Men as well as women can be pressured by a significant other into actions they do not want to take. Bill, for example, had a vasectomy at his wife's insistence. “I didn't want that vasectomy, but thought I'd feel too guilty if I didn't do what she wanted. What's worse, I gave into her on other important issues too. Maybe they weren't important to her, but they were to me. I believe compromise is necessary for a good marriage, but I was doing all the compromising. Sure I'm still married, but I lost my self-respect.”

Bill and Toni feared the guilt involved in disappointing someone they loved and quite possibly, of incurring their spouse's anger and rejection. In this respect, they were guided by false guilt when they acquiesced to their spouses demands. However today they feel the pangs of true guilt, a guilt based on not acting on their true convictions and not standing up for themselves.

True guilt is widespread for few people are always faithful to themselves. In fact, true guilt can be as repressed as our shadow or other anti-social impulses, because to acknowledge the ways in which we have let ourselves down can be excruciatingly painful. When we are true to our inner callings and personal convictions we run the risk of being criticized or even ostracized by others. In some cases, being true to ourselves can cost us our lives or the lives of those whom we love. On the other hand, to not be ourselves and to not actualize our dreams has another penalty: the horror letting oneself be “paralyzed by fear, fashioned by environment, petrified by routine...[or], sterilized by conformity” and permitting oneself to simply copy others instead of being and developing oneself (Tournier 1977, 55).

True guilt has sometimes been called authentic guilt or guilt which arises from your own standards rather than guilt which arises from someone else's standards. Yet some people find themselves in situations where there is massive pressure to abandon their own beliefs and conform to others. The resulting spiritual or moral guilt is a major cause of survivor guilt, depression, and a host of other trauma-related disorders. This topic will be explored more fully in Chapter 4: Content Survivor Guilt.

Self-Assessment for True Guilt

On a fresh piece of paper, write the heading “True Guilt v.s. False Guilt.” Try to write three or four sentences in response to the following questions. Be as honest as you can be. Remember nobody needs to see your responses but you.

The following exercise on true guilt v.s.. false guilt may be very difficult to complete. In many ways, true guilt is perhaps one of the most painful types of guilt you can experience because it doesn't involve others betraying you: it involves you betraying yourself. However, keep in mind that few people are free enough from economic necessity, family obligations, and social pressure to be true to themselves all the time. It is entirely normal to give in to pressures to act a certain way rather than follow the desires of your heart or conscience.

Think of at least three instances where you gave in to pressures outside of yourself and acted against your own self-interest, your own development, or your own moral values? Write at least seven or eight sentences describing these instances in detail. Pay special attention to the kinds of pressures being placed upon you by others or by circumstances. Be sure to include one or two sentences describing how you reacted to your decision to give in to these pressures. For example, did you punish yourself in some way? Did you try to harm those who pressured you in some way and then feel guilty about that? Did you try to put the incident out of your mind?

In your present day life, are you currently acting against your values or your own growth? How is any guilt you are experiencing about your behavior affecting your self-esteem, your emotional health, your physical health, your personal relationships, your family life, or your career? Write two or three sentences about each aspect of your life which is affected by your true guilt.

Looking over your answers to the questions above and comparing them with your answers to the “Shoulds” exercise earlier in this chapter, do you see any similarities in how you respond to feelings of guilt? Can you list at least three ways your response to guilt today is similar to your responses as a child or young adult? Can you list at least three ways your responses to guilt today are different from your responses as a child or young adult?

Return to list

Growing Stronger Newsletter #7: Types of Guilt continued

In the previous newsletter, the difference between rational and irrational guilt was explained. Rational guilt refers to actions, thoughts, and feelings over which you had some control; irrational guilt, to situations over which you had little control. The first step in dealing with guilt is to break it down into the various types of guilt. In this article, Guilt #2. we will look at infantile guilt, guilt from failing to meet social expectations, shadow guilt, religious guilt, survivor guilt, true guilt (vs false guilt) and guilt from failing to meet social expectations. These kinds of guilt overlap, but it is still useful to try to divide up guilt into different categories because otherwise our guilt feelings will be overwhelming, and we will feel crushed by them, or we will feel overwhelmed and run from them.

INFANTILE GUILT

“All upbringing is a cultivation of the sense of guilt on an intensive scale,” writes Tournier ( 1977, 10 ). According to Freud (1996), guilt begins in our childhood when as infants and young children we are completely dependent on our parents and other adults for our well-being. Since our survival depends on pleasing our caretakers, when they scold or become angry with us, we fear that we will be abandoned or neglected. Along with that fundamental fear, comes guilt at not having pleased the parent or caretaker.

Freud used the term infantile guilt to describe guilt you felt as a child when you were reprimanded or rejected by your parents or other caretakers for not pleasing them. This type of guilt motivated you to change your behavior in order to avoid parental scolding or neglect. Through direct teaching as well as parental admonitions, you probably learned the morale and rules of your household and society. In Freudian terms, you internalized the parent's or caretaker's value system and expectations and automatically felt guilty when you violated parental or societal norms. Even when your parents or caretakers weren't around to scold you, you probably scolded yourself for disobeying their rules. For example studies of two year olds have shown that even when their mothers were not around, they called themselves “naughty” and “bad” for having violated a household rule (Aronfreed et. al. 1971 ).

Freud coined the term superego to refer to internalized parental and societal expectations and morals. He theorized that if people developed a healthy superego, as they became older, they would not require their parents or other adults to make them feel guilty for violating a family or societal rule or moral. Their superego would remind them of their transgressions and they could make themselves feel guilty all by themselves.

Freud further postulated that as people grew older they could transfer their infantile guilt from their parents and caretakers to other authority figures, such as teachers, clergy persons, work supervisors or superiors, political figures or others with religious, political, economical, or vocational status or power. Hence even a sixty-year old man could feel guilty about not meeting the expectations of someone in an authority position, for example, his work supervisor. Psychologically, the man feels as if his supervisor has the power not only to harm his professional standing, but to obliterate him. This fear not only of being scolded or shamed in pubic by an authority figure for not meeting a certain standard but of being annihilated by that person stems back to infancy and childhood. At that time being judged as deficient in some way could have lead to being rejected and neglected, which could have lead to death itself. On another psychological level, parental, caretaker, or teacher rejection and condemnation can severely stunt or damage a child's self-esteem, since children rarely have sources of validation other than the adults who take care of them.

Infantile guilt involves fear of losing the esteem and love of other people (Tournier 1977, 89) and evokes a fear of physically dying or being psychologically obliterated as the result of displeasing others. An adult whose life is organized around avoiding the criticism of others, especially authority figures, can be seen as suffering from infantile guilt. In more popular terms, infantile guilt can be seen as “people-pleasing,” which refers to putting aside one's own needs and desires in order to give precedence to the needs and desires of others.

When infantile guilt, or fear of condemnation from others, guides people's lives, they may have difficulty recognizing their own needs or talents and discovering their own convictions. On the other hand, children who fail to develop a healthy superego may need constant supervision in order not to be destructive to themselves or others and can grow up to become criminals, socio-paths, and other menaces to society.

Infantile guilt can compound survivor guilt in instances where an individual's failure to obey or please an authority figure resulted in the death or injury of another. For example, Amanda was raised to believe that children were supposed to obey their parents. In nursing school, she learned to obey physicians and head nurses. However in one instance, Amanda balked when the head nurse ordered her to complete a procedure which she felt was injurious to the patient's health. Based on lab reports and the opinions of other nurses, Amanda was almost certain the suggested procedure might harm the client.

Amanda refused to comply with her superior's instructions, only to discover the head nurse was right. While the head nurse tried to find someone else to complete the procedure, the patient developed an infrection. Amanda's guilt for the patient's infection was compounded was compounded by her infantile guilt at disobeying an authority figure, the head nurse..

GUILT DERIVED FROM FAILURE TO MEET PARENTAL EXPECTATIONS

Infantile guilt provides the basis for two other types of guilt, guilt at failing to meet specific parental expectations and guilt at failing to meet societal expectations.

As an adult, you may experience guilt feelings just because you fail to please an authority figure or a person who is emotionally or otherwise important to you (infantile guilt). But you might also feel guilty for not living up to the specific expectations placed upon us by your parents or caretakers. Hence if your father was a meticulous gardener and instilled in you the value of maintaining a garden of the highest quality, as an adult, you might feel guilty, when you allow the weeds to take over your garden. Somewhere in the back of your mind your father's voice (your superego) reminds you that you have failed to complete your gardening duties.

In some cases survivor guilt can be intensified by guilt for not having lived up to certain parental dictums or expectations. For example, Mrs. Chan brought her son a motorcycle for his 21st birthday. Two weeks later, her son in a motorcycle accident that lead to nine months of hospitalization and several surgeries. Mrs.. Chan blames herself for her son's pain because she ought his son the motorcycle in the first place.

However, Mrs. Chan is also experiencing some infantile guilt because in purchasing her child an expensive gift like a motorcycle, she violated two of her father's admonitions. The first admonition was against “spoiling children” by not having them earn the money to purchase their own clothes and luxuries. The second was against spending money for luxury items under almost any circumstances. Mrs.Chan's father firmly believed that every extra penny should be saved for the future and in his own life, he barely spent money on anything except necessities.

Every time Mrs. Chan went to see his son at the hospital, she could hear her father's voice saying, “Spending money on fancy cars and toys is foolishness. See, I told you so. I warned you that it was wrong to spend money on expensive items and luxuries. If you had saved your money for the future, like I taught you to do, this would have never happened.”

Camry, a military nurse, suffers from double guilt also. She was on the front lines nursing a wounded soldier when the enemy attacked again. A speeding bullet grazed her face and killed a soldier next to her. She then used the soldier's corpse as a shield against the continued fire. To this day, decades later, she feels she should have died with the soldier ( a form of survivor guilt).

But Camry also suffers from guilt for violating her father's repeated admonitions about respecting the dead. Her father had been a soldier during WW2. He had served under a general who insisted that his troops respect not only their own dead, but enemy dead. Soldiers under this general were harshly punished if they mutilated the bodies of the dead. Camry's father had instilled in all his children the value of consecrating the remains of the dead. As a result, Camry feels as if she betrayed her father and all that he stood for, when she used the corpse for protection.

If your mother had one set of values and your father another, or if either parent (or both) were confused about their values and gave you two different sets of expectations, your guilt may be especially complicated.

For example, if your mother taught you to stand up for yourself when someone spoke to you disrespectfully and your grandfather taught you to turn the other cheek, perhaps you lied to your grandfather when you talked back or perhaps you lied to your mother when you walked away from confrontations. Another possibility is that you didn't tell either of them how you responded to insults and put-downs and tried to carry the burden of being verbally attacked all by yourself. Did you need to lie, steal, pretend, run-away, hurt yourself, or hurt animals or others as a result of the contradictory messages? What happens now when a physician, hospital director, patient or nurse co-worker treats you as an underling or insults your competency?

GUILT DERIVED FROM FAILURE TO MEET SOCIETAL EXPECTATIONS

Your parents and caretakers aren't the only source of the demands to meet certain standards. Society places pressures on people also. Regardless of how independent anyone thinks he or she might be, almost anyone can be made to feel guilty for not living up to cultural expectations their culture places upon them.

For example, many women in Western culture feel guilty about not being slender enough, even if they grew up in homes that paid no particular attention to female body size. Because the culture tends to measure the worth of a man by the size of his bank account, men who are unemployed or who are burdened with financial hardships tend to experience guilt for not being financially successful. Even men who grew up in homes which valued spiritual matters over the acquisition of material goods can experience some level of guilt for not living up to the cultural expectation that, as men, they should have a job, a home, a car, and plenty of money in the bank.

Parents or caretakers can make people feel guilty for not living up to societal expectations, but their friends and associates can also play a role. “In everyday life ...we are continually soaked in this unhealthy atmosphere of ... criticism” (Tournier 1977, 15). Sometimes the criticism is “keen and outspoken, sometimes silent” but it is “not less painful for being so. We are all sensitive to it, even if we conceal the fact” (Tournier 1977, 13).

. For example, Maureen is overweight and feels guilty about not meeting societal expectations that she be slender. When her daughter was sexually abused by her husband's brother, Maureen felt guilty and wished she could have been abused in her daughter's place. “She was a young girl who had everything to look forward too. I'm an overweight middle aged woman. If someone had to be raped, it should have been me,” she sobbed in session.

Maureen's survivor guilt was exacerbated by her guilt about her weight. Even though her eating habits and body size had nothing to do with her daughter's molestation, in her mind, they did. Maureen confused the two guilts-- her guilt over her appearance and her survival guilt. She illogically concluded that her overeating and overweight somehow caused the rape of her daughter. She felt that if she had been thinner she might have married a different man, one who didn't have a brother who was a child molester.

Maureen's therapist pointed out that while it was true Maureen might have married a different man if she had been thinner, this would not have prevented her daughter from getting hurt. For example, Maureen might have married a man who was a child abuser himself or who had a nephew or father or friend who was a pedophile. Only if Maureen had witnessed her daughter being abused or in some other way had been aware that her daughter was being hurt and, instead of helping her daughter, chose to go to go food shopping or on a eating binge, then and only then could her eating problems be related to her daughter's rape. Furthermore, Maureen needed to remember that it was not she or her overeating, but a pedophile, who had violated her daughter.

CHILDHOOD OMNIPOTENT GUILT and SUPERMAN/SUPERWOMAN GUILT

Another form of guilt is childhood omnipotent guilt -- a well-documented tendency of young children to think that the world revolves around them and that they control everything that happens. Young children think that if they wish something it might come true. For example, when children become frustrated with a parent or sibling, they often think or say, I hate you -- I wish you were dead, which is a perfectly normal expression of aggression. But, if for some reason that parent or sibling subsequently becomes ill, dies or leaves the family, the child thinks that he or she caused this person to become ill, die, or leave.

This is called magical thinking, because hating one's parent, sibling, spouse or friend, or even wishing another person dead, does not cause these people harm unless the aggressive wish is acted upon.

No matter how old or how mature we may be, a part of us -- consciously or unconsciously -- may still be engaging in magical thinking or seeing ourselves as omnipotent. When someone we know commits suicide or if a patient we disliked becomes more ill or dies, the child in us may feel that our hostility killed that person because we sometimes harbored hostile feelings toward him or her.

But hating people doesn't kill them or make them sick. Our angry, hateful feelings and wishes in themselves cannot cause the physical death, suicide, illness or injury of another, with one important exception: if you severely or continually maltreated someone, and then that person committed suicide or acquired an illness or injury directly related to your treatment, some of your guilt may be appropriate. If not, some of the guilt you are experiencing may fall into the category of childhood omnipotent guilt.

In adolescence and adulthood, childhood omnipotent guilt can be transformed into a type of guilt called “superman or superwoman” guilt. In order to cope with a traumatic or extremely stressful situation, people can come to believe that have superhuman qualities. The more helpless and powerless people feel in a life or death situation, the greater the need for superhuman powers. One theory (Krystal 1971) is that

during traumatic conditions, people tend to revert to childlike thinking, including the tendency towards childhood omnipotent guilt.

Kubany (1994) , Opp and Samon (1989), Parson (1986) and others have found that survivors of traumatic circumstances often experience guilt and feelings of failure for not knowing what no human being could have known and for not having abilities that are beyond human capability. Examples are medical staff who feel guilty for not being able to save everyone, parents who feel guilty for not being able to protect their children from all illnesses and harm, soldiers who feel guilty for not having foreseen all enemy assaults, and relatives of seriously ill persons who feel guilty for not knowing the outcome of certain medical procedures.

If you suffer from superman/superwoman guilt, then you are telling yourself, “‘I'm in charge of all the variables for lie and death' and “I knew things would happen before they did.'” (Opp and Samson 1989 p. 162).

RELIGIOUS GUILT

Sin and guilt are the themes of many major religions. Many of us have been taught to feel guilty when we fail to adhere to the tenants of our faith or to expected forms of worship. Furthermore, some faiths, for example, Christianity and Judaism, espouse the notions of original sin and man's inherent guilt. According to Christian beliefs, all people are born evil, and are therefore guilty, unless they are redeemed through the faith.

Religious guilt is frequently present with survivor guilt. For example, it is not uncommon for soldiers to experience guilt about violating the religious code of “thou shalt not kill” by being warriors. Some domestic violence survivors, such as battered women and physically or sexually abused children, are coerced into committing cruel or sadistic acts towards other; into lying, stealing, or committing certain sexual acts (including prostitution); or into killing animals or people, as in cult abuse. People who are victimized in these ways can suffer from severe religious guilt, which is often at the core of their content survivor guilt.

In some cases, nurses who have lost a patient or who have lost a loved one to suicide or homicide attribute the death of this patient to their one to their having violated a tenant of their faith. For example, Tanya still suffers from survivor guilt over the suicide of her daughter some fifteen years ago. However her survivor guilt is compounded by her religious guilt for having an adulterous affair during her marriage. On some level, she feels that the death of her son is divine “payback” for violation of her marriage vows. Other examples are Esther, whose teenage son was mugged, and Brenda, who had a patient who became progressively ill, rather than better. When these nurses are honest with themselves, they feel their difficult circumstances are forms of punishment for leaving the religion of her childhood and converting to another faith.

Another type of religious guilt is almost the exact opposite of the religious guilt described above. This guilt involves rejecting your previous religious and spiritual beliefs and traditions. Hence family members of children who have died as the result of illness, murder or suicide may have stopped believing in their God because their prayers for their child were not answered. People trapped in natural disasters, such as fires or floods, and persons trapped in man-made disasters, such as violent or abusive homes, may abandon their religious beliefs when the God of their understanding does not provide them the help and rescue that they need.

However, there can be guilt in abandoning or rejecting one's former religious or spiritual beliefs, especially if family members or significant others are critical of this change. Hence persons of a particular faith who come to reject the tenants of their faith as the result of a severe trauma or stress may feel guilty about not being able to truly believe what they used to believe or not being able or willing to attend services as they used to.

GUILT OF BEING V.S. GUILT OF DOING

Guilt can arise from violating a religious taboo or not living up to a moral code espoused by one's religion of choice, regardless of the particular religion. This type of guilt is called the guilt of doing. However some religions, for example those in the Judeo-Christian tradition, also foster another kind of guilt: the guilt of being.

The guilt of doing involves the sense that you can not live up to a certain religious or spiritual ideal because of something you did wrong or something you failed to do right. In contrast, the guilt of being refers to the sense that you can not live up to your religious and spiritual beliefs because of what you are -- a vulnerable, frail, and according to some faiths, by nature, a sinful human being.

In the Judeo-Christian tradition, the guilt of being derives from the notion of original sin. In other religions, for example, Islam, there is no parallel to the idea of original sin (Swanson 1995). While guilt of being can originate from religious ideas about the inherent sinfulness of being human, it can also arise from being the emotional scapegoat in a family or group. White supremacists make African-Americans, Asians, and other non-white people the scapegoats for their internal ills and problems in the world which they feel powerless to remake according to their own desires. Most hate-groups, regardless of who they hate, think that if they only eliminate a certain kind of person, then they will feel happy and peaceful inside and the world will be put in good order.

Hate groups blame their problems on the sheer existence of people of a different color, national origin, religion or sexual orientation. The guilt of the people who are different than one's self is the guilt of being alive. This is the guilt of being.

For example, it doesn't matter to a white supremacist what an African-American does or feels. He or she could be a brilliant doctor or a street thug. It's all the same to the white supremacists because, in the extremist mind, the African-American is a criminal that needs to be punished if not obliterated because he or she exists. Of course, if the African-American commits a crime or makes a mistake or somehow fails in being a modern day saint, then that adds fuel to the fire. But it isn't the cause of the fire.

In families, the same process of scapegoating can occur. Usually one child or family member is selected. However in some families, more than one person can be placed in the role of scapegoat. There can be so much emotional and verbal abuse of the family scapegoats, that they can easily begin to feel they should have never been born. This sense of guilt at being is even greater if those who are being emotionally scapegoated are also being physically or sexually abused.

Family scapegoat who become the objects of frequent or ongoing verbal or other forms of abuse need to develop coping strategies to survive, some of which may be dysfunctional. For example, abused persons with little support and no way out may start to drink, use drugs, overeat, lie, steal, or they have memory problems and make frequent mistakes. These behaviors then become the object of criticism by the other family members and the scapegoated person may criticize himself or herself as well. The self-criticisms and the criticisms of others lead to guilt of doing, which only reinforces the scapegoat's fundamental feeling of guilt of being.

Another important factor in such situations is the humiliation involved in being the recipient of verbal, physical or sexual abuse. The awareness that one is being used and that others have power over one's body, emotions, thoughts erodes the integrity, which can make one feel like a thing, not a person. This vulnerability to the verbal and other forms of attack to others can create a sense of powerlessness and worthlessness that can lead to a sense that one does not deserve to live and a feeling of guilt at simply being alive.

One woman writes: “I've been criticized from the day I was born. My mother told me she was ashamed to have such an ugly child. My dad wasn't happy with me either. I felt I shouldn't have been born and never existed. I felt guilty for being alive -- for breathing, eating, sleeping, having fun, working, anything. Even today I can feel guilty about anything I do, even going to church or taking extra good care of my patients at the hospital, because I feel like I shouldn't have been born.

“To try to steal a little peace and happiness, I lied a lot about what I did and where I went. I stole money too, to feed my addiction. Of course the family caught me lying, stealing, and drinking, which only gave them more cause to hate me and criticize me. I couldn't argue with them because, of course, it was wrong to do those things. But even if I never told another lie and was the holiest person in the world, I would still be guilty in their eyes -- guilty for being me or for just being.”

“ I've cleaned up my act somewhat. No more drinking, stealing, lying. But I slip sometimes, and when I do, I'm scared that doing just one little wrong thing will cause my family to reject me. Then I'll be outcast. It's like they are all watching me, waiting for me to make a mistake. I know I'm exaggerating the feeling of being watched, but it's also true that they look, and judge me, more than they do others. I'm not imagining that they are looking and judging. They are. And they only see the bad, not the good. I can feel the negative energy coming towards me and it destroys me. I don't even have the energy to fight back. I shrivel up. Then that makes me feel guilty for taking up room on the world, guilty for just being alive.”

SHADOW GUILT

Related to religious guilt, but somewhat different, is shadow guilt. According to psychologist Carl Jung, the human personality has many parts. One part of our personality -- the person we present to the world -- is called “the persona.” The person has learned socially acceptable traits and knows how to modify certain instincts and desires in order to fit into society and not be punished for breaking societal rules.

Another part of the personality, however, is called the shadow. The shadow is the reservoir of many of our desires and feelings that we, or society, feel are unacceptable. Hence the shadow contains our lust, greed, vanity, aggressiveness, pettiness, selfishness, capacity for violence and evil and all those parts of that are “bad” and should definitely not be acted upon. Also contained in the shadow are qualities that are not considered “evil” but are socially undesirable, for example, vulnerability and emotionality in men and aggressiveness in women.

Some people are relatively unaware of their shadow. They don't even know it exists. If you ask the average person if he or she has ever lied, cheated, wanted to kill someone, or lusted for someone who was not their mate, most likely that person would say “no.” That might not be the actual truth, but to that person, most of the time, it is the truth because he or she is not aware of his or her shadow. It is too horrible to contemplate. The idea of being murderous or lustful is so unacceptable, the shadow is suppressed out of awareness.

However, according to Tournier (1977), even though our shadow is usually repressed and even if

we do not act on the impulses and desires in the shadow, we are aware that we have secret desires and temptations which we, or others, judge to be immoral. Our awareness of our shadow, however vague, unclear or confused, breeds a sense of guilt. “In an existential sense....man feels guilt with regard to himself... because there are within him obscure forces, impulses, and inhibitions which neither his will nor his intelligence or his knowledge can master” (Tournier 1977, 48).

In addition, no matter how much we suppress our shadows, the primitive urges and feelings contained in it continue to emerge. They are very powerful.

One way to handle the shadow is to deny it exists, but to satisfy it by watching other people act as if motivated by their shadow. That's one reason why movies with lots of sex, killing and other socially unacceptable behavior are so popular -- people release their shadow urges by watching others act out those urges.

The average person wouldn't dream of robbing a bank, plotting a financial swindle, killing, raping, or wishing someone in their family or under their care dead. But people spend time and money to watch television programs and movies where such things are commonplace. In other words, one way to handle the shadow is to allow it to live vicariously through reading books or watching dramas where people act in ways we wouldn't dare for fear of being condemned by society. Another way is to admire people who act out or who are thought to act out their shadow. For example, a recent study concluded that voters “secretly” want presidents and elected officials to be adulterous and have sexual escapes (Morin 1998).

However, people who have been in stressful life circumstances leading to the death, injury, or debasement of others have often encountered the shadow not in movies or in distant political figures, but in real life. They may have seen people act out their shadows and may have been in situations where they were forced to act out their shadow or where their shadow urges were activated.

Anyone who has been the victim of sexual assault, war or other forms of violence has seen people who are acting out shadow urges. Anyone who has been exposed to injustices based on prejudice due to race, gender, sexual orientation, religion or disability and anyone who has grown up in a home where there is emotional or other types or where one or more family members suffer from an alcohol, drug, or food addiction has seen people whose shadow selves are damaging not only their own lives, but the lives of others. Those who have been forced to abuse another person, lie, steal, or cheat or go against their own moral standards in order to save their own lives or the lives of others were forced to act out parts of their shadow.

Even if you were not forced to betray your values during your stressful experiences, if you have ever felt vengeful or murderous towards those who hurt you or someone you loved, you have met your shadow. Having self-destructive thoughts is also a part of the shadow personality and persons coping with survivor guilt frequently have thoughts of suicide, self-mutilation, and self-abasement.

To go through a stressful life event and not encounter the shadow in oneself or another person is impossible. In fact, it is encountering the shadow in others and oneself that makes these types of life situations so stressful, if not traumatizing. Your experience has taught you the capacity of others for evil, deceit, or negligence. You have seen these qualities in others and, in one way or another, whether you have had to act on them or not, you may have seen them in yourself. If you are the survivor of a man-made trauma, you are probably acutely aware of the possibility of human evil. However, even those of you who have suffered as the result of the expected loss or illness of a love one, an unjust personal or job-related situation, or an act of nature may have been exposed to human error and malice.

Even if you have never acted on a shadow impulse, you may experience shadow guilt because when you are honest with yourself, you realize that no matter how hard you try you can not eliminate the shadow part from your being and because you sense that the shadow, although repressed, has the potential to erupt and cause havoc in our lives. The fantasies and desires of our shadow, whether they be of sloth, murder, greed, lust, or self-aggrandizement, “defy the censorship of our will. It is another self which is in us, which we cannot stifle, and which we fear will be discovered” (Tournier 1977, 47-48).

TRUE GUILT v.s.. FALSE GUILT

Infantile guilt, religious guilt, and the guilt resulting from failing to meet parental or societal expectations result from not measuring up to the expectations set by others. Psychologist Carl Jung and psychiatrist Paul Tournier (Tournier 1977) contrast these types of guilt, which label they label false guilt, with true guilt, or not meeting standards you have set for yourself. True guilt involves letting ourselves down, whether in the form of not taking care of ourselves, not developing our talents, allowing others to mistreat us, or not pursuing our personal dreams. False guilt derives from “fear of social judgement and the disapproval” of others ( Tournier 1977, 69), but true guilt derives from not being faithful to ourselves.

For example, Toni's husband insisted that she have her tubes tied when she was twenty-one years old. They already had two children. He didn't want any more children, but she did and she wanted to retain the capacity to have children. When she suggested a vasectomy, her husband refused. He pressured her until she relented. “I didn't want to do it. I felt I was too young to get my tubes tied. But my husband made me feel guilty about not doing what he wanted. I went along because I wanted to be a good wife,” explains Toni.

“Today I feel guilt towards myself for doing what he wanted instead of what was important to me. We separated soon after I got my tubes tied and many of the men I met wanted to marry a woman who could have a family. Of course, I couldn't have any more children, so it was hard for me to find a new life-partner. But even if I had remained married to my ex-husband, I would still be mad at myself today for not sticking up for what I wanted.”

Men as well as women can be pressured by a significant other into actions they do not want to take. Bill, for example, had a vasectomy at his wife's insistence. “I didn't want that vasectomy, but thought I'd feel too guilty if I didn't do what she wanted. What's worse, I gave into her on other important issues too. Maybe they weren't important to her, but they were to me. I believe compromise is necessary for a good marriage, but I was doing all the compromising. Sure I'm still married, but I lost my self-respect.”

Bill and Toni feared the guilt involved in disappointing someone they loved and quite possibly, of incurring their spouse's anger and rejection. In this respect, they were guided by false guilt when they acquiesced to their spouses demands. However today they feel the pangs of true guilt, a guilt based on not acting on their true convictions and not standing up for themselves.

True guilt is widespread for few people are always faithful to themselves. In fact, true guilt can be as repressed as our shadow or other anti-social impulses, because to acknowledge the ways in which we have let ourselves down can be excruciatingly painful. When we are true to our inner callings and personal convictions we run the risk of being criticized or even ostracized by others. In some cases, being true to ourselves can cost us our lives or the lives of those whom we love. On the other hand, to not be ourselves and to not actualize our dreams has another penalty: the horror letting oneself be “paralyzed by fear, fashioned by environment, petrified by routine...[or], sterilized by conformity” and permitting oneself to simply copy others instead of being and developing oneself (Tournier 1977, 55).

True guilt has sometimes been called authentic guilt or guilt which arises from your own standards rather than guilt which arises from someone else's standards. Yet some people find themselves in situations where there is massive pressure to abandon their own beliefs and conform to others. The resulting spiritual or moral guilt is a major cause of survivor guilt, depression, and a host of other trauma-related disorders.

EXISTENTIAL SURVIVOR GUILT VS. CONTENT SURVIVOR GUILT

All people have to deal with infantile guilt, societal imposed guilts, religious guilt, shadow guilt, and true vs. false guilt. However, in times of stress, such as the loss of a loved one or in working in a health care profession where people's lives depend on you and where you are surrounded with illness and death, you are especially subject to survivor guilt as well.

There are two types of survivor guilt: existential survivor guilt and content survivor guilt. Existential survivor guilt refers to feelings you have about staying alive in situations where others died or about being less injured or harmed than others. Content survivor guilt refers to guilt feelings about something you did, thought or felt in your efforts to stay safe and protect yourself from psychological or physical harm. Both types of survivor guilt are forms of self-blame.

EXISTENTIAL SURVIVOR GUILT

Do you feel guilty because you made it out alive and others didn't, or because you were less injured or less damaged than others? Are you confused about why you escaped emotional pain, financial distress, illness, or social disgrace or humiliation when others had to suffer these hardships?

Have you ever wished you could bear the suffering of another, or others, whether it be physical, mental, emotional, or financial? Do you ever wish you could exchange places with the person or persons who died? Do you ever feel that you should have died and they should have lived? Do you believe that the dead would have had a better life than you and more to live for? Do you feel the dead are luckier than you are because they have no more pain and suffering whereas you have inner torment?

Do you feel guilty about something you did to stay alive or prevent being injured? Do you feel guilty for certain thoughts or feelings you had while you were trying to protect yourself from injury or mistreatment?

When you see your patients or others injured or dying, do you think to yourself, “Thank God it wasn't someone in my family,” but then feel guilty for thinking such thoughts?

Do you feel you are living primarily for a person or for people who are dead rather than for yourself or people who are currently alive?

Do you love or think about people who are dead more than people who are living? Do you feel like a “cheat” in that you are only alive because someone died in your place?

Do you feel you don't deserve the love of others, professional success, or any type of good feelings about yourself?

Do you engage in high-risk activities in hopes of getting yourself killed?

Do you find yourself using alcohol, drugs, or excess food to cover up feelings of guilt?

Have you ever been diagnosed with clinical depression?

If you have answered yes to some of these questions, there is a high probability that you suffer from survivor guilt.

Survivor guilt involves asking the existential question of why you suffered less than someone else or why you lived while others died. You may be sincerely confused about why you fared better than someone else and the meaning of your good luck, or your very survival. Survivor guilt forces you to ask questions about the meaning of your existence and the meaning of life itself, questions which many people avoid thinking about because of their seriousness and complexity. Such questions bring to the fore ethical and spiritual issues over which theologians, philosophers, writers, artists, and intellectuals and religious leaders of many different schools of thought have debated for centuries.

Asking such questions and trying to answer them to your satisfaction can create anxiety, self-doubt, and doubts about the values of your family, your immediate social circle, and society at large. The fact that survival guilt can lead to such a deep penetrating look at life is one reason why people with survival guilt might want to suppress that guilt. To experience the guilt, is to give rise to a host of spiritual, existential, and moral questions which have no easy answers.

The sheer weight and complexity of questions pertaining to the meaning of life can make you want to avoid the subject. You might also want to avoid the subject because when you try to talk to others about your survival guilt and any existential and religious issues raised by your survivor guilt, you may not always receive a warm reception. In our society, others tend to become highly anxious or threatened by discussions about such serious matters. As Marin (1981) observes our society has a limited capacity to deal with the psychological and ethical problems that stem from being in situations that give rise to survivor guilt. Hence individuals with survivor guilt may find themselves isolated and forced to limit their sharing to therapists, religious or spiritual leaders, or a few trusted friends.

Many times survivor guilt leads to people wishing they could take the place of the injured or dead, that is, become ill or die for them. For example, Doris, an emergency room nurse has a recurring dream where she frantically runs around an operating room trying to save someone's life. But no matter how hard she works, her patient dies. As she goes to cover the dead person's face with a sheet, she sees that it is she who is dead.

“I feel that with every patient that died, I died too, so to finally die myself die, was a relief. In the dream, I'm taken aback when I see that it's me whose dead, not someone else. But I'm only petrified for a split second. Within a minute, I'm no longer afraid when I see that it's me who is dead. I feel glad. At last. It's over. The horrible guilt is over,” Doris explains.

Vietnam combat veterans sometimes dream about replacing their dead comrades. In some dreams, they envision their names on the Vietnam Wall. In other dreams, their dead comrades jump out of their graves, or the Wall, and ask them to join them in the land of the dead. There is fear and apprehension in these dreams, but their is also a profound sense of peace. “At least in my dreams, I'm where I belong -- with the guys that died over there,” a veteran explains.

SURVIVAL GUILT AS A FORM OF MAGICAL THINKING

Survivor guilt is not just compassion for those who have suffered more than you. It is also a way of saying, “If I had suffered more, you would have suffered less.” Such thinking is not logical, but it makes emotional sense. It can be a defense against the pain you felt at seeing others hurt. It also reflects the very human wish not to see those we love or care about suffer or be injured or killed. Taken to the extreme, we might wish that we could lay down our life in substitution for theirs or that our suffering can be substituted for theirs.

Survivor guilt hearkens back to atavistic notions about making sacrifices to the gods to assure a desired outcome. History is full of examples of peoples who practiced the custom of sacrifice. Typically they sacrificed grain, animals, and even children or young people to the gods in order to insure good weather, victory at war, protection from disease, and fertility. Sacrifices were also made as form of repentance for sin or various kinds of wrong doings.

For many individuals with survivor guilt, all or certain aspects of their lives, become the sacrifice.

The ultimate form of self-sacrifice is suicide. In some instances, a motivation for suicide is the wish to join the dead or to atone for whatever you did, thought, or felt, which you feel contributed to the death or injury of others.

With survivor guilt, the idea is that by punishing yourself (or perhaps even killing yourself), you can undo the damage, or at least keep bad things from happening again. But, of course, the world doesn't really work that way.

Nevertheless, when the longing for things to have turned out differently is strong and when the pain of the losses involved is deep, it can be a relief to continue to feel guilt and act in ways that harm yourself or block you from achieving full happiness and growth. As illogical as it might sound, feeling guilty and acting in a self-punishing manner can help you maintain the illusion that if only you suffer hard enough or long enough, you can change the past. It is as if you keep feeling guilty and denying yourself (or actively hurting yourself), hoping that this time the life event with the sad ending will eventually have a happy ending. Of course, this wish does not come true. Furthermore, if you interpret the lack of a happy ending to your personal failings, sins, or limitations, then your self-esteem is decreased even further and your survivor and other types of guilt can easily be intensified.

The fact that survivor guilt can function as a form of wishful thinking does not mean that you lack sincere remorse or genuine caring for the individual who has died or was harmed. Indeed, sometimes using self-punishment and survivor guilt as a means of rewriting history is may not be a conscious process, or perhaps it is only semi-conscious. It hearkens to a belief in magic and to a wish that through one's power, even the power of self-hate and self-punishment, one can bring about a desired outcome, in this case, a reversal of certain tragic events.

THE REPRESSED PART OF SURVIVOR GUILT: GRATITUDE

Survivor guilt also involves gratitude. It is difficult to accept that you might be grateful that it was someone else who suffered and not yourself. “It sounds heartless,” some people will openly admit, “but if someone had to die. I'm glad it someone else, not me.” Yet some people can not accept the idea that, on some level, they are glad they were not the one who died, was injured, or otherwise harmed and this part of their survivor guilt is repressed.

However hard this feeling is to face, it is nothing more than expression of the natural and vital instinct for self-preservation. Yet this part of survivor guilt can generate a considerable amount of guilt and internal confusion. It is difficult to be grieving the suffering of someone else while at the same time rejoicing in your own relative good fortune. For example, Paul and his wife Karen were driving home one night when their car was struck by a truck. Karen was severely injured, but Paul was not. Paul wondered why he was spared injury while his wife had to endure numerous surgeries and much pain. “ It should have been me. And if it couldn't have been me, why couldn't the injures at least been divided equally between us?” Paul told others.

Paul meant what he said. He sincerely wished he could have suffered in place of his wife or at least borne half the pain. On the other hand, he was glad he had been spared Karen's ordeal. He didn't know if he could take being bedridden for months like Karen. The very thought of enduring the kind of pain she had was unimaginable.

Most of the time Paul didn't think much about how grateful he was that he hadn't been injured. The minute such a thought would pop into his mind, he would quickly dismiss it. He found such a thought unacceptable. After all, he loved Karen. She was his wife and he was a dedicated husband. However, every time Karen moaned in pain and every time appointments had to be made with doctors, physical therapists or more surgeries, Paul found himself secretly sighing with relief that he didn't have to tolerate all these medical procedures.

Paul felt guilty about being grateful he wasn't hurt, just as guilty as he felt about not having been injured. It is this terrible contradiction, between wishing one could suffer for the other and being grateful that one has been spared the suffering, that makes survival guilt very difficult to deal with and talk about openly.

Just as often as people think, “Thank goodness it wasn't me,” they may look at their love ones and think, “Thank goodness it wasn't one of them.” “ When I found out my neighbor's son was slipping into alcoholism, couldn't help thinking, ‘If someone's son has to be a drunk, I'm glad it's my neighbor's son, not my son.' I felt a little guilty for thinking that way, but I couldn't help it. When I really felt guilty was when my cousin's boy was shot to death. I looked at my son and said, ‘Thank God it wasn't you.'

“‘But what about cousin Billy. Don't you care about him?' my son said.

“Sure I care about Billy, but I care about my son more. It's natural, I supposed, but I feel guilty about it. What my son said made me feel guilty, but I was already feeling guilty.. Like it's selfish and heartless of me to be glad that my son is alive.”

SURVIVOR GUILT AND RESPONSIBILITY GUILT

If you held a position of responsibility during the circumstances where there was a loss or someone was harmed, it is possible that you developed an extra strong sense of survivor guilt as the result of being technically responsible for the welfare of others. Kubany (1996) stresses that individuals, such as parents, teachers, squad leaders, airline pilots, nurses, and others who have obligations towards others, tend to feel responsible for negative outcomes towards these others because they confuse their assigned responsibility with being accountable for any negative events.

Wang Dan,

A real life example of role-related survivor guilt is that of Wang Dan, the Tianamen Square protest leader. He helped organize the Tianamen Square demonstrations for democracy in China . His idea for a hunger stroke brought millions of Chinese to the square. However on the night of June 3, 1989 , hundreds and, according to some estimates, thousands of Chinese civilians were shot to death by the Chinese army (Sun, 1998). Almost ten years later, in l998, Wang Dan stated that he will always feel guilt over the hundreds who died in the Army crackdown.” Wang Dan is experiencing survival guilt.

In retrospect he can see that he made some mistakes in planning the demonstration that may have contributed to the deaths. However, he does acknowledge that “the main responsibility was not ours, the main responsibility was with the government who actually did the killing (Sun, 1998, A3). Nevertheless, his sense of survivor guilt is profound.

Survivor guilt related to role is especially strong among parents and grandparents. Human beings, both male and female, are biologically wired to respond to the helplessness and dependency of their young and when a child dies, regardless of the child, the survivor guilt can be enormous. For example, Sarah was sitting by her living room window watching her husband show their baby daughter the roses twining on the fence , when suddenly a dog jumped over the fence and attacked the child. Though Sarah was a pediatric nurse who had seen many injuries and illnesses, at the sight of her own child being harmed, she became immobilized, unable to call for help. Fortunately her husband was able to ward off the dog before the child was killed.

The child required numerous plastic surgeries to restore her face. Sarah, however, required many years of therapy to deal with her self-recriminations for her temporary paralysis, which she feels, resulted in her daughter's face being scarred.

CONTENT SURVIVOR GUILT

Content survivor guilt refers to guilt which is the result of something you did to keep yourself safe or stay alive (Williams 1987). It can be broken down into a host of other types of guilt, including negligence guilt, competency guilt, moral or spiritual guilt, daemonic or atrocity guilt, superman/superwoman guilt, “Catch 22" guilt, and guilt over coping mechanisms, such as denial, rationalizing, lying and stealing. It also refers to having certain thoughts or feelings during a trauma or during a stressful ordeal. One of these feelings has already been discussed, that of feeling “grateful” that you were spared.

Many times during stressful events people do things to protect themselves which they later regret because these actions violated their personal code of ethics or the moral code of their family or society. However it is quite unlikely that most of these people would have behaved in the same way in non-stressful conditions.

The classic example is that of soldiers who kill and maim in time of war. Killing is their military duty, however it violates the code of “thou shalt not kill” which is found in certain religions. For some soldiers, the code of “thou shalt not kill” is as deeply ingrained as their commitment to follow military orders. As a result, some soldiers feel guilty for killing, even though they did so in the line of duty. However, had these people not been in the military, most likely they would not have become involved in killing others so frequently or routinely. Furthermore, if they had not participated in trying to destroy the enemy, they would have been considered traitors and cowards and held guilty of contributing to the injuries or deaths of their comrades.

Similarly, people who live in abusive households or who are trapped in prostitution, forced labor rings, ritual abuse cults, or other types of hostage situations, are sometimes forced into shoplifting or other unethical or illegal acts in order to avoid being beaten or to forestall the abuse of another person or pet. It is highly probable that these same people would not have become involved in stealing or other illegal acts had they not been coerced by threats of violence or harm. Even though they were terrorized into violating their own moral standard, they can feel tremendous guilt about committing such acts. This is a form of content survivor guilt in that it involves feeling guilty about doing something in order to stay alive or preserve one's safety or sanity.

Faced with danger, people can find themselves acting, thinking, or feeling like a “different person” -- a person they don't like and aren't proud of. All such acts, thoughts, and feelings are part of content survivor guilt. Content survivor guilt tends to be especially strong among people who feel they acted in a cowardly rather than a heroic manner, for people who denied help to those in need, for people who made mistakes which caused the death or injury of others, and for people who found themselves acting with more violence, brutality and sadism than they thought possible. Yet they may have acted in these ways as a form of physical, emotional, or mental self-preservation.

FEELING LIKE A COWARD

For example, a woman who hid in the bathroom while her husband was verbally abusing her son feels guilt for not having protected him. She let her son fend for himself because she feared that if she intervened, her husband would punish her with verbal abuse, financial restrictions, and limit her visits with her family. Also, had she tried to intervene, her husband might have become so angered that he might have gone on to verbally abuse the son more viciously, for example, by calling him a “sissy” or a”girl” for having a woman try to defend him. Her involvement could also have triggered an act of physical violence if not immediately, at some later point in time. She chose to act is the most reasonable least risky manner, yet she feels like a coward.

Another example is that of the rape victim who doesn't put up a fight because she fears being harmed for resisting. Many rape victims, both male and female, feel guilty for “giving in.” But they didn't “give in” because of a cowardice or a character deficiency. They might have had a freeze reaction or they might have made a quick assessment that it was safer to acquiesce than to fight back. Had they resisted and been beaten or injured in other ways, they might have felt guilty for not having “known better” and not having been able to predict that the rapist would become even more violent. (Fight-flight-freeze reactions are discussed in more detail in a later section of this chapter.)

IGNORING REQUESTS FOR ASSISTANCE

A woman and her elderly father are attacked by a mugger. The woman and her father begin to run, when the father trips and falls. The father calls out for help. When the daughter turns around, she sees the mugger stabbing her father mercilessly in the chest. Her father continues to cry for help. For a minute, she considers running back to answer her father's call. Instead she turns around and runs for help.

Today she feels like a coward. She also feels “heartless” for not answering her father's call. Yet she knew wasn't strong or skilled enough to fend off the attacker. If she had rushed to her father's aid, not only would she have been unable to save her father, but there was a high probability that she would be harmed or killed also. By running away while she could, there was at least a chance of obtaining help for her dad.

A rescue worker ignores a trapped car accident victim's cries for help because he can predict that the car will explode momentarily. Within seconds, the car explodes into flames. It's obvious to all that the rescue worker would not have had time to cut the victim out of the car before the explosion. Had he tried to save the victim, he would have caused two deaths, his and the victim's. Rationally, he knows that he had little choice but to do what he did, unless he wanted to throw away his life. Emotionally, however, he suffers from survivor guilt for “letting someone die.”

MAKING MISTAKES

Making mistakes during a stressful or traumatic situation is also a major cause of survivor guilt. For example, it has been found that killing Americans by accident in friendly fire incidents was a top source of combat-related guilt in Vietnam veterans (Brende 1991 ). Doctors, nurses, and medical staff who, under extreme duress, make mistakes which hurt their patients or cause them to die suffer from extreme survivor guilt. Yet on the front line in wartime or in the midst of a natural catastrophe, such as a hurricane or tornado, it is easy for anyone to make mistakes, even trained professionals.

Many mistakes are the result of fight-flight-freeze reactions, basal constriction, and other physiological changes which occur involuntarily during times of extreme stress. These processes are discussed in a later section of this series.

THOUGHTS AND FEELINGS.

During times of stress or trauma, people also have thoughts and feelings which they didn't expect to have and which they judge they judge as inappropriate at best and “bad” or “evil” at worse. For example, upon hearing that her brother was hospitalized for a tumor, Sally thought, “Oh good. I get the television all to myself.” Within seconds, she felt guilty for having such a thought and even more guilty when she realized how automatic the thought came to her.

In some situations, people care so much about another person or feel so responsible for that person's well being, they may wish that person dead so that they can be free of the responsibility. Bernice, an abused teenager who ran away from a home where most of her brother and sisters were being abused, felt extremely guilty for leaving the others behind. She felt so protective of them that at times she wished they would die so she wouldn't feel she had to go home to do what she could to help keep them safe. Yet Bernice felt she was a horrible person for wishing her brothers and sisters dead.

Bernice failed to realize was that she really didn't want her brothers and sisters to die: what she truly wanted was freedom from the burden of feeling she should return to a situation which was hellish for her in order to protect them from harm. She felt powerless and helpless to help them except by sacrificing herself. Had she felt other options were available to save her brothers and sisters, most likely she would have never wished for their deaths.

People exposed to dead persons or severely injured or mutilated bodies sometimes find themselves looking at the bodies with objectivity and curiosity. “It was really interesting to see what the inside of a stomach looked like, or what human brains looked like,” police, rescue workers, medical staff, soldiers, and others who have seen death sometimes say. Later on, they may feel guilty for looking at the body without emotion.

“I should have been feeling bad the for the person who was dead, not looking at them like I was doing a science experiment,” explains Michael, a rescue worker. Yet his objectivity and the emotional calmness with which many people confront the dead and dying is a way of distancing from the pain and death of others as well as from the truth about their own vulnerability to illness or injury and the inevitability of their own death.

GUILT OVER COPING METHODS

In Courage to Heal, authors Bass and Davis (1988) write about some of the ways survivors of sexual abuse developed in order to cope with the abuse. These include minimizing, rationalizing, denying, forgetting, making jokes, being super-busy, escaping, lying, stealing, overworking, gambling, overindulging in sex, developing a mental illness or an addiction, self-mutilation, or suicide attempts. These coping methods are common among many types of trauma survivors, not only sex abuse survivors.

They are also common among persons who have survivor guilt. These coping tactics may have been necessary to insure emotional and physical survival or to maintain the ability to keep on functioning. Yet later on, when people reflect about how they acted or felt during their trauma or stressful event, they can feel tremendous guilt for having used any of these coping mechanisms. This guilt can exist even when people did not consciously chose to minimize, deny, rationalize, develop an addiction or a mental illness or utilize any of the other coping mechanisms listed above.

Minimizing and Denial . Minimizing means reducing the severity of the event, its impact, or its meaning. For example, the mother of a child with a 105 degree fever is minimizing when she thinks to herself, “My child isn't that sick;” the friend of a rape victim, when he or she thinks, “What's a little rape compared to losing a parent?”

Trauma survivors sometimes minimize the impact and meaning of other people's traumas. Hence combat soldiers can wonder what incest survivors are “complaining about” by thinking that incest is “nothing” compared to the horror of war. Incest survivors, in turn, can wonder what combat soldiers are “complaining about.” Some point out that whereas soldiers fought for their lives in danger zones for one to

four years, they may have fought for their lives and were subject to assault for ten to fifteen years, if not longer.

Denial means acting as if the event never happened. “Denying is turning your head the other way and pretending that whatever is happening isn't, or what has happened didn't” (Bass and Davis 1988, 42 ). Minimizing, like denial, serves to protect people from the emotional shock of the event as well as from their own feelings of helplessness and powerlessness to make things better or to avert an insult, injury, or death. In such instances, minimization and denial can also reflect the inability to handle the intense feelings of anxiety, fear and grief which would involved in directly facing the event or trauma.

For example, a husband whose wife complains of a lump in her breast might minimize the possibility that the lump is malignant by saying, “It's just a cyst. You get them all the time. They come and go. Don't worry about it,” or “It's not that big. Even if it is cancer, it can't be that bad.” Or he might even deny the existence of the potentially life-threatening lump by saying that he can't see it or feel it. Even if a physician verifies the reality of the lump, the husband may insist that the physician is in error.

“It's plain as day. There is no lump,” a distraught husband may argue with his wife's doctor. Later on, when it becomes obvious that the lump is cancerous, the husband is overwhelmed with guilt for his mimization and denial. He feels he failed his wife by minimizing and denying the possibility of cancer. Two factors contributed to his minimizing and denial. The first was his fear of unable to pay the medical bills involved in treating cancer. The second reason was even more important. He feared his wife's death. He simply could not conceive of life without her. Ironically, it was his very love and need for his wife which were prompted his minimization and denial.

Minimization and denial can also serve to protect people from the responsibility of having to make a decision about a course of action. In times of stress or trauma, decisions about what to do or not do are often complex. Sometimes each option seems inadequate, morally dubious, or fraught with risks and pain. One solution is to avoid the necessity of having to make a decision to take action by minimizing or denying the reality of the situation which is calling for a response.

For example, a mother of a teenager with a drinking problem denied the extent of her son's addiction because she feared confronting him. Predicting that he would yell at her, reject her, and feel alienated from her if she forced him to seek treatment, she assumed the emotionally safer position of denial and minimization. However, later on, when her son ran over an elderly woman due to driving while intoxicated, the mother suffered the pangs of survivor guilt.

“That car accident was my fault. Instead of facing the truth of what was going on, I took the easy way out. I pretended it wasn't that bad or that it wasn't happening, or happening that much. That way, I didn't have to do anything. In a few moments of lucidity, I did see what was going on and tried to think of what I could do. But there seemed to be no solution.

“No. I take that back: there were solutions, but they all cost too much money or took too much effort or endangered my pride and reputation.

“It was all too much for me, so I guess my mind flipped out and decided that the only way to handle this problem was to say it wasn't a problem, or at least a problem I had to do anything about. I comforted myself by telling myself that time would take care of it or that I was just overreacting as usual. But what I was doing was denying. If I had tried to stop his drinking, maybe the accident wouldn't have happened. I'm sorry now, but it's too late.”

In therapy the mother learned that her passivity towards her son alcoholism stemmed from growing up in a home where she was the scapegoat of her parents' anger. As a child she learned to fear anger and confrontations, for they inevitable lead to her being denigrated and restricted. As a young woman, she married a man who came to physically abuse her. In her marriage, she learned to avoid confrontations because they usually meant beatings ... for her.

She divorced the man who abused her, but she did not divorce her fear of speaking up in problematic situations. What saved her life in the past, avoiding confrontations, created problems in the present when it was necessary and appropriate for her to be vocal about her beliefs and concerns.

Like this mother, people who use minimization or denial as coping mechanisms sometimes feel like “cowards” later on. Upon closer examination, however, minimization and denial may not reflect cowardice, but a fear for one's own safety and survival, or a sincere confusion about the significance of the event.

For instance, in work situations, you might see a co-worker being mistreated, but you minimize or deny the mistreatment for two reasons. First, you may want to avoid the emotional pain involved in feeling compassion for your co-worker, especially if you are already experiencing personal stress in other areas of your life. Becoming emotionally involved with the co-worker's pain could put you on overload and cause you to become less efficient and productive. Secondly, if you support the co-worker and this becomes evident, the supervisor who is harassing your co-worker may well begin to harass you as well.

For example, Arnie observed his boss upbraid the office manager on trivia, such as how she was xeroxing two pieces of paper, and change his directions to her on how to xerox at least a dozen times. By the end of the three hours, the office manager was weeping and the boss's face glowed with glee at her suffering.

Arnie dismissed the incident by viewing it as the boss simply having a bad day. He assumed the incident would not repeat itself. At this point, he was not necessarily minimizing because he did not have enough information to assess the situation. In the weeks to come, the boss denigrated the office manager staff meetings, ridiculed her physical disability in front of guests, and made frequent public comments about how he'd like to be rid of her. It was obvious to other office staff that the office manager was being harassed. However, Arnie viewed the situation as a “minor personality conflict” between the office manager and his boss.

Even when the boss called the office manager a “cripple” and almost shoved her, Arnie minimized the situation rather than see it for what it was -- an instance of harassment based on gender and disability. “It's not that bad,” Arnie told himself. “After all, the boss isn't hitting her. She still has a job.”

In time, the office manager had a mental breakdown and resigned. Afterwards, Arnie felt guilty for minimizing the events and not intervening on behalf of the office manager. “I could have at least said something at those staff meetings where she was being humiliated. Or I could have documented the abuse in case she ever went to court. But instead I did nothing. I was a coward. I was afraid of losing my job because my boss had hinted to me that anyone that didn't go along with his policies could expect a poor evaluation and a possible removal. I looked around for other jobs, but there were none, so I knew I had to stay there and I couldn't stay there if the boss got on my back like he did the office manager's.

“Today I feel guilty because I didn't stand up for what was right. The boss just gave me a promotion and I feel guilty about it. I feel like it's contaminated with the heart's blood of the office manager. A wimp like me doesn't deserve a raise!”

Minimization and denial are common defenses against the reality of emotional, physical or sexual abuse in any setting, especially in families. The victims may deny or minimize their abuse in order to lessen the pain and make their lives tolerable. At the same time, the perpetrators of the abuse also tend to deny or trivialize the abuse. Herman writes “After every atrocity one can expect to hear the same predicable apologies: it never happened; the victim lies; the victim exagerrates; ... the more powerful the perpetrator ... the greater his prerogative to name and define reality” (Herman 1992).

However, it is not just victims and the perpetrators who use minimization and denial -- but the bystanders as well. The bystanders can include other family members, neighbors, and friends. For example, Irene recalls seeing her older brother hold her younger brother down and yank his arms. “They're just rough-housing,” Irene thought. Even when her younger brother needed medical care after a few “rough-housing” incidents, Irene still viewed the abuse in her home as a case of “boys will be boys” rather than what it was: sibling abuse.

Today, she feels guilty for not having helped her younger brother. “How could I have been so blind? So stupid? So dumb? If I had done something, maybe my younger brother wouldn't be so insecure today,” she says. However she forgets how much she needed to believe that her family was perfect and how much she feared her older brother would turn on her.

Similarly, mothers who see their boyfriends, husbands, uncles or other male relatives inappropriately fondling their small daughters may miminize the violations they are witnessing. “He's just cuddling with her,” Or “He's just trying to calm her down,” or “He doesn't mean anything by it,” a woman might think. These are all forms of minimization. Instances of total denial are also possible. Mothers can walk into a situation where they see their daughters (or sons) being sexually or otherwise violated and then deny that they saw anything extraordinary occurring. (This type of denial could also be a form of dissociation, which is discussed later on in this chapter.)

If, at a later date, the protective shield of denial and minimization are shattered, victims and bystanders can feel ashamed and guilty about not having seen the abuse for what it was and taken appropriate action. For victims, the guilt stems from feeling that they let themselves down by not acknowledging the abuse. For bystanders, such as family members and friends, their survivor guilt stems from the realization that if only they hadn't minimize or denied what was going on, they might have been able to help the victim. (The section on “Fight-Flight-Freeze Reactions” later in this chapter can provide further insight into the causes of denial and minimization.)

Rationalizing . Rationalizing means using rational ideas to make excuses for someone who is being abusive or using logical thoughts as a way of excusing your own unwillingness to act in a manner that would help preserve the safety, integrity, or life of another. For example, in the previous example Arnie was rationalizing when he tried to figure out why his boss was harassing the office manager and made excuses for the boss by thinking that the boss was “having a hard day” or that the secretary “deserved a little discipline” because she had been lax in some manners. Irene, who observed her older brother physically abuse her younger brother, would have been rationalizing if she decided that her older brother needed to get rid of pent up energy because he was taking some difficult courses at school. With respect to hate crimes based on race, sex, religious affiliation, or physical disability, rationalizing is based on thinking that certain people deserve to suffer or die because they are irrevocably flaws or inferior.

Like minimization and denial, rationalizing functions as a defense against acknowledging a painful reality and one's powerlessness or restricted ability to rectify matters. When confronted with a stressful or traumatic circumstance where all of your options seem inadequate to solve the problem and where all of the options involve great emotional or physical costs or even risks to your own life, rationalization offers a way out. Instead of agonizing over which of several unacceptable and frightening choices you could select, you reduce the problem by finding a reason to explain it. This helps free you from the dilemma of deciding how to respond when all possible responses are unacceptable or ineffectual.

Being Superbusy, Developing an Addiction, Escaping

Being super-busy, developing an addiction to a substance, gambling, or sex or becoming involved in escapist activities, such as taking long vacations, are all forms of managing the anxiety associated with being in a stressful or traumatic situations. People become workaholics (or the opposite, engage in escapist activitites) or develop substance abuse problems or other forms of addiction in an attempt to reduce their pain and to preserve their sanity. While these might not be the most constructive choices, sometimes they are the only choices people feel they have available or know about other than self-mutilation, suicide, or insanity. There may be other options, but they are not known, are not available, or are too costly.

Nevertheless, people can suffer great survivor guilt for having used one of these coping methods during a crises or traumatic circumstance. “Here my sister was being hit in front of my eyes and all I was thinking about was getting enough binge foods,” a woman explains. The guilt is even greater if the person was engaging in the addiction, escapist activity, or overwork when the victim was in special need.

“I was working late at the office, as usual, when my daughter Diane was contemplating suicide. If I had gone home at 5 or 6, like most men, I'd have seen how poorly she was feeling and taken her to a hospital. But, no, compulsive worker that I was, I had to finish the project I was working on. My workaholism killed my daughter. I'm sure of it, and I'll never forgive myself for it,” explains one father.

This father had begun working late in order to escape a domestic situation where his wife verbally abused and scapegoated one of their daughters. He had tried to intervene several times, but his wife had berated him so severely, he eventually withdrew from the mother-daughter arguments. Since he couldn't stand to be in the home when his wife was punishing his daughter, he took up sports as an escape, and then work.

To this day, he feels guilty about his escapism and overwork. Yet these activities in themselves did not cause the suicide. Most suicides are highly complex matters. In this suicide, the mother's abusiveness towards her daughter as well as the father's inability to protect his daughter from his wife, were obviously contributing factors. But they were not the sole factors leading to the girls death.

Part of the father's healing involved looking at why he could not stand up to his wife. The reasons included fear of his wife's criticisms and the need to preserve his ability to function so he could provide for the family.

“Whenever I fought with my wife about the ways she mistreated our daughter, my wife would insult me to the core. I was so devastated by her comments, I couldn't fight back. Then at work the next day I was half a man. I was afraid I couldn't function if I kept on arguing with the wife about Diane. I had to keep my job, didn't I?” the father explains.

Dissociation: Forgetting, spacing-out, tuning-out .

People often suffer from survivor guilt because they “spaced out,” “tuned out” or “forgot” during an event or series of events which lead up to or involved the injury or harm of another person. In psychological terms, these experiences of “spacing out” and “forgetting” are called dissociation.

Have you ever been driving to a familiar place and missed the exist on the highway because your mind was somewhere else? Have you ever left your keys or wallet somewhere by accident because you were stressed out or “ on overload?” Have you ever forgotten meeting someone or doing something because, at the time, you were preoccupied with other important matters?

Such experiences of forgetting are common to everyone. They are minor forms of “dissociation” or a problem in memory where certain parts of reality are overlooked and other parts are focused on intently.

Without dissociation, we could not study for tests or even watch a movie because any concentrated activity requires paying attention to one part of reality and blocking out another. Many people who have lived through severe stress or trauma wish they could have “dissociated” from the situation so they could simply have a little peace. To truly dissociate involves not only temporarily forgetting or dimming some of the stress, but diminishing, or almost obliterating, feelings about the stress.

Dissociation is a normal reaction to trauma. It is just a common reaction to extreme stress and trauma as are clinical depression and post-traumatic stress disorder. During dissociation, which is often described as “tuning out” or “numbing out,” your feelings become disconnected from your experience. You feel distant from what is going on about you, almost as if you are an observer rather than a participant in your own life. Amnesia about all or part of a specific traumatic event may also develop.

These forms of emotional and mental “shutdowns” are to be expected under conditions of extreme stress or trauma. Emotionally, most people can't tolerate living in a constant state of extreme feeling, whether that emotion be grief, panic, or anger. Physiologically, the body can not remain in a constant state of hyperalert without reprieve. The usual response to being in a prolonged state of emotional and physiological flooding or overload is a slowing down of all systems -- emotional, mental, and physical.

. In many cases, dissociation can be a lifesaver. For example, the ability to dissociate helps medical workers, rescue workers, firefighters, and policeman to focus on the task at hand by ignoring their emotions. Dissociation also helps children from homes where there is physical or sexual abuse do their homework and sexual abuse survivors to bear unbearable conditions.

Dissociation often occurs in intolerable situations when there is no other way out. If you can not flee physically, dissociation permits you to flee in other ways. However people who do dissociate or “tune out” or “numb out” often feel guilty for being in this state because they feel this state prevented them from correctly assessing the difficulties at hand and from taking action to help themselves or others.

“My dad yelled at my mom all the time. He said some very mean things to her, but I didn't hear them. Well, not exactly. I did hear what he was saying, but I don't remember the exact words and I blocked on the emotional significance of the words. I didn't react with anger and hurt. I was like a blob, a mummy. Here was my dad calling my mom all kinds of names and to me it was as if he was discussing the weather. I feel I betrayed my mother by not being present and appreciating the full impact of what was happening to her. Even if I couldn't have stopped my dad's rages, at least I could have reacted and felt something. Instead I felt nothing and I feel real guilty about that,” explains Carlos.

As Carlos's reaction illustrates, true dissociation can involve not only a blocking of information or memories, but a numbing of the emotions associated with that information or othose memories. Similarly, veterans may not recall a firefight or may be confused or vague about the specifics of the battle, but also report that they cannot remember their feelings at the time or that they have few feelings about the event today.

If during battle, some friends died or were wounded, a veteran may have few feelings about these events. This lack of feeling can be a source of considerable guilt. For example, after several days of battle, Bryan was called over by his lieutenant to a truck load of dead American soldiers. The lieutenant was new to the front and did not know his men by sight. He asked Bryan to identify the bodies, since most of the dead had lost their dog tags. Bryan , exhausted from days and nights of fighting, remembers looking at the dead men like they were pieces of meat or pieces of ammunition. Today his guilt at not feeling appropriately grieved when he saw his dead friends plagues him almost daily. “ I let them down,” he says in session. “I didn't kill them, but I betrayed them by just rolling off their names like they were nobodies. I didn't honor the dead, and in my book, that is just as bad as killing them.”

He often has flashbacks of the cartload of dead soldiers which are exact replays of the traumatic event, with one difference: the faces of the dead stare at him accusingly. “Why aren't you here with us? And why didn't you mourn us? Why did you treat us like dispensable objects instead of warriors who needed to be honored and respected for their sacrifice?” the dead faces seem to say to him. Bryan seeks relief from his torment in alcohol, marijuana, and in isolating from his family.

Developing a mental illness, self-mutilation, or suicide attempts . Developing a mental illness, self-mutilation and suicide attempts are ways of coping with the stress involved in being a situation where someone is being or can be harmed. They often reflect the intensity of the stress, rather than the person's personal strength, moral character, or love and concern for the victim or potential victim. In addition, people who become mentally ill, self-injurious or suicidal are probably also being harmed themselves or lack sufficient inner resources, external supports, or financial or other means to bring about the resolution to the stressful situation. We are only human and given enough stress, we are all vulnerable to developing a mental illness or such a severe depression that we want to harm ourselves.

“Here I was, in the mental hospital with a depression when my nephew needed me. I had no right to be mentally ill when he was going through so much. If I had been well, I could have been there to guide him. Instead, he turned to drugs and alcohol. That's my fault,” says a distraught uncle. Yet the uncle did not will himself to become mentally ill and there were other influences on the nephew besides the absence of an uncle which caused him to develop an addiction.

COMPETENCY GUILT

Competency guilt involves feels guilty for not having acted as efficiently or wisely as you think you should have. In truth, you may have not been functioning at your best or meeting your personal performance standards during the time you were being stressed or, if you were traumatized, during the trauma. However, you need to take into account the bigger picture -- the fact that you were operating under conditions of trauma, or conditions of extreme stress.

As Kubany (1996) points out, different decision making rules apply during trauma than during every day life. In the first place, trauma is usually both unexpected and chaotic. Even though your senses are on hyper alert, there is usually much going on during a trauma, and at such a rapid pace, that no one person can accurately observe all that is taking place. a whole team of people would be needed to obtain a more total view of the situation and afterwards come up with a list of viable options and an effective action plan.

If, for instance, you were held up by an armed bandit, you may find yourself focussed on his gun, not his face or his clothing. You may or may not see that there is another bandit with him, or that there is a police officer one block a way. Such information could influence what you decide to do or not do. But all the information necessary for the best decision possible isn't available because of the tendency, under conditions of trauma, for there to be selective attention to the most life-threatening aspect of the situation. In the mugging situation, for example, your attention might be focussed on the gun -- because that gun has the power to destroy you-- not on other aspects of the situation.

In the second place, during trauma time is precious. You do not have the luxury of brainstorming alternatives and carefully examining all the options available before you make a decision. If you are running away from a rapist or a mugger or have only a few seconds to escape from a fire or flood, you may not be able to think of all your options and carefully select the best one. You have to act right away, or risk dying or being injured, or the deaths or injuries of others. You also have to act (a) without having the time to ask the opinions of people who may know more than you about what to do; (b) at a time when your mind may not be functioning at its best, due to the terror and the stress; and © at a time when strong emotions, such as fear and panic take over and you have no choice but to feel them and try to make a good decision in spite of them.

There are other conditions of extreme stress which are not unexpected or chaotic. Instead, they are expected, if not chronic and long term in nature. Even though they are not intense traumas like family violence, war or a natural catastrophe, they can still be emotionally, physically, and mentally draining and can impair your ability to function. Not only during traumas, but during stressful life events, different decision making rules apply than during every day life. Unlike an unexpected traumatic event, the stress you experienced may have been fairly predictable. For example, if you were tending to a sick parent or child, the illness, after the initial shock, the illness may have become a routine part of your life. Similarly, if one of your co-workers was being harassed, you might have become used to seeing them mistreated. However, just because your stress was somewhat predictable or expected doesn't make it less stressful. The very fact that someone is ill or in danger of being hurt, injured or mistreated can put you in a state of emotional overload.

You were probably subject to work overload, as well as emotional overload. In most stressful situations an important source of the stress is the sheer number of tasks that need to be performed. For example, if you have parents who are ill, you may have extra responsibilities such as preparing meals for them, cleaning their home, taking them to the doctor, coordinating their doctor's appointments, picking up their prescriptions, etc.. These extra responsibilities, in addition to your regular load of responsibilities, can fragment your energies, making it difficult to focus clearly on all the factors involved and impairing your ability to make sound decisions, not only for them, but for yourself and your family.

Another stressor may be financial and yet another, social isolation. As you focus on managing the stress at hand, you have less and less time for socializing, recreation, and other forms of pleasure and stress reduction. You are being emotionally drained while at the same time you have less and less time and resources with which to emotionally replenish yourself. These and other types of stresses can weaken you, not only emotionally, but physically and mentally as well. In this state, it is humanly impossible to function at peak efficiency and competence in every area of life and you are more likely to forget important matters, make faulty decisions, or other mistakes than if your life was relatively stress-free.

Your awareness that your functioning powers are impaired creates yet another stress. a vicious cycle begins where the stress creates more stress, making you feel less and less able to cope. Even though you may be trying hard to be as responsible and helpful as possible, your mental, emotional, and physical powers are, to one degree or another, weakened, which makes it harder for you to think logically and rationally. In addition, there are usually so many matters to attend to that it can become hard to think clearly and make accurate predictions about the best course of action.

Competency guilt has also been called “I should have done more guilt” (Williams 1987). Underlying your belief that you should have done more are several assumptions: first, that you could have done more; secondly, that what you did do in the situation was ineffectual or unhelpful; thirdly, that people can control their physiological and emotional reactions; and fourthly, that under conditions of stress and trauma people, including you, could be and should be functioning at your best.

In reality, under stress people can not always control their physiological and emotional reactions. Nor can they force themselves to remember accurately or think quickly and rationally. It is a myth that our performance under conditions of stress or trauma “should be and can be perfect” (Williams 1987, 151). By focusing on what you think you should have done, you may overlook the positive contributions you made by what you did do.

NEGLIGENCE GUILT

Closely related to competency guilt is negligence guilt or the guilt which can result from some form of negligence in performing your assigned duties or executing your designated role. Do you feel guilty because you were negligent in your duties and someone died or was injured as a result? For example, if you are a parent, did you fail to check with your pediatrician before you gave your child the medication which nearly caused your child's death? If you are a nurse or medical professional, did you forget to monitor your patient's blood sugar level only to find that patient in a diabetic coma? If you work in an office or a factory, did you fail to document instances of harassment of a co-worker as you had promised because you were too tired or too busy with other job responsibilities? Regardless of your vocation, were you taking a break, eating, smoking marijuana or drinking when you should have been tending to your duties?

As with competency guilt, it is important to examine your negligence guilt in the context of the larger picture. Sometimes negligence is the result of the stress or trauma itself. For example, if you work in an environment where a co-worker is being harassed, the stress of that situation may compel you to take additional breaks or days off or take a drink. Similarly, if you are a medical professional who works long hours or with many complex cases, you may indulge yourself in a way that appears like negligence but more truthfully is a means to replenish yourself emotionally or physically so that you can continue to function in a demanding environment.

An important question to as yourself is what prompted the negligence? Was it a sincere desire to cause harm or abdicate responsibility or was it instead a misguided, but nevertheless sincere, effort to reduce stress or to meet some of your legitimate needs? Were you truly negligent or were you simply not trained or inadequately trained for the task at hand?

HINDSIGHT BIAS

Kubany (1994, 1996) defines hindsight bias as the tendency to think you were smarter than you actually were during a difficult time or to think that you knew things while you were under stress which you only realized after the stress was over. For example, people under stress tend to evaluate what they did or didn't do based on the information they have about the outcome of the stressful event or options they thought of long after the stressful event was over, rather than on the information they had and options they thought of during the time of the event itself.

For example, a father and mother allow their three daughters to go to the beach with a favorite aunt and uncle. During the vacation at the beach, the uncle rapes one of the daughters. Several years later, the daughter reveals this rape to her parents. Since the rape was disclosed, the parents have learned from other sources that this particular uncle was a known child abuser. However, he had cleverly hid the information from his family, even his wife.

The parents feel guilty. They feel they should have known the uncle was a pedophile. Yet at the time, they had no knowledge of this uncle's sexual history and what they did know about this uncle was that he was very kind and generous with their daughters and appeared to be a devoted family man.

A similar example is that of a nurse who administers medication to a child and the child has a severe allergic reaction. The nurse feels she “should have known” the child was allergic to the medication, yet she had no information about the child's allergies neither was there any evidence that this child was allergic. The nurse's intention in administering the medication was to alleviate the child's suffering, not to harm the child. She feels guilt anyway.

Another example is that of a man in an war-ravaged city that was almost depleted of food, water, and medical care, decided to send his family to a rural hiding place. He loaded his family on a truck bound for a small village and thought they were safe, only to find out later that the truck was ambushed and all the passengers were killed or sold into slavery. He blames himself for not anticipating that the truck would be ambushed, not into consideration that had he known the truck was going to be captured, he would have kept his family with him.

His intention was to save his family, not have them hurt. Yet his hindsight bias has resulted in a deep and abiding sense of guilt.

.“‘Catch-22' Situations:

Stressful life events, especially if they are traumatic, are full of lose-lose situations, where all the choices available are unacceptable or involve a violation of personal ethics. Usually, no matter what choice one makes, one is betraying one's self, or an important value. The teacher who has a problem student can feel guilty for ignoring him and giving her attention to students who want to learn. On the other hand, if the teacher gives her attention to the problem student, she might feel guilty for taking away time from the rest of the class. The husband who has to spend time taking care of his sick wife can feel guilty over not being able to give his children the attention they are accustomed to receiving from him. On the other hand, if he doesn't help his wife and spends time with the children instead, he could feel guilty for not assisting his spouse in time of need and neglecting his children's mother.

The woman who is alone in the office with a co-worker who has just collapsed on the floor and is having trouble breathing can feel guilty for leaving her co-worker to search for help. On the other hand, if she had stayed with the co-worker and been unable to help him, she could feel guilty for not trying to obtain medical care. The abused wife who leave her husband can feel guilty for depriving her children of a father and of a comfortable standard of living. On the other hand, if she chooses to stay, she can feel guilty for exposing her children to violence and to a chaotic life-style. The combat veteran who shoots a grenade-laden toddler can feel guilty about killing a child. But if he hadn't killed the child and the grenade went off and killed his squad, then he would feel guilty about not preventing the deaths of his comrades.

The mother of a teenage boy who committed suicide could feel guilty about not having supervised her son's every move. If only she had kept tighter control over him, she could have caught him before he took that overdose of pills. On the other hand, if she had kept watch over her son every minute, she would have felt guilty about not permitting him the freedom to enjoy the activities and friendships that were giving her son some satisfaction and will to live. Also, she would have been told by others that she was creating depression her son by being “overcontrolling” and not allowing him enough autonomy. Then if he had killed himself, she would have blamed herself for having made him unhappy by keeping too close a watch over him.

Kubany calls this type of guilt “Catch-22" guilt because no matter what choice is made, there is an undesirable outcome. (Kubany, 1994, 1996). In these situations, the least bad choice is the best choice, but people who have undergone severe stress or a major trauma rarely view matters in this way. They tend to evaluate their choice against a wished-for, magical, or unrealistic ideal choice that was not available at the time. (Kubany, 1996). Until they have the benefit of examining their behavior, feelings, or thoughts in a rational light, their suffering from guilt can be enormous. Indeed, this type of guilt is often at the root of substance abuse problems, eating disorders, and suicidal depressions.

Guilt over Helplessness and Powerlessness

Some people feel guilty about being helpless and powerless during a threatening or dangerous time, yet being relatively -- or totally - helpless and powerless in the face of a major threat is the very definition of stress. Being rendered helpless in a situation of great danger, where there is a threat of death, is the very definition of trauma. Since people prefer to think that they are able to control their lives, it is easier to blame themselves for negative events than to acknowledge that sometimes life is unfair or arbitrary and innocent people can be victimized for no reason.

Guilt over Fight-Flight-Freeze and Other Emotional and Physical Reactions

THE MIND-BODY CONNECTION

Our emotions, thinking, and body are inseparable. The way we feel affects how we think and the way we think affects how we feel. The state of our body affects the state of our mind, as well as our emotional state. Endless examples can be provided to illustrate the fact that the mind, body, and the emotions are not separate entities, but intimately related. Nowhere is this more true than in the case of extreme stress of trauma, where many of the psychological symptoms and relationship problems are not just “in the head,” but “in the body” as well.

Like the rest of your body, your central nervous system is vulnerable. Given enough physical or emotional stress, it too can bend or even break. When you experienced your extreme stress or trauma, your central nervous system received a series of shocks. The fewer the social supports and comforters you had during the trauma and greater the intensity and the longer the duration of the trauma, the greater the possibility that the delicate biochemical balances of your body might have been disrupted.

Despite an increase in research on the biochemistry of trauma and extreme stress in recent years, there is no single definitive theory as to how severe stress affects the body. One theory is that trauma destabilizes the autonomic nervous system; another is that trauma changes body chemistry so that the individual is more prone to anxiety. Yet another hypothesis is that trauma disrupts certain specific biochemical balances, for example, serotonin or catecholamine levels (Murburg, 1994, 1995; Mc Farlane 1996; van der Kolk et. al., 1996).

Another theory is that under conditions of danger, the organism coordinates a mental, physical, and emotional effort to respond in a self-preserving manner. After the emergency is over, then the organism returns to the thinking, feeling, and physiological states appropriate for daily (non-traumatic) living. However, when stress is extreme, such as in trauma, or when stress is prolonged, all systems do not return to previous levels of daily functioning. They may remain in a state of emergency (Giller, 1994). Evidence for this theory are studies which show that some twenty years after trauma, some survivors live in an altered state of arousal. Persons with post-traumatic stress disorder have been found to excrete more neurohormones of epinephrine or norepinephrine than non-traumatized persons and than persons suffering from major psychiatric disorders, such as schizophrenia or major depression. (Van der Kolk, 1996b, 1994a, 1994b). Although not all studies of trauma survivors show these results, many do (Murburg, 1996).

No single biological explanation is satisfactory in that no one theory can explain the wide range of symptoms in trauma survivors. Yet it is an established fact that PTSD, for some trauma survivors, especially those subjected to repeated trauma, has both physical and emotional effects.

When Dr. Abraham Kardiner, a psychiatrist who treated combat veterans during World War I, described shell shock, he described it as a “physioneurosis” in that the individuals who suffered from war-related PTSD had not only psychic disturbances, but physical ones as well. These included body tremors, urinary incontinence, heart palpitations, sweating, and increased incidence of heart and other diseases. In fact PTSD was first “discovered” by Charcot, a neurologist in 19th century France, who became intrigued by hospitalized women who had physical complaints and ailments with no known physical basis. Most of these women proved to be victims of child abuse, wife abuse, rape, and other trauma. When they were hypnotized or otherwise encouraged to talk about their trauma and got in touch with their memories and their feelings about these memories, many of their physical symptoms disappeared.

RESEARCH ON THE BIOLOGY OF PTSD: THE DANGER OF OVERSIMPLIFICATION

In recent years, considerable research has been completed on survivors of various traumas, from Holocaust survivors and abused children to rape victims, combat veterans, and car accident survivors. This research suggests that in certain cases profound physiological changes accompany severe or prolonged trauma. The nature of these changes and how they affect relationships could fill an entire book and are only briefly presented in this chapter. However, it must be emphasized that research on the biology of trauma is in its infancy and that all statements made in this book regarding the biology of trauma may well be out of date in ten years from now.

The greatest danger in presenting the subject of the biology of trauma is that of oversimplification (Murburg, 1994, 1996). The workings of the brain and the way changes in the brain affect emotions, sexuality, physical health, thinking, and memory are still great mysteries and fraught with controversy. In addition, most of the research on the biology of traumatic reactions has been completed only on trauma survivors available for research, namely inpatient psychiatric patients or outpatient mental health patients. Trauma survivors who can not afford or who are not interested in therapy or who have died or become physically ill or psychotic as the result of their traumas have not -- for obvious reasons -- been included in these studies.

Also, results of the studies have been influenced by the age and socio-economic status of the participants, as well as factors such as the type and severity of the trauma and the traumatic reactions; the co-existence of traumatic reactions with substance abuse, clinical depression or other psychiatric disorders; and the physical health and habits of the participants. For example, research results have varied depending on whether or not the subjects being studied were overweight, smoked, or drank coffee, as well as if they were experiencing current stress their lives, especially on the job. Research results have also varied depending on type of technology used, e.g., whether blood samples as opposed to urinary samples were examined, and whether the testing was conducted in a hospital, university, community clinic, or home environment (Murburg, 1994, 1996).

Nevertheless, certain general trends emerge: mainly that persons who have been severely or chronically traumatized tended to either overreact or underreact during the trauma, as would be expected and as would be necessary for survival, and to either overreact or underreact to present day situations, creating anxiety and shame within themselves and creating chaos in their relationships. If you have been traumatized, it is critical for you to understand both the immediate and possible long term biological consequences of the stress you have endured. If you got “hyper” during the trauma and still get “get hyper” today when reminded of the trauma, or, if you “got stupid” and felt dead inside during the trauma and still, at times, do today when reminded of the trauma, it may help you to know that these extreme reactions are not signs of moral or emotional deficiency.

Rather, these extreme reactions, which create so much pain in yourself and so much havoc in your relationships, are, to a great extent, the result of physiological processes out of your control. They are not acts of will or choice, but part of survival-based physiological responses which are largely involuntary.

ACUTE STRESS REACTIONS: FIGHT-FLIGHT-FREEZE REACTIONS: ADRENALINE AND NORADRENALINE

Figure One illustrates some of the emotional and physiological reactions to trauma. Emotionally trauma gives rise to at least four overwhelming emotions: fear, grief, rage, and anxiety. These feelings are so powerful that to experience them in full force at the time of the trauma would be personally disorganizing and might endanger survival. Therefore, these emotions tend to be suppressed, to one degree or another.

When emotions are not suppressed during the traumatic event, at least in part, individuals can become non-functional. For example, they may not be able to move or think clearly due to uncontrolled bouts of weeping or screaming or due to hallucinations or any one of a number of psychotic breaks from reality. When overwhelmed by emotion during the trauma, some individuals have committed suicide, homicide, or acts of self-mutilation (such as cutting, burning, head-banging) which hamper their coping abilities and endangers the safety of others.

The life-threatening nature of trauma also gives rise to certain physical emergency responses which are designed to help people survive the trauma. Included in these three responses are the “three F's” -- fight, flight, freeze. (See Figure 1.) Under conditions of danger, the adrenal glands release either adrenaline or noradrenaline. Adrenaline enables people to move quickly and powerfully, whether to fight with renewed strength or to run (flight) with increased speed. Some rape victims, for example, have become so empowered with adrenaline that they have fought off attackers three times their strength. In other cases, rape victims have found themselves “frozen” -- literally unable to move -- or otherwise unable to act on their own behalf due to the release of noradrenaline. This numbing reaction is similar to the way some animals play dead when threatened.

Some mugging victims have reported being surprised by how they reacted to being attacked. One woman explains,” I always thought that if I would be mugged, I'd totally comply with the mugger. I'd hand him my purse, write him a check, or do whatever he wanted in hopes that he wouldn't cause me bodily harm. But when I actually was mugged, I fought back. I punched the mugger, pulled his hair and tried to tear the clothes off of him. The mugger was one foot taller than me and double my weight. It wasn't a matter of logic. Something came over me -- a surge of energy -- and I just lunged at him like a wild woman. Looking back I can't believe it was me, timid me, who to this day is afraid to squat a fly.”

When this woman was mugged, she was with her four year old child. When she tried to attack the mugger, she completely forgot about the child. “What if my child had run into the street and was hit by a car or taken by a stranger while I was pulling off my Amazon act?” she now wonders and feels guilty over what might have happened due to her adrenaline surge. She also feels guilty because her child told her that he became frightened when he saw her fight back. “You were like a witch, Mom,” the child said. “Are you going to be like that with me when I do something wrong?” The types of guilt this woman feels are forms of content survivor guilt..

This “timid” woman had been struck by a surge of adrenaline that made her feel as physically powerful and daring as a professional boxer. On the other hand, professional boxers and men trained in the marital arts have found themselves “frozen” by noradrenaline when in danger. For example, Sam, a former boxer and an ex-Marine, was held up in his home. When he was asked to open the safe, much to his amazement, he couldn't remember the combination, even though, until that moment, he knew the numbers from memory.

“My mind froze,” Sam says. Then, to Sam's further amazement, when he put his hand in his pocket where his gun was hidden, his hand “froze” too. He couldn't grab the gun. Sam was used to violence and physical aggression, but in this instance, the numbing response flooded his central nervous system, temporarily paralyzing his mind and his limbs.

Because his wife was assaulted during this robbery, Sam not only feels ashamed of freezing, but suffers from survivor guilt over going numb.

Similarly, Mike, a combat medic, describes how he had been “living on adrenaline” working non-stop on wounded soldiers with an almost super-human form of energy for days on end. Then, one day, speeding towards a bleeding comrade, he “froze.” He couldn't move, even though he wanted to, and remembers nothing of what happened between the time he first “froze” until he woke up three days later. To this day, he doesn't know what happened during those three days. Not only his body, but his memory had gone numb. Because he could not attend to the bleeding comrade, he suffers from survivor guilt, which is only compounded by the fact that he has no way of knowing if that bleeding comrade lived or died.

BASAL CONTRICTION vs BASAL DILATION

Both Mike and Sam were suffering from basal constriction or a shrinking or closing of the veins and

arteries in the extremities of the body which occurs when the heart rate begins to rise in response to danger. In simple terms, under stress, veins begin to close and people begin to lose fine motor skills. For example, they may be able to lift a heavy box, but they can't write a letter or shoot a gun or perform surgery. An analogy is what happens to our hands and other extremities during the cold weather. For example, we lose our dexterity and it becomes hard to use a key to open a door. This is identical to what happens in basal constriction (Grossman 1998).

Basal constriction can also affect our hearing, peripheral vision, and depth perception. Policemen and soldiers report hearing the first shot in a fight, but often have diminished memory or perception of later shots. Many trauma survivors report “tunnel vision” where they can only see what is directly in front of them, nothing more. They lose their peripheral vision due to basal constriction. This can be a source of guilt later on, when upon reflecting over the trauma, they wonder why they didn't see something. For example, a married couple, Rosa and Cornelius, were tending to their store when they were held up by a gunman who fired several shots at them to frighten them into compliance. After the first shot, Cornelius'eart rate escalated to the point where he lost his peripheral vision. He was fixated on the gunman's weapon and saw little else. When his wife told him later that she had been dragged to the back of the store and raped by two of the gunman's companions, at first Cornelius did not believe her. He hadn't heard or seen anything.

“Does this mean I don't love my wife? Does this mean I am not a man because I was so afraid of the gunman that I refused to see what was happening to the woman I love?” Cornelius wonders. The answer to his question are all “no.” He was simply experiencing basal constriction, with the associated features of loss of hearing and loss of peripheral vision, over which he had little control.

Basal constriction can lead to a distorted sense of time (slow motion, fast motion). This can lead to survivor guilt in that traumatized people may think they had more time or less time Basal constriction can also lead to diminished bleeding when wounded in the extremities. Hence soldiers who are wounded in the shoulder, arm, or leg during battle may think they only have a minor flesh wound until the battle stops. During the battle, their heart rate is high, basal constriction is operating, and there is minimal bleeding. After the battle, when the heart rate drops, basal dilation (the reverse process of basal constriction) occurs and the bleeding begins. This phenomenon is the source of considerable survivor guilt not only among soldiers, but among policemen, firefighters, and persons involved in many kinds of trauma.

For example, when a hurricane hit his home, Dan could see that his daughter's arm had been injured. But she was hardly bleeding, so he dismissed her injury as minor. As soon as the hurricane started dying down and the danger began to diminish, the daughter's heart rate decreased and blood began to gush out of her arm (basal dilation). Dan rushed his daughter to an emergency medical facility, only to be told that her injury was serious and that he “shouldn't have waited” to get her medical attention.

Dan wondered if he “just didn't see” the extent of her injury (which would have made him a negligent parent) or if he “just didn't want to see” the extent of the injury, because that would have meant taking the dangerous step of venturing forth to the medical station in the midst of a hurricane. Dan didn't know how to blame himself enough but the reality was that during the trauma, it was the daughter's natural basal constriction which resulted in Dan not taking her to a doctor, not any failure of perception or dedication on Dan's part.

The problem of lack of obvious bleeding due to basal contriction frequently occurs in policework. There are numerous instances where partners are under fire and one partner is shot, but due to a relative lack of bleeding, the other partner assumes that the wounded partner is only suffering a flesh wound. However, after the danger has passed, for example, after the criminals have been apprehended or have fled, the wounded partner begins to bleed profusely, making the unwounded partner feel guilty for not having observed the true extent of his partner's injuries

Time distortion is another effect of basal contriction. Under certain traumatic conditions, people feel they had more time than they actually had: five seconds can feel like an hour. As a result, people sometimes feel they could have saved someone, when actually the time contraint would have made a rescue impossible. Hayashi (1997) reports that following the 1995 Kobe earthquake in Japan, many survivors suffered from guilt because they thought they had time to save someone, when, in fact, their sense of time was distorted. In reality, they had insufficient time to warn others, save others, or save property. Depression, even suicidality, was one of the commonly reported results of these feelings of guilt and failure.

WHY FIGHT and FLIGHT and not FREEZE?

We do not know why some people have fight or flight, as opposed, to freeze reactions or why some people experience basal constriction sooner than others do. One theory is that the more severe the trauma, the more likely that a “freeze” reaction will occur, if not initially, then during the traumatic event. This theory holds that at the first sign of danger the body pumps adrenaline which energizes the organism to respond. However, after a certain threshold of stress is reached, ( i.e. if the stress is too severe or too long), the adrenaline flow ceases and a numbing reaction begins. Basal constriction is part of this process.

Perhaps an analogy can be made with putting your foot on the gas pedal in order to increase the speed of your car. You press down to go faster, but if you press down too fast or too many times, you might flood the engine and it stops. This is similar to what can happen when adrenaline is pumped too fast or too long: eventually the energizing adrenaline response ceases and the numbing response takes over.

Experiments show that when experimental laboratory animals are subjected to shock or some other form of punishment, they first secrete massive amounts of adrenaline, epinephrine, and other activating hormones. The animals then scamper all around the cage trying to find a way out. Or they“fight” the bars of the cage by biting them or pushing against them. However, if the electric shock persists and the animals see that no matter how much they try to fight or escape, they are still being shocked, the adrenaline surge ceases. In its place comes the SIA (Stress Induced Analgesia) response mediated by the endogenous opioid system (to be explained in the section below). The animals become “numb” or “passive.” They stop trying to escape and show little interest in food, play, or sex. (These experiments are the basis of Seligman's theory of learned helplessness, described in “I CAN'T GET OVER IT: A HANDBOOK FOR TRAUMA SURVIVORS.)

However, not all experimental animals react the same way at the same pace. Some become numb and passive right away, others only after repeated shocks. Are the ones who become numb early on “weaker” for not continuing to fight, or are they “smarter” in that they could foresee that putting up a fight was hopeless?

Passing moral judgements on these animals makes as much sense as passing moral judgement on traumatized people, some of whom become numb faster than others for reasons that no one has yet adequately explained. In Western culture, action is valued over inaction, hence trauma survivors who “put up a fight” or try to beat the odds by trying to escape tend to be valued more highly than those who “freeze.” However an individual's response may have more to do with the severity and the duration of the traumatic stressor or that person's biologically determined threshold of stress than any character trait. Indeed, the numbing response needs to be seen as the body's attempt to preserve the organism from unbearable pain and stress, as well as a way to conserve energy, to deal with future stress (Glover, 1994). According to Glover, “numbing represents an effort to diminish the psychophysiological experience of stress, “ (Glover, 194, p. 644) As van der Kolk explains it, people with PTSD are easily overstimulated. Because of this tendency to become overstimulated, “they compensate by shutting down” (van der Kolk, 1996, p. 14). Furthermore, some people evidence both adrenaline and noradrenaline responses within the same traumatic incident, or over a series of traumatic incidents.

Under the influence of increased adrenaline flow, there can be increases in heart rate, blood sugar level, muscle tension and perspiration. The pupils dilate, digestion slows down, and blood coagulates quicker, to prevent too much blood being lost. The lungs can be come more efficient, providing the increased oxygen which not only allows more rapid and powerful movements, but which can also vastly improve the acuteness of the senses and the mind's alertness. Sounds, smells and other sensory data, for example, are perceived more vividly. The brain uses this sensory data to assess the situation, thus maximizing the chances for survival. Due to the increased oxygen, the brain can work more quickly and efficiently to make the best decisions possible.

The emergency alert response of adrenaline strengthens functions essential to survival, such as the ability to perceive and move, and diminishes non-essential functions, such as digestion and reproduction. While digestion and reproduction are important functions, they are not as important as survival itself.

Think about it. If you are being chased by a tiger, blood and oxygen are needed in your muscles, so you can run fast, not in your stomach to digest food or in your genitals for mating or reproduction.

Research on traumatized women has shown that after a certain threshhold of stress is reached, reproductive functions such as ovulation can be affected. Hence some abused women cease to menstruate or have other gynecological problems which are the result of prolonged stress. Bodily resources are being directed to essential functions, such as trying to manage the batterer's behavior, protecting children from abuse, planning how to get away from the violence, not to the relatively non-essential functions of reproduction.

Even the immune system may temporarily shut down because it's more important to get away from the tiger (i.e., escape danger) than to fight microbes and bacteria. This effect of increased adrenaline flow on the immune system explains why persons exposed to prolonged stress (where the emergency response is overused) are subject to more illnesses and tend to die younger than peers who were not multiply traumatized. (Perry, 1994)Laboratory animals subjected to repeated inescapable shock tend to develop more tumors and other illnesses than control animals (van der Kolk, et. al. 1996; Murburg, 1994 ).

Increased adrenaline may cause other negative effects, such as hyperventilation, rapid shallow breathing from the upper lung vs. more normal, gentle breathing from the lower lung. Hyperventilation, in turn, can lead to irregular heart rate and dizziness, shortness of breath, choking sensations, lump in the throat, heartburn, chest pain, blurred vision, muscle pains or spasms, nausea, shaking, and numbness or tingling of the mouth, hands , or feet. It can also generate mental confusion and difficulties with concentration.

EXHAUSTION

After periods of increased adrenaline flow, the body can collapse into a state of extreme exhaustion. This principle is well known to coaches of major sports teams. During half-times and other breaks, coaches usually don't allow players to take a rest. Instead they huddle with the players and keep the adrenaline flowing by rousing them with words of encouragement and challenge and keeping their bodies moving. They know that if the players literally stopped, their bodies and spirits could easily slump into a severe state of exhaustion. In some games, this exhaustion effect is seen during the second half or later part of a game where players seem to have lost their spark. They can't move as quickly or efficiently and make many mistakes. All these effects are the result of the exhaustion which is to be expended after an expenditure of adrenaline.

Many facts influence the length and intensity of the exhaustion: for example, the amount of food and sleep deprivation; the degree of exposure to dehabilitating natural elements (such as heat, cold, rain, insects or dangerous animals); the degree of sensory deprivation (such as darkensss and loneliness); and the individual's personal state of health (Grossman 1996). Another major factor is the sheer length of the adrenaline flow. Someone who has been living on adrenaline for four days is going to be less exhausted than someone who hasbeen propelled by adrenaline for four moths, or four years.

This exhaustion can be the source of considerable guilt, if while one was sleeping, someone else was injured or died. For example, soldiers on guard duty who fall into deep sleeps and thus fail to inform their comrades of enemy advances can suffer profound survivor guilt over having fallen asleep. The child in a violent home who sleeps through the beating or torture of another family member feels guilty for not being available to help. Yet at times the body acts autonomously. For every physiological process which occurs, there is usually a reverse process. Just as basal contriction eventually gives way to basal dilation, a prolonged state of hyperalertness can lead to a profound state of numbing or exhaustion.

ENDOGENOUS OPIOIDS: NATURE'S STRESS ABSORBERS

Freezing and “numbing” reactions are also caused by the endogenous opinoid system, the body's natural tranquillizers and stress reduction hormones and biochemicals. “Endogenous opioids, which inhibit pain and reduce panic, are secreted after prolonged exposure to severe stress.” (van der Kolk, 1996, p. 227). Persons subjected to intense and prolonged physical or emotional pain often report that, after a certain point, they “didn't feel pain anymore.” For example, it has been found that severely wounded soldiers during World War II did not require as many pain-killers as civilians with similar or even lesser wounds.

Similarly, there are numerous documented accounts of refugees, soldiers, and accident victims who have walked great distances with major wounds while reporting only minimal pain. Some abused women and children have reported that, after a certain point, the beatings hurt less and the emotional lost much of it's impact. The emotional pain was muted, but so were other more positive emotional states, such as joy and love.

In one case a woman whose husband beat her then tried to crush her by piling furniture on top of her, rose from the floor after her husband left, and proceeded to cook dinner for her children as if nothing happened. Only when one of the children noticed blood and the mother's bone sticking out of her arm did the woman realize she had been injured. Yet she felt no physical pain -- and no emotion. “I became a robot during that marriage. I fulfilled my duties, but I had no feelings -- no anger, no sadness, no joy, no nothing. I just functioned,” she says.

In sum, on both the physical and emotional level, it seems that we are provided a buffer against unbearable or intense pain by means of SIA, or Stress Induced Analgesia. According to van der Kolk (1996, op cit. p. 227), SIA is now believed to be the result of the release of endogenous opioids. (van der Kolk, et al., 1989, Pitman, et al. 1990a, 1990b.)

Experimental animals which have been given excess doses of opiates (or the equivalent) have become apathtic, lethargic, and drowsy; have shown less interest in nurturing their young or in sexual activity; have shown less distress upon separation from a parent; and have been found to not stay in close proximity to one another (Glover, 1994). How much we can generalize from animal studies to human behavior is an area of great debate. Yet, like the drugged experimental animals described here, trauma survivors in the state of numbing show less interest in socializing, mating, and parenting. Even though they may strive to meet their obligations in these areas, doing so requires a great deal of effort and struggle. In my clinical experience and according to available research, individuals who are numb derive much less satisfaction from being with others than persons who aren't numb. Family members and friends often view the numb trauma survivor as “cold,” “distant,” “unemotional” or even “made of ice.”

Heightened sexuality, as well as the opposite, sexual shut-down, are also by products of the fight-flight-freeze cycle. Stress and traumas vary in intensity. Under conditions of extreme trauma and stress, sexual desire and feeling tends to diminish. A person who is fighting for their life is not thinking about making love, but being safe. The blood is flowing to the leg muscles for purposes of running or to the arms, for purposes of fighting. In other conditions of extreme stress, as in concentration camps or abusive homes, victims are often sleep-deprived, malnourished, or physically ill. All of these factors contribute to a low sex drive. For example, prisoners in Nazi concentration camps rapidly lost their sexual desire. When they dreamt, they dreamt of food, not sex.

On the other hand, a moderate adrenaline flow can enhance sexual appetite and feeling. In addition, under stress, the part of the brain that thinks, analyzes, worries, tends to shut down and the part of the brain which concerns itself with biological functions, such as staying alive, finding food, and reproducing the species, tends to dominate. This leads to heightened sexual desire and feeling. Survivors sometimes feel guilty about enjoying sex in the midst of stressful, or even traumatic, circumstances. They interpret this as meaning that they didn't care that others were injured or died. However this interpretation is probably incorrect. The enhanced sexual desire is more likely motivated by the hormonal and other effects of severe stress or trauma.

In sum, some trauma survivors feeling guilty about having intense fight-flight-freeze reactions or other strong emotional or physical reactions. Yet all of these reactions are involuntary. The combat medic whose hands begin to tremble as the result of extreme combat trauma isn't choosing to develop these tremors. The rescue worker who becomes overwhelmed with fear isn't choosing to be afraid. The rape victim who “freezes” and can't defend herself doesn't chose to “freeze.” On the other hand, the rape victim who fights back and is beaten for it by the rapist, didn't chose to become filled with an adrenaline surge, attack her attacker, and be punished for it.

Sexual abuse survivors can feel guilt if they become sexually aroused during the abuse. Yet sexual arousal as a result of sexual stimulation is not an act of will or choice, but an involuntary biologically programmed response. Nevertheless, guilt over involuntary reactions such as these can last a life-time.

Atrocity or moral/spiritual guilt .

In some types of trauma, people participate in or witness morally questionable activities. In war, soldiers are exposed to or engage in atrocities; in abusive homes, family members may be exposed to or participate in cruel and sadistic forms of torture of people or pets. As a result of being exposed to the “monster” or “beast” in oneself or in others, people can come to feel they are tainted and come to view all other aspects of their personality as being evil or despicable. There is also a feeling of being cut-off forever from society because of what one did, or what one saw. The kind of guilt involved in having witnessed or participated in atrocities has been called moral pain, moral guilt, or atrocity guilt.

The agony of this guilt is much worse if you have actually committed an act with “real and terrible consequences” (Marin 1981) than if you merely witnessed it. However, even people who harmed no one, but simply observed an atrocity or immoral act can feel contaminated by what they saw or heard. It's as if they absorbed the evil they witnessed into themselves, even though they did not conceive of or participate in the killing, maiming, or torture. On some level, they feel responsible for the event simply because they were physically present.

For example, some Holocaust survivors report feeling like subhuman beings, not only because of how they were treated, but because they saw so many acts where others were treated inhumanely. Even though they didn't commit any acts of cruelty and even though it was impossible for them to stop the slaughter, some survivors suffer from atrocity guilt and moral pain because they feel contaminated simply by having observed what the inhuman acts of others (Niederland 1964). In a parallel manner, survivors of ritual or cult abuse can feel morally “dirtied” by having been present during cult rituals, even if they did not participate in the torture or killing of animals or in the abuse or murder of human beings.

Soldiers are profoundly affected by this type of guilt. Grossman (1996, 75) writes, “The combat soldier appears to feel a deep sense of responsibility and accountability for what he sees around him. It is as though every enemy dead is a human being he has killed, and every friendly dead is a comrade for whom he was responsible. With every effort to reconcile these two responsibilities, more guilt is added to the horror that surrounds the soldier.” Survivors of other kinds of traumas, for example, domestic violence, sexual abuse, cult abuse, or political torture can probably identify with the feelings of soldiers. For instance, someone growing up in a violent home can feel responsible for all the abuse he or she sees, not just any abuse that he or she might have perpetrated under coercion.

Another part of this type of survivor guilt stems from being unable to protest the atrocity or unable to stop it. Yet there are circumstances where stopping an atrocity may be virtually impossible without endangering one's own life or the lives of others. In some circumstances, even sacrificing one's life to try to avert the atrocity would be ineffective. For example, cult abuse survivors who refuse to participate in the mutilation and abuse of children or animals can be abused or tortured as a punishment for non-compliance and still unable to stop the horror around them. In fact, their non-compliance could spur the abusers to become even more abusive of others. Under these circumstances, the choice with the least negative consequences is compliance, as morally unacceptable as that might be. It bears repeating that being held captive by hostile forces which present the captives with a set of morally questionable or personally dangerous options is the essence of trauma.

Those who suffer the most intense form of atrocity guilt are those who actually killed or maimed others or those who engaged in cannibalism (Neiderland 1994). As Grossman (1996, 1998) points out, each living species, including humans, has a natural resistance to killing it's own kind. Most animals, including humans, will fight one another, but killing only occurs in self-defense, as the result of conditioning, or as the result of the presence of a powerful force, such as an authority figure, which urges or demands the killing. Until recent centuries, with the use of psychological conditioning techniques, even in wars, many soldiers hesitate to kill at close range and pretended to kill. However, if they were attacked or if they had to kill to save their lives, they would kill. The point here is that it takes a powerful force for human beings to counteract the tendency to not kill other human beings. In trauma, such forces can be manifold. People with life and death power over others can use that power to command those under them to commit all manner of atrocities, including torture and murder.

After WW2, people wondered how law-abiding decent German citizens could have become involved in maintaining the Nazi death camps. A psychologist named Milgram (1963, 1965) designed a set of experiments showing that a majority of people would agree to torture another person, if told to do so by an authority figure. In these experiments, Milgram used Yale college students as subjects. The college students were taken into a booth and told to administer electric shock to subjects who were in another room strapped to a chair. The students were told that the shocks were harmless and would cause no harm.

In reality, no electric shock was being administered, but the students didn't know that. When they administered the shock, the subjects in the chairs moaned in pain. The experimenter, who functioned as the authority figure in this situation, then asked the students to increase the voltage. Approximately 65% of the students complied, even though the subjects in the chairs evidenced considerable agony and pain. The experimenters kept telling the students to increase the voltage, even when some of the strapped subjects seemed to faint from the voltage. These experiments showed that even “good” people would harm other human beings if told to by an authority figure.

Since the Milgram experiments were first completed in the late 1940's, they have been replicated over thirty times with subjects of different ages, races, and ethnic backgrounds and in different countries (Grossman 1996, 1998). The results are always the same: people tend to do what they are told to do by an authority figure, even when it involves harming or killing others. Additional experiments have shown that the power of the demands of authority increase with proximity to and respect for authority (Grossman 1996).

If college students and adults can be coerced by authority figures to harm others, how much more vulnerable are children to pressures to obey authority figures? Furthermore, in these experiments, there were no punishments specified for students who were unwilling to administer the shock s. In real life traumas, there are often severe punishments specified for non-compliance with the commandment to kill or harm another living being. For children, the threatened punishments always include abandonment. As explained in Chapter One on Types of Guilt, children are utterly dependent on their caretakers. Noncompliance with parental and other caretaking authorities is almost a death sentence for children.

Another factor which counteracts the inhibitions against harming or killing others is group pressure and the pressure to conform. In a famous series of experiments, Asch (1955) showed how group pressure could make people say that long lines were short and short lines long. In other words, under the pressure of the group, people would distort their own senses and make statements which contradicted what they could plainly see for themselves.

Understanding the power of authority figures and group pressure can help some survivors lighten their burden of guilt. Nevertheless, the sense of guilt experienced by persons who, as part of their trauma, harmed or killed animals or other people can come to ruin their lives. It is a major underlying cause of suicide among soldiers and abuse survivors who were forced into harming or killing others by their abuser.

For example, Rachel recalls being made to kill her dog and to sexually abuse a four year old child by members of a cult to which her parents belonged. The shame and guilt she feels about these acts has caused her to feel worthless and undeserving of any happiness in this life. Her survivor guilt has been so intense she has become suicidal at times, even though therapy has made her aware that there was no escape from the cult when she was a child. Had she not followed the cult's orders, she might have been harmed, or even more pets and children might have been abused or killed as a means of punishing her disobedience. At the time, however consenting to follow the cult's orders was perhaps the least morally objectionable choice available to Rachel.

Prior to the Vietnam conflict, soldiers generally received absolution for their killing and maiming in the form of societal validation and appreciation for their military actions. Warriors of the Vietnam conflict tended not to receive this societal validation and hence many of them bore the weight of having killed alone, without societal absolution (Grossman 1996).. Cult abuse survivors, family violence survivors, and other kinds of trauma survivors who are coerced into illegal activities or actions they find immoral hardly ever receive societal understanding or absolution, which only heightens their sense of moral guilt.

One of the difficulties in writing about moral pain is that killing is a taboo subject. As Grossman (1998) explains, even in the military, there is no discussion about the experience of killing other human beings. While soldiers are prepared for seeing friends die or become wounded, or for their own death or injury, there is no preparation for what it feels like to take a human life, at close range. In fact in recent years, in some military circles, the subject as been skirted by avoiding the very word “killing.” Instead of saying that we are going to kill the enemy, now we are told we are going to ‘service the target,” (Grossman 1998).

Another difficulty in discussing moral pain is the notion that therapists are supposed to be morally neutral and not pass judgements about “right” and “wrong” and refer issues of “right and wrong” or “good and evil” to theologians or religious or spiritual advisors. In the therapy session, most mental health professionals have been trained to either avoid the subject of moral pain or treat it like a symptoms that can perhaps be analyzed away.

However, treating moral pain as a “neurosis, or a pathological symptom, something to escape from rather than something to learn from, a disease rather than ... an appropriate if painful way to respond” to such situations is woefully inadequate way to deal with it” writes Marin (1981 71). This type of perspective on moral pain trivializes the pain and anger felt by people who have been in situations where they were propelled into acting against their conscience or best selves and who must face the fact that they caused another person's death or injury.

Not only is psychotherapy limited in being able to alleviate and respond to moral pain, but it can exacerbate the frustration of people who suffer from moral pain by promoting the myth that “the past can be avoided, that happiness is always possible, and that insight inevitably leads to joy “(Marin 1981 75). In the case of moral pain, more insight into the experiences involved can sometimes bring more pain, more despair, and a greater feeling of alienation from others.

This section on moral pain is not intended to indict or chastise people who have injured, killed or tortured living beings as part of their trauma. These deeds, like other acts committed under conditions of extreme stress such as war or family violence, must be seen in the context of the pressures of the situation and the relative unavailability of alternative courses of action. In my experience, persons suffering from moral guilt tend to forget that they were operating in life or death situations or had lived in circumstances that would have hardened the heart or brutalized almost any one. They also tend to forget that they did not create these barbaric circumstances and that had they not been in a particular situation, they probably would not have generated a plan to commit an atrocity or to kill or injure others. Instead they tend to take on the guilt for the entire situation, including the guilt belonging to the original instigators of the violence.

Few among us can be as heroic as Uncle Tom, the African-American slave in Harriet Beecher Stowe's book Uncle Tom's Cabin . Uncle Tom was a slave who was willing to work hard for his masters and did not rebel against his slave status. But there was one thing he would not do: beat or harm another slave. When his evil master Simon Legree ordered him to whip a slave woman, Tom refused, even though he knew this refusal would result in his being beaten and perhaps being killed. Tom dies as the result of the beating he received for his refusal to act against his conscience.

Other slaves in the novel are not as heroic, for example, the slaves who obeyed Simon Legree's order to brutalize Uncle Tom. These slaves undoubtedly suffered from atrocity or moral guilt. Similarly in concentration camps, some prisoners were used to supervise, and beat, other prisoners. The prisoners who agreed to this role were given extra food, better living quarters and other life-preserving favors.

When people are forced to betray their own attachments and personal loyalties, the resulting moral or atrocity guilt can be is enormous. As Marin states, this is a type of guilt which opens up “areas of pain for which there is really nothing like a ‘cure;” (Marin 1981, 75). With regards to moral or atrocity guilt, religious guidance and spiritual help may be needed. In Shakespeare's play, Macbeth , Lady Macbeth helps kill the king of Scotland so that her husband, Macbeth, can be crowned king in his place. The murder of the king leads to more murders to cover up the original murder and to consolidate Macbeth's power.

For a while Lady Macbeth acts rationally and powerfully and feels no guilt at all. After all, she had asked evil spirits to “unsex her” and fill her “from the crown to the toe top-full of direct cruelty” (Harrison 1948, Macbeth, Act 1. Sc. 5, l. 41-44). She also asked them to cause her to have no remorse for the murders.

Eventually the moral pain hits her. She begins walking in her sleep and while she sleep-walks, she imagines that her hands are full of the blood of the murdered king and others who were murdered. She tries in vain to wash her hands of blood and speaks in fragmented ways about the various deaths she has caused by pushing Macbeth to kill the king.

She looks at her hands and says, “ Out, damned spot! Out, I say! One, two -- why then, ‘tis time to do'it. Hell is murkey. ... Yet who would have thought the old man to have such blood in him? (Macbeth, Act V, sc l, l 34-38).

She then smells her hand and thinks there's still blood on it.“Here's the smell of the blood still. All the perfumes of Arabia will not sweeten this little hand” (Harrison, 1948, Macbeth, Act V, sc. 1, lines. 50-52).

A doctor is called in, but he concludes that he can not help Lady Macbeth. In his view.

Lady Macbeth needs spiritual help, not medical attention. “This disease is beyond my practice,” says the doctor. “More needs she the divine than the physician.” ( Harrison 1948, Macbeth, Act V, sc. 1, l. 57, line 74).

Lady Macbeth becomes increasingly delusional and increasingly loses touch with reality. The implication in the play is that she, who prided herself in being cruel and strong and who acted as if she could handle everything with equanimity, loses her sanity, and ultimately commits

suicide because of her moral pain.Consider Lady Macbeth. Although she does not suffer from survivor guilt, the guilt she feels for participating in murders illustrates the internal devastation that can be wrought by participating in criminal acts as well as the need for a spiritual solution

The message here is not to be like Lady Macbeth and commit suicide if you have moral pain. Rather the message is that moral pain can run deep and that if you have been in circumstances which have given rise to moral pain, you owe it to yourself, no matter how undeserving you feel you may be, to talk to someone who can understand your pain. That person may be a therapist, provided it is a trauma therapist, or a spiritual or religious advisor, provided that individual can offer you spiritual guidance, and not a form of spiritual damnation.

Therapy from a trauma perspective can help you put your actions in perspective and view your behavior in the context of the situation you were in. However, spiritual help is also recommended. If you suffer from moral pain, you may want to seek out a spiritual advisor or religious leader from your faith of choice. Many persons who suffer from moral guilt have been helped by a spiritual perspective and from participating in purification rituals, whether they be formal penances as in the Roman Catholic church or other types of atonement processes

Outside of certain religious practices and consultation with a spiritual or religious advisor, people have found relief from and meaning in their moral pain in other ways. Some examples of this include making some form of amends, if not to the original victims, than to other people or in other ways; finding survivor missions; or establishing some type of monument or memorial for the victims. In cases where those who died did not receive formal burial or recognition, a formal funeral service or last rite can prove helpful.

Some survivors of war, cult abuse, or other situations where they were coerced into commiting acts which they judge as immoral feel guilt not only about committing the act, but about feeling numb or emotionless while doing so. For example, soldiers may feel guilt not so much about killing, because that was their duty, but because they killed and maimed with little compassion for their victims. Similarly, some cult abuse survivors describe killing animals feeling that “it was nothing” or similar to a mindless chore, such as sweeping the kitchen floor.

If you feel guilty about how you were feeling while engaged in an act about which you feel ashamed, re-read the sections in this chapter on Fight-Flight-Freeze reactions. Keep in mind that emotional numbing usually reflects extreme terror or a deep loyalty or compassion towards one's victims as well as other factors, such as exhaustion, starvation, brainwashing or other forms of mental indoctrination, sleep deprivation, emotional abuse, financial and other types of deprivations and threats or the development of clinical depression or another medical illness.

For example, in the ancient story of the Trojan War, the Greek king Agamemnon is told that he must kill his daughter, Iphigenia, if he is to be granted favorable winds so that the ships carrying his troops can sail to Troy . For quite some time, Agamemnon doesn't know what to do: sacrifice his daughter and insure passage to Troy or let his daughter live and let down his troops. Finally he decides that he can not forsake his role as military leader and that therefore, his daughter must die.

Upon making this decision, he begins to weep uncontrollably. However, by the time he actually slays his daughter, he is numb. He feels nothing and he kills his daughter as easily and unempathically as if she had been a fly on the wall. Agamemnon became so hardened by what he had to do, that he basically stopped having any kinds of feelings other than anger or lust. He was so hardened he didn't even feel guilty about killing his daughter. But he was criticized by others, not so much for killing his daughter because it could be understood that he had little choice but to follow the dictates of the gods, but for doing so emotionlessly. Yet he had as little choice over going numb as he did over the god's decree. In fact the degree of his numbness was but a mirror of the degree of his love for his daughter and his horror at having to kill her.

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Growing Stronger Newsletter #8

Guilt as Defense Against Grief

 

SURVIVOR GUILT AS A DEFENSE AGAINST GRIEF AND POWERLESSNESS

If you are in a twelve-step program, group or individual counseling, or another kind of healing or growth program, you may have found yourself at a “stuck point” or “plateau” in your recovery and personal growth. Perhaps you have overcome an addiction or compulsion or other self-defeating behaviors, only to discover that you seem to have an undefined or ill-defined internal block which prevents you from enjoying your accomplishments thus far and which stops you from making further therapeutic progress or from enjoying life pleasures. For example, you may be having difficulty enjoying the improved self-esteem, that can now be yours due to all your hard work in therapy or other recovery program. It's as if you cleared the ground to plant a rose bush and spent time watering the rose bush and fertilizing the soil. However when the flowers start to bloom, you avoid the rose bush and don't take time to enjoy its beauty.

Some mental health professionals view this kind of “stuckness” as a form of masochism, wherein clients seem to somehow enjoy suffering and punishing themselves by denying themselves the good things in life. However, there is another explanation: unacknowledged and unresolved survivor guilt and the grieving that goes hand in hand with it. Counselors with a Freudian orientation often talk about “resistance” in therapy. By this they do not mean the client is resisting getting better because the client wants to suffer. Rather the idea is that the client can't move forward because to do would bring to the surface an awareness of some painful event or painful emotion which he or she tries not to remember.

Survivor guilt and grieving and the incidents which gave birth to them are extremely painful and wrenching experiences. No wonder people try not to think about them. These people aren't trying to avoid making progress: they are trying not to be devastated and shattered by the pain of grieving.. Staying “stuck” in survivor guilt can help many people deflect experiencing grief and can forestall the pain of the grieving process. Many people cling to attitudes and habits in their lives which are self-limiting or self-punishing because to give up these manifestations of survivor guilt would mean facing the raw truth of their powerlessness as well as facing the true extent of their sorrow.

In this sense, survival guilt is a defense against grief and powerlessness. As Opp and Samson (1989) point out, a possible purpose of guilt for some (not all) people is to help them avoid the “overwhelming pain of feeling that the [negative] outcome [of a particular event] was totally outside of one's control.” “Feeling helpless is more painful than feeling guilt” (p. 160).

The tendency to experience survivor guilt as a means of avoiding feelings of helplessness has been found among combat veterans (Opp and Samson 1989), Holocaust survivors (Krystal 1971), and traumatized children (Terr 1983).

SURVIVOR GUILT AND THE GRIEVING PROCESS.

Grieving is perhaps one of the most difficult aspects of human existence. Emotionally, grieving is such a challenge that most people, whether or not they have been traumatized or had stressful lives, tend to avoid it at all costs.

In many respects, it is easier to feel guilty than to feel sad. When you are guilty, you can retain some sense that you had some control or power in the situation. Perhaps you did have some power or control, but not enough to save the life, prevent the injury, or rescue a person from mistreatment. Nevertheless, feeling as if you had some control or power is better than feeling absolutely powerless, which is one of the dominant emotions involved with grieving.

When you are grieving you feel like a collapsed balloon. The pain of loss engulfs you and you feel vulnerable, defenseless and weak. And you hurt. You hurt so much you feel like you are dying inside.

You never though it was possible to suffer so. You'd give anything, pay any price to end the suffering of remembering what you lost and may never have again. If you are to be healed, you need to grieve. However, if the prospect of grieving overwhelms you or you don't have the time, place, or social support to grieve, it may be safer, and easier, to feel guilty.

In her landmark book, On Death and Dying , Dr. Elizabeth Kubler Ross (1981) explains that the grieving process consists of five stages: denial, anger, bargaining, depression and acceptance. Not only those who are dying but anyone who suffers major losses in life usually experiences the five stages of grief.

These “stages” do not always occur in precise order. A person can be in more than one stage at a time, and the length of the time spent in each stage varies from person to person, as does the depth of feeling. Throughout the five stages, feelings of fear, despair, disorganization, guilt and anxiety and even adrenaline surges, may be experienced (Staudacher 1987, 1991).

In some cases, survivor guilt is a means of avoiding the grieving process. In other instances, survivor guilt can be viewed as being “stuck” at the third stage of grief: the bargaining stage.

Denial . In the first stage -- denial or shock -- the loss created by the loss and its aftermath is not acknowledged. For example, an abused wife would most likely go into denial or shock the first time her beat her. So disbelieving would she be that someone she loved and trusted could turn on her, that she probably would not be able to identify her losses. But those who have abused have many losses: their hopes for protection and care from a loved one and the physical injuries they have suffered among them. Even though the abused wife may go into shock about these losses, if her children witness the abuse, they might be keenly aware of her losses and develop guilt feelings about not being able to protect her and survivor guilt about not taking the beating in her place. Alternatively, the children may go into a state of “shock” or denial also.

Similarly, people who have seen others injured or die, whether in a car accident, war, hurricane or technological disaster can easily go into denial regarding the injuries and deaths they observed. They might even feel they were dreaming instead of living real life. Some individuals deny the reality of the deaths or injuries around them by unconsciously hoping for miraculous resurrections.

This stage of denial often keeps not only grief, but feelings of guilt, hidden or only partially revealed.

Anger. Once your denial is cracked, expect to be flooded with anger. You may be angry at life for giving you such hardships. If you are religious, you may be angry at the deity of your understanding. If you were in a situation where others were injured or died, or had a loved one who was kind of situation, you may be angry at the individuals and institutions involved. You may be furious at the human error, human indifference, or human malice which caused the human suffering which you saw or learned about.

If were unable to help, you may be angry at your powerlessness. If you made any mistakes, you may forget the positive contributions you made and instead be furious at yourself for your errors. At times, you may be angry that you ever were born and that you have to go on living when you have to carry so much loss, and guilt.

Bargaining. The bargaining stage of grief is similar to survivor grief in that it is characterized by fantasies of “what if” and “if only.” It is also characterized by excessive and irrational self-blame. If you were carelessly driving a car that caused a ten-vehicle crash on a highway, killing a dozen people, then you might have a right to hold yourself responsible and feel guilty. Similarly, if you killed or abused others, then you need to take responsibility for your actions. However, you also need to ask yourself why you were driving carelessly or why you killed or abused others.

However, its more likely that you didn't purposely cause the misfortune or its aftereffects. Continuing to punish yourself for the what-ifs and if-onlys is the essence of survivor guilt. It serves little purpose other than to wear you down and perhaps ultimately destroy you. If part of your survivor guilt involves wishing you were dead or as injured as another, then survivor guilt itself may serve as an efficient tool for your own self-destruction.

Depression. There are many kinds of depression: the normal fluctuations in mood experienced by almost everyone; clinical depressions requiring medication and psychotherapy, and the depression associated with the grieving process. You may be experiencing this last type. If so, remember that this is a normal response to an extremely stressful situation.

If you are grieving a loss, whether that loss be of someone's life, someone's health, or someone's emotional, physical, or financial well-being, you are under severe stress. Not only are you coping with your everyday feelings and needs, but you are coping with your grief, as well as the reactions of others. You are also probably making complex arrangements for the reordering your life and obtaining medical, legal, and other help for yourself and others involved in the events leading to the death or injury.

At the same time, you are also suffering the loss of yourself as you once were, the disruption to your marriage, family life, or career caused by the tragic incident and its aftermath.

Depression is a natural response to all these stresses and losses. Even though the depression associated with the grieving process is temporary, it can still be intense and painful.

You can expect all the symptoms associated with clinical depression: difficulty concentration, low- self-esteem, changes in your eating, and sleeping habits, feelings of futility and hopelessness, or various physical problems such s backaches, headaches, vomiting, or constipation.

Extreme fatigue, and its opposite, physical agitation, are common to depression. You may find every little task an overwhelming burden, see little hope for yourself or your situation, feel tired all the time and receive little or no pleasure even from people or events that normally would please you.

Acceptance. Acceptance is the final stage of grief. After you have passed through the other stages, you will feel less depressed and enraged about your losses. You will simply accept them and the emotional toll they have taken on you, your family, and nay others involved. Acceptance does not mean that you are happy, but rather that you have stopped fighting your own limitations and the reality of what has happened to you.

You can compensate yourself to some extent for what you have lost. However part of acceptance is realizing that whatever compensations you arrange for yourself are partial, at best. There is no way to restore what you have lost. In the acceptance stage, you accept those losses. You accept your pain. You learn to be as kind and loving to yourself as you would be to a wounded child who is in the process of healing, but realize that even your self-love can not take away all the pain.

SURVIVOR GUILT AS A MEANS OF HONORING THE DEAD

Oftentimes survivor guilt serves the function of “preventing the event from becoming meaningless” (Opp and Samson 1989) and of honoring the dead.

If you suffer from survivor guilt, you may feel you should not go on with life, or at least not enjoy success or happiness. You may secretly be giving up a part of your life as a tribute to your dead friend, associate, or loved one. For example, you may have given up an activity that gave you joy as a way to honor the deceased or you may feel you aren't entitled to have children, an intimate relationship, good friends, or professional success because it would be disrespectful to those who died.

“My husband and son died in the car crash,” explains a widow. “Even though it was years ago, I feel I must not go out socially or ever remarry, or have any more children. I know that being a recluse and staying home won't bring them back from the dead. I also know that my husband and son would want me to go on with my life, but I feel that doing so would dishonor their memory and I just won't do it. My guilt and my grief are the only things I have left. My guilt and my grief bind me to them. I can't give these feelings up. I was in that car crash. I should have died too.”

Survivor guilt can also feel like a means of preserving the memory of the dead. This is especially the case if the person or persons who died were not given a proper funeral or sufficient recognition. In some ways, some of the symptoms of post-traumatic stress disorder can be seen as a means not only of honoring the dead, but keeping their memory alive.

For example, Andrew, the combat veteran who acquired malaria, was sent to the rear for treatment returned to the front lines only to discover that his squad had been annihilated by the enemy during his absence. He has frequent nightmares about the dead. He came to therapy seeking relief from these dreams because they made it difficult for him to work the next day and made him irritable around his family. Several types of dream therapy were attempted. None of them worked. Finally Andrew came to the conclusion that he didn't want the dreams to stop:

“I want to have the nightmares. I want the flashbacks. I want to see those guys' faces. I want to remember because if I don't remember, who will? The average citizen? I'll take the guilt. I'll take the grief. If feeling guilty is the price I have to pay for keeping their memory alive, that's fine. That's nothing compared to what they sacrificed.”

Similarly, Tanya doesn't want to give up her guilt feelings about her mother's heart attack in order to keep her mother close. “I know it wasn't my fault mom died of a coronary, but my mind keeps harping on the fact that I didn't push her to go the doctor soon enough. To me, feeling guilty is a way of being close to her. Rehearsing in my mind the conversation we had about whether or not she should go to the doctor and where I didn't insist hard enough that she make an appointment, makes me feel guilty, very guilty. But it also brings me comfort. That conversation was the last conversation I had with her before she died.”.

“I don't want to give her up. So I'll cling to that memory, and the guilt that goes with it. I want to keep her memory alive, in my mind and in my heart in every way possible. And if guilt is the price I have to pay, I consider the agony of that guilt to be far less weighty than the agony of losing one more memory of her.”

In writing about Holocaust survivors, Danieli writes that the “hearts of the survivors have served as the graveyards for the known and the nameless dead of the Holocaust who were turned into ashes and for whom no graves exist.” (Daniele 1994 4). As Daniele (1994) explains, for some Holocaust survivors to complete and grieving process would feel like repeating the crimes committed by the Nazis, who wanted the deaths of the Jews and their other victims to be invisible, and forgotten. As Berger ( 1977 ) states, the survivor is an “interminable state of mourning for the dead ... because the dead had not received the proper burial rites.”

Combat veterans and others who have been involved in political or domestic struggles where the dead have not received proper recognition by others or by society at larger often feel that if they “forget” the dead, these dead will be forgotten and once again dishonored, as they were during the trauma. For example, Joellen, a cult abuse survivor who was forced to kill small children and small animals, experiences tremendous remorse and self-hate over these acts. Despite years of therapy where she has come to see her actions in the context of the terror of being born into a family that practiced ritual abuse and where the only escape was death, her survivor guilt, self-hate, and grieving surrounding the deaths of these playmates and pets does not abate.

“When the cult killed them, they burned the corpses and threw the ashes into the trash. If I stop remembering how they died, which includes what I did, and if I stop feeling guilty, then I feel like I'm dumping them in the trash too. I can't even remember the names of those kids that died in the cult. If I stop thinking about them or stop feeling guilty about killing them, then I'm just as bad as the cult leaders who made me do it and then told me to forget all about it.”

When recognition is given to the dead, in the form of memorial services or monuments there is less need for individuals to hold on to their survivor guilt as a form of memorial or monument for the dead. However, in many instances where the pain and guilt of a loss are not communalized and no rituals are established to help people with their losses. Under such circumstances there is a greater tendency for people to carry the guilt as a form of memory within themselves, in the form of thinking or dreaming about the dead, or in the form of survivor guilt.

People who have suffered through such losses find it easier to work through their survivor guilt or grief if they can establish and time and place to mourn and involve others in the grieving. Some solutions include establishing some kind of memorial, either in the form of a building, a work of art, or writing, or making an audio or video-cassette describing what happened so that the dead can be honored and not forgotten (Williams 1987, Danieli 1994)

This major issue, undergoing the grieving process, belongs to the realm of grief work and will not be covered in this article. The following books offer information and guidance about grieving: On Death and Dying by Elizabeth Kubler Ross, Men and Grief: A Guide for Men Surviving the Death of a Loved One and Beyond Grief: A Guide for Recovering from the Death of a loved One ; and chapter 9 “Stage Two: Understanding Grief and Sorrow” in I Can't Get Over It: A Handbook for Trauma Survivors by Aphrodite Matsakis.

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Growing Stronger Newsletter #9 The Aftermath of Trauma:

by Aphrodite Matsakis, Ph.D. Sept. 13, 2001

I kept putting off this article because I wanted to pretend that what happened in New York and DC didn't bother me. Like others, I've been through hard times. So, a terrorist attack, what's new? As a history major and avid student of the world wars, the Stalinist regime, Far East history and as a therapist who has worked with hundreds of combat veterans, abuse survivors, and others with permanent wounds from terrible events beyond their control, I thought I'd be immune to any substantial reaction.

But now I see this is denial, the first stage of the grieving process so eloquently described by Dr. Elizabeth Kubler Ross. We know yet we don't know. We realize the tragedy is real, but we don't feel it's impact. Our head knows it happen, but our heart refuses to feel the hurt. For me, its pain and sorrow, as well as fear. Pain and sorrow that such evil abounds and that such evil is nothing new. Just think of the Holocaust, of Stalin's slaughtered millions, of Cambodia , of Central Africa and the many cultures that have known genocide, tyranny, and incredible forms of injustice.

As is being said over and over again, the US has been protected. But no longer. The oceans don't protect us. Our technology and security efforts failed us and the lessons of Vietnam emerge. Guerilla warfare, this time in terrorist form, is very powerful. The enemy is elusive and often, extremely intelligent. Willing to use any means, they can be inordinately successful in achieving their goals. There is a racist element here. Many of the Vietnam veterans I worked with thought the Viet Cong were inferior – because they were shorter, thinner and their country was poorer and many, far less educated. Their medical systems seemed more primitive, and after all, many families didn't have VCR,s, ten pairs of shoes per person, or the many luxuries we take for granted. These supposedly “less civilized” persons who lived on a near subsistence were surely no match for the greatest country in the world. But they were, and I can't tell you how many of our soldiers emerged from the war with immense respect for the Viet Cong – their intelligence, tenacity, organizational skills, etc... “They were enemy, but I have to take my hat off to them. They were real soldiers, smart ones too. My experience blew all the stereotypes,” one vet told me.

Now with the terrorists being assumed to be Arabs, we confront our stereotypes about Muslims, Arabs, who some of us may see as being inferior in intelligence, planning skills, etc.. But these so called “inferior” persons outwitted us, and like the Viet Cong, the used any means possible.

“I admired the Viet Cong's military skills,” the vet cited above told me, “But I lost all respect when they used their own people to achieve their ends. They were willing to blow up their own kids to get one of us. They were willing to plant razor blades in the vaginas of their women, so that when those women had sex with us, we were cut. But the women were cut too and many died. They sent us infected women to sleep with, but who was hurt more... us or those women?”

And so the terrorists are willing to die for their cause. That's terrifying in itself.

Denial is the first stage: this includes pretending it never happened or minimizing the costs and the aftermath. In denial we like to think that cleaning up NY will be like throwing trash in the dumpster, or, well, maybe a little more like that. But it could take... how long? Nobody knows. Senator Hillary Clinton emphasized that the phone and infrastructures are severely damaged, as is the subway system. The costs are enormous and even with everyone trying as hard as possible, it will take much longer than we like to think.

Anger is the next stage. We feel rage at the terrorists, or perhaps at our own institutions and the airline security systems. If we have lost someone, we may have rage at the universe, the God of our understanding, or at anyone who is happy when we feel like dying of grief.

Then comes bargaining:, the “if only's” and “ what if's.” In this situation, we may try to bargain with life, saying things like “If I'm good, or if I promise to do (such and such), then maybe a terrorist attack won't happen to me or my loved ones.” We like to think we can control evil through good behavior or self-sacrifice. But the events of September 11, 01 show us how random misfortune can be. There's so little we can do to protect ourselves in these kind of circumstances. This sense of powerlessness must be the most terrifying feeling a person can have. One defense: Surely there's something I can do to protect myself and my loved ones.

While there is much we can do to life in a self-protective way, to affirm life and to help the world become a better place, we can not protect ourselves from certain catastrophes. This is the ultimate truth: we are not promised tomorrow and in life, there are no guarantees.

After bargaining, comes depression. You have to push yourself to get back to the routine. You don't want to go to parties. The foods that used to be so delicious to you don't taste that good anymore. You go buy yourself something to reward yourself, then find that having this object doesn't bring you the satisfaction you desired. The only thing that really helps, I feel, is other people. We need people more than ever in times like this. We need to talk about what happened and how we feel about it. This isn't dwelling on it, self-pity, etc... This is an absolute necessity. One way to free yourself from the paralyzing effects of such a national tragedy is to share it. This doesn't mean gluing yourself to the tv day in and day out, but it does mean taking out some time to deal with your feelings and to connect with others.

Talking to others, praying, writing or however you chose to deal with the events is a way to NOT dwell on it, to get back to living. Sharing with others affirms life. This is the beauty of religious services and other gatherings focused on grieving and remembrance. At the same time that they validate the losses and give voice to the pain, the presence of others gives hope and affirms life.

After depression, comes acceptance. This doesn't mean resignation and laying in bed for a week. It means facing the fact that it happened, it was terrible and you and the world will never be the same. It's painful. Very painful. Horribly painful to accept reality.

Therefore, don't be surprised if you go from acceptance to denial to anger, etc.. The stages don't follow in a neat row or schedule. People go back and forth, form one to the other. These internal changes confused people, especially if they are used to feeling stable. People with depression, anxiety disorders, etc.. know about mood swings. They aren't as thrown off balance by the emotional fluctuation of grieving and responding to trauma. They are used to not knowing how they are going to feel or what their energy level is going to be. But for those who have been lucky enough to be able to count on their mood and energy, it's a shock to be out of control of one's inner feelings. It's very destabilizing and scary and traumatizing in itself.

Those who struggle with psychiatric problems may find their symptoms worsen and start feeling hopeless. It was hard enough to cope with one's disorder before all this – now an external bombshell is making life all that much harder. To those of you in this category, I suggest doing whatever you did to keep yourself together before... only double it. Don't give up: Use the methods you used before. They can help.

Sociologists who study mass disasters tell us that there are two predictable results of mass disaster: First, a pulling together of communities and Secondly, a we vs us mentality. We have seen the incredibly organized pulling together of help – the blood drives, the rescue workers, and so many more. We have also seen people start categorizing people into us and the “other” – the enemy, all Middle Easterners, etc... It's almost inevitable to start thinking like this. Even the most intelligent of us who know that all Middle Easterners aren't terrorist, may start feeling resentful towards our Arab neighbors. But feelings aren't facts. That “us” vs. “them” mentality is a primitive response to danger. That's what happens in war: someone is for you or against you, there is no in-between. But, as I said, feelings aren't facts. The facts are that the Arab grocery clerk you've known for ten years is probably not a terrorist. Similarly, there may have been non-Arabs involved.

Fighting the reptile brain that needs to categorize everything in “black and white” is hard. But it is possible. The first step is to recognize that it's there and it's purpose is self-protection. In today's world, it may not serve the purpose of insuring survival, that it has among animals in the jungle.

There's much more to say, but I must get on with my day, my routine, which now seems more precious than ever before. I return to my safe little world of habit and appreciate it deeply, knowing how fragile it is and how it could be disrupted so easily, if not destroyed entirely. Fears of economic ruin, world war, more terrorist attacks, biological warfare, poison gas float through my mind. I wonder.. am I being a pessimist? How will it help to indulge in such gloom and doom thinking? On the other hand, the threat of worse to come is not entirely unrealistic. The hard part is that nobody knows. Experts can give opinions, but the truth is, nobody knows.

History has taught us repeatedly that in times like this, anything can happen – and then again – maybe nothing will happen. Maybe it's over. Personally, I think not, but then again, I don't know – neither can I speculate on the future. The enemy we are confronted with is tricky and in hiding and not all in one place.

I don't want to believe that I, like my fellow Americans, am living in a limbo. I resent having to deal with these fears. I just want to enjoy life, to go back to the worries I had before all this happened – the broken dishwasher, the scheduling problems and all the what now seem petty concerns of the day. Now my mind has been invaded by speculations about what the world will hold for me and my children and I don't like it – not one bit.

But, to pretend that all is well, doesn't feel right either. I have to let myself shake inside, tell myself that it's okay to be scared and sad or however I feel, then go about my life the best I can.

I feel so grateful that my loved ones who were in the vicinity of the attacks are all well. I can not imagine the grief of those who lost their family members and friends. I know I must act – in a positive way. I will find a way to help, by giving blood, by praying, by being kinder to the people around me, by telling those I love that I love them, by looking at trees and flowers and appreciating them more and more. I will take in the words of our President and other leaders: destruction happened but it will not destroy me. I will feel whatever I feel, but I will go on. I will act as if life can be beautiful, as if goodness and love matter, and as if what I do, to help the world be a better place, will make a difference.

I encourage you to not let the terrorists win a second time. Sure they have frightened all of us and we must allow ourselves to be affected, but they have not taken our hearts and souls and we can use all our positive energies to do something creative, loving and good. There is no other choice.

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#10 Coping with Trauma

by Aphrodite Matsakis , Ph.D amatsakis@erols.com www.matsakis.com.

 

As professional women, we have learned how to maintain emotional control and stay functional during hard times. But September 11 th set off a bomb in all of us. Not only were we grieving the massive loss of life, but we touched our own death. We also had to digest the fact that we were no longer invulnerable, the possibility that more attacks might follow and the terrifying realization that our lives could never be the same.

Coping with the economic, personal and other insecurities created by September 11 th requires not only determination and grit, but emotional honesty. High-functioning women sometimes find it hard to admit to feeling helplessness; overwhelmed with sadness or fear; or disoriented, confused, emotionally “raw” or subject to unwanted mood swings. These emotions can be so overwhelming that the psyche, in self-defense, shuts down and we feel little to nothing. All of these, both the emotional reactivity and the emotional deadness, are the expected effects of trauma. Unfortunately, they can and do disrupt concentration, memory, work performance and motivation – an anathema to women who are used to being competent or whose colleagues may expect them not to “act like a woman” – that is, be emotional.

Fighting the feelings, by telling ourselves we “shouldn't” let our feelings interrupt our lives, is like sitting on a volcano to stop it from erupting. Managing the powerful feelings evoked by trauma requires that we accept them, allow ourselves to feel them and find healthy ways to release them. Sharing with others, writing about your reactions, exercising and contact with nature (and pets) can be helpful. For some, prayer or religious services give strength and comfort.

Put your anger, fear, and grief energies to work! Any form of constructive action helps: whether it be cleaning out a closet; improving your professional skills, getting to know your neighbors better or helping others. Opportunities to give are countless. Finding ways to support your local rescue or firefighting squads and other support services is just one possibility. Do anything you can think of to make your world safer, no matter how small or silly. You also have the right to decide for yourself how much or how little you watch or talk about the news and to change your mind as needed.

As a Greek-American, I have predecessors who lived through the Nazi occupation of Greece , the Asia Minor Holocaust where millions of Greeks and Armenians were slaughtered. Greek history and literature as well as the literature of the many other countries that have known famine and war brim with examples of persons who not only survived but found love and purpose during times of unimaginable adversity and uncertainty. The Greek national anthem was spawned during the Greek's efforts to rid themselves of four hundred years of foreign occupation, during which families were required to hand over at least one of their children to the authorities to be used as sex slaves or warrior. The anthem tells of Greek soldiers who are ready to give up. They're exhausted, cold and hungry. But then they see a tall radiant woman walking towards them. Her name is Liberty and just the sight of her brings strength to their weary bones.

Like the soldiers, for we are now all soldiers, we must find a vision that causes the rush of life to flow through our veins. You may already have a vision, but if you are trying to create one, you can help yourself by tapping into various resources and using what you find helpful. For me, Greek music, like other folk music, energizes me by giving voice to the pain of living. Role models can also be found in the many books and poems written by persons from all nations – individuals who have endured cancer, death camps, family violence, car accidents, crippling illnesses and other terrors of life and yet found reason to live, and even some joy. Slave diaries, African-American spirituals, the accounts of Nazi concentration camp survivors and any music or art form that expresses our feelings can also help sustain and guide us. Perhaps you know a combat veteran or people who have known other traumas, such as the loss of a child or the sudden death of a loved one. Talking to them (but only if they want to) about how they coped can help strengthen you.

September 11 th forced our leaders to reorder national priorities. Research on rape survivors show that despite the devastating impact of their trauma, some were propelled by the rape to reevaluate their lives and take more control. Many decided to stop people-pleasing and pay more attention to their dreams, their talents and the people they love. Perhaps we can use September 11 th as a time to reevaluate our priorities and gain greater clarity about our true desires in life. Yia Sas .

Additional coping suggestions can be found in issues of “Growing Stronger” on www.matsakis.com. Dr. Matsakis is a licensed clinical psychologist, the author of ten books on trauma, and teaches at John Hopkins University and the University of MD , College Park , MD.

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#11 Helping Children Cope with Trauma

Trauma and Threat

1. Life threat : Threat of losing life, limb or health.

2. World view threat :

Trauma forces children to encounter human evil, vulnerability, and error. Trauma raises the question of why do the innocent suffer and challenges the idea that the world is basically safe, orderly and fair and the notion that “If you strive to be careful, competent, and good, you can avoid harm to yourself and your loved ones.”

3. Self-ideal threat

Trauma can cause children to act, think or feel in ways that contradict their views of themselves or the ways they feel their parents and teachers expect them to be. Trauma can cause regression in behavior and thinking. During times of stress, it is common to go back to earlier ways of coping and thinking. This can be a cause of shame and embarrassment to a child, especially if it is noticed by others.

Like adults, children, can be humiliated by feelings of helplessness and fear, by any symptoms they develop due to the trauma, and by times when they don't function as they wish.

4. Threat to emotional stability: Emotional Overload

Children, who are struggling to learn how to control their behavior and emotions, may find themselves even more afraid than adults when the “bomb” of their feelings go off inside them . They can become frightened not only of the terrorists, but of the strong feelings they are experiencing. Just having these strong feelings (fear, anger, sadness, confusion) can be traumatic to the children because the feelings seem to be controlling them and there is little they can do about it.

Also, sometimes these feelings come at unexpected times. Hence the feelings themselves can feel like “attacks.”

This is where parents and teachers can be very helpful in teaching children how to identify and manage their emotions and how to calm themselves.

5. Threat to thinking and logical abilities: Anxiety generates more anxiety: A Vicious Cycle

Intense grief and anxiety make clear thinking difficult, if not impossible. Under the influence of the trauma, children have trouble getting along with others, concentrating, remembering and completing tasks. When they observe themselves having these difficulties, they can become even more anxious, which makes them even less functional, which leads to more anxiety, which leads to more dysfunction, etc., thus creating a vicious cycle. In short, having anxiety generates more anxiety.

6. Breaking of parent-child protective membrane

Implicit in the parent-child relationship is the expectation that the parents will protect the children. Parents expect themselves to be able to provide this protection and children expect it of their parents. When traumatic circumstances show that parents can not offer necessary protection, parents experience helplessness and a blow to their self-esteem.

Children, even if they logically understand why the parents can't protect them, may feel betrayed by the parents and angry at them. Some children fear that of their parents found out how disappointed and angry they were, the parents would reject or abandon them.

7. Intensification of current non-traumatic stresses and difficulties.

Trauma can put prior or ongoing problems in perspective, but in some instances, trauma can make them harder to deal with or bring up old problems.

Vulnerable Children : Disabled children and children who were under stress before Sept. 11, due a death in the family, school problems, change in school, changes in the family, a period of life transition, a major illness or disappointment, may be especially vulnerable. Parents can help children distinguish the effects of Sept. 11 th from the effects of other disturbing situations.

Variations due to temperament: Just as some children are genetically predisposed to be more social or more physically active than others, some are more emotionally reactive and sensitive. This is not a sign of weakness or deficiency. Everybody's central nervous system is different.

8. Decreased self-esteem; Decreased sense of personal power.

As the combined result of (a) the direct threat and (b) the various mental and emotional consequences of trauma, children experience a blow to their self-esteem and sense of personal power.

9. Unique aspects of Sept. 11

Not only was Sept. 11 a surprise, but the threats and resulting economic instability are ongoing. The feeling of being under attack and vulnerable on our own soil are new feelings for many Americans. Terrorism raises concerns about the effectiveness of traditional means of defense ( armed forces, technology). We are also dealing with mixed messages from the government and the media: “Go about your business” yet “Prepare for more attacks.”

It was easy for many Americans (and children especially to identify) with victims of Sept. 11 th . Children were killed and people going to work ( just like their parents) were killed.

Antidotes

1. Strong and safe human bonds : “Grandparent” Therapy

2. Belief System

3. Inner Safety

“Name the Demon” – Learning about post-traumatic reactions

Learning to identify feelings

Expressing feelings rather than acting them out or taking them in

Learning how to calm oneself: how to manage anxiety and fear

Countering irrational beliefs

Developing a sense of mastery and competence: Building on strengths (physical, spiritual, academic, artistic) and developing new ones

4. Outer Safety: Making the external world as safe as possible

5. Re-evaluation of Priorities :

What can we learn or gain from this experience?

What's really important in life?

Taking the time to relate to and discuss serious issues with family Bringing the family/community/neighborhood together in important ways.

Taking time to reach out to the community, neighbors, others

Establishing new cultural heroes: Rescuers, contributors vs. movie stars

 

Common symptoms of grieving, anxiety, post-traumatic reactions

Behavioral and Emotional

Pre-School Age Children

Bed wetting, thumb sucking, babytalk, fear of sleeping alone; stomach cramps or headaches; reluctance to go to school, defiance

Grade-School Age Children

Regressive behavior: All the above

Sleep problems: nightmares, night terrors, insomnia, frequent awakenings

sleeping in strange places, climbing in bed with parents

Disbelief and shock; Fear and anxiety about the future

Disorientation, difficulty making decisions or concentrating

Apathy and emotional numbing

Irritability and anger; Mood swings; Defiance

Feelings of powerlessness

Extreme changes in earing patterns: overeating, not eating

Crying for no apparent reason

Headaches and stomach aches

Withdrawal from friends and family; Problems at school and with peers

Adolescents

All the above

Alcohol and drug usage

When should I be concerned? The following are rough guidelines. If you have any doubts: consult with your child's teachers, school counselors or a qualified mental health professional.

Severity, duration and number of symptoms It takes time to “digest” major events like Sept. 11, especially when terrorist threats are ongoing. Symptoms that appear after a new threat, such as a new anthrax scare or the layoff of a parent or parent of a friend, are to be expected.

A single infrequent symptom that seems to be improving over time is not as much a concern as a child having several symptoms, some of which seem to be worsening. Yet more than three symptoms or one or two weeks of the same symptom with no sign of improvement suggests that you consult a school or other counselor, Significant declines in school performance and socializing are serious, as are any of the following:

1. Sleep disturbance for more than several days, esp. if frequent nightmares

2. Separation anxiety, clinging behavior, reluctance to go to school

3. Phobias about school, tv, cars, etc,

4. Repeated conduct disturbances

5. Doubts about self, talk of death, persistent withdrawal

Suggestions

All suggestions need to be modified according to the age, needs, temperament and sensitivities of the child. If you have concerns, consult a qualified mental health professional.

1. Keep in mind the child's developmental level.

Children's ability to benefit from your efforts will be affected by their stage of mental development. According to Piaget, children's mental abilities do not reach full capacity until adolescence because their brain development is not complete until then. Until the teens, they not only know less than adults but think differently from them.

Stage One : Ages 0-2, Sensorimotor stage. Children understand the world through their senses – touch, taste, sound, etc.. At this stage, children may be picking up on any increases in anxiety and tension in the home rather than responding to the news. Cuddling is more effective than logical discussions.

Stage Two : Age 2 to about 7. Pre-operational Stage. Children's ability to comprehend reality is limited by egocentrism (not selfishness, but rather the tendency to think of themselves as the center of the world, their inability to view things from another person's perspective, and a tendency to think they are the cause of most events). At this stage, children are capable of thinking that somehow they caused or could have prevented a parent's illness, a divorce in the family, or events like Sept. 11. Children are also animistic: the attribute qualities to objects, hence they may say things like “the sun is sad” today.

Your efforts to convince the child that they didn't cause events like Sept. 11 th or the family's distress over it may have limited effectiveness. But keep on telling children it isn't their fault anyway. You might become frustrated when they don't seem to comprehend what you are saying, but be patient: their mental ability to understand cause and effect is limited.

Stage Three : Age 7 to teen years. Concrete Operations Stage. Children can reason about

concrete objects, but have difficulty grasping abstract concepts, such as “democracy,” “government,” “terrorism,” etc. Abstract logical arguments designed to counter their fears will have difficulty sinking in. As much as possible, talk to them in concrete, not abstract terms.

Stage Four: Teen to adult years. Formal Operations Period. Children are capable of abstract thinking and understanding concepts such as “unity,” “military efforts,” etc.. However, under the stress of trauma or other stresses, teens, like adults, can revert to prior more immature ways of thinking. Once again, you may feel you are talking to a brick wall and become frustrated that your children don't “get it” and aren't soothed by your attempts to comfort them. This can lead to tensions between you and your children, which only aggravate the problem.

2. “Good Enough Parents ” If parents were saints and had nothing to do but parent, life would be a lot simpler. But this is not the case. Parents have many responsibilities and can not expect themselves to respond perfectly, exquisitely attuned to the unique needs of their child and their developmental level, every single time the child is in need. “Good is good enough.”

Just taking the time and trying, even if you “could have done it better,” and don't see immediate results, doesn't mean you have failed or wasted your time. Children pick up the concern, the intention, and the caring behind your efforts.

You are learning too . Most parents have not had years of experiencing helping children cope with events like Sept. 11 th . It's a new situation for many. You are learning as you go along.

“It takes a village to raise a child,” wrote Mrs. Clinton. Join with other adults in trying to help your children. Having talks with other parents and their children or bring in other adults to help your child.

3. Avoid shaming or humiliating children for their fears and needs.

Parents sometimes inadvertently shame children for being afraid or asking for help. Perhaps the parents are stressed out or overloaded with other responsibilities and the child's fears and needs are placing yet another demand upon them. In other cases, parents themselves were shamed by their parents or others when they appeared “needy” or were afraid.

Examples of Shaming Messages :

“You are too old to be scared of ....,”

“Where's your head? It's ridiculous to ___ .”

“If you want to grow up to be a man, you shouldn't ask for Mommy to hold you or for a bedtime story.”

“Only babies ....”

“You say you want to be a ____ when you grow up. How can you expect to do that if you

are so whiny, clingy, yellow, stupid as to believe ___ or be afraid of ___?”

“Can't you see I'm busy now? Everybody knows that's not true.”

“I can't be bothered with your ridiculous ___.”

“Didn't they teach you in Sunday School to pray to God and that God will make everything okay?”

Don't compare your child to others. E.g., don't say, “How come your sister/brother isn't as scared as you? How come you can't be strong like ....”

Why adults sometimes shame children .

Sometimes children's fears trigger anxiety in the parent because the parent shares the fears and is having trouble coping with his or her own fears. The child's needs can bring a parent's fears to the surface. This can be destabilizing to the parent if the parent is ashamed of not coping “better” or feels that they have somehow failed the child.

Should the child pick upon the parent's anxiety, the child can feel guilty for disturbing the parent, as well as angry that the parent isn't available. The child may then decide not to ask the parent for help because asking seems to make the parent nervous, tense or upset

The parents seeming unavailability can then create more insecurity in the child. If the parent senses the child is withdrawing, the parent might become more anxious and tense, if not aggravated. Then the child becomes more withdrawn and a vicious cycle begins.

Myth: On the other hand, the belief that if parents remain cool, calm and collected there will be no panic, fear or symptoms in the child imposes an impossible burden on parents. This belief perpetuates myth of blaming parents for their natural reactions to stress and holds parents responsible for reactions of children.

Observing a parent having strong feelings and then returning to a functional calm state can provide a good role model for the child. You can show your child that it is possible to experience fear, grief, etc. and then, in a while or even right away, go on about your business.

TIP: If you show distress when you talk about your fears, assure the child that no matter how upset you are, you will always take care of and love him or her, that being upset doesn't mean you will stop being their mother or father and doing all the things parents do to take care of their children.

However, there is a difference between showing strong emotion and “falling apart” and repeatedly forsaking parental or other responsibilities. Parents who become dysfunctional can terrify a child . The child may then feel there is no one to take care of him or her and can develop fantasies about the world coming to an end because the persons the child depends upon have collapsed. If you fall apart, then who will be there for him or her?

Some parents might benefit from time-limited professional help around this issue. Furthermore, with some children, it may be important not to share the full extent of your anxieties. You know your child. You know what they can handle. Remember, you are the expert on your own child.

A positive message is: “It's okay to be afraid. We should be afraid. Scary things are happening. But if we talk about them and how we feel, we will not be as afraid and we will be stronger. There are many things we can do to feel less afraid and to help ourselves.” It can also be helpful to talk about your fears in a calm manner.

4. Talk to your child about Sept. ll, the ongoing threats, etc.. if the child wants to talk about it. If the child is too young or can't articulate thoughts and feelings, nonverbal methods, such as drawing and play therapy may help.

Invite the discussion . “We don't have to talk about it, but if you want to, I'm here for you. We can talk about any part of it you like and stop any time you like. If you don't want to talk about it now, that's okay. If you want to talk about it some other time, just let me know.”

Talking and dreaming don't make it so. Assure the child that talking about Sept. 11 or some other threat can't make it happen again and doesn't mean it is happening right now. Children often have the magical thought that talking or dreaming about something will cause it to happen again. Even adults who are traumatized, when they talk about their trauma, can feel as if it happening again, right at that moment. Their heads tell them this isn't so, but emotionally, it feels that way.

Let the child speak first . If the child wants to talk, first ask him or her what they think is going on, what he or she knows about current events. By finding out what the child thinks before you start talking, you can assess how much they know and the accuracy of their information.

In our current situation, it's sometimes hard to know exactly what information is accurate or not. But some of the child's beliefs about what is going on may be totally off base.

Ask: What makes you most scared? What worries you the most?

Monitor the child's reactions: A little upset is to be expected, otherwise the child wouldn't be turning to you for help. However, if the child shows extreme signs of anxiety, like shortness of breath, sweating, dizziness, starts crying or complains of an upset stomach or headache, it's time to stop and ask the child how she or he is feeling.

You know your child. If your child has unique signs that shows they are becoming out of control, which is a terrifying experience in itself, STOP the discussion and help calm the child.

The 1-10 Scale : One way to help monitor the child's distress is to have a 1-10 scale of “feeling scared” or “feeling bad” or whatever terms you use with your child. 1 is “very happy” like at birthday party and 10 is “very very unhappy.” Ask the child where they are on the scale. If they are over 6, it's time to stop.

Watch out for and correct all-or -nothing thinking : Offer a more complete but honest perspective

Because so much is at stake during a traumatic incident, issues tend to become black or white. Either someone is for you or someone is against you: there is no in-between. There is no such thing as fighting a child abuser or a mugger “in moderation” or killing an enemy “just a little bit.” In trauma, “moderate”and “medium' responses are not effective and often not even possible.

During trauma, all that matters is the moment at hand. It doesn't matter what someone did in the past or will do in the future. All that matters is what he or she is doing now.

Therefore a child may think: “If I'm scared or feel sad today or if I can't do well at school right now, I'll be like this forever.” This is not true. Or ,“Either everything is like it was or the world is going to end tomorrow.” “Either we have the power to get rid of terrorists entirely or they will take over.” The truth, however, may be somewhere in-between: the terrorists have power, but so do we. They can cause damage, but the damage may not be total.

A More Complete Perspective (suitable only for older children who can comprehend)

Do not lie to children by telling them that “all is well,” when the news media, peers and overheard discussions give a different message.

It's okay to tell your child that you don't know what might happen .

Acknowledge uncertainties and concerns about power of terrorists; but also the strengths of our country and people .

You can use historical examples like Oxi Day to demonstrate how people who are outnumbered can fight back. Fears about potential dangers to come need to be countered with certain facts, such as the strengths and resources of our country, the protection offered by our advanced technology and by the brilliant minds that are now working on solving the problems of bioterrorism, etc.. The terrorists are small in number and, given the status of their women, they have only half the brain power and labor power of countries where women are more equal citizens.

5. Comfort the child.

Holding, Physical Soothing

Ask yourself, “What is true? What is stable? What can the child count on?”

Your commitment and love to the child is true. That can never be stated enough for, on some level, children, even teenagers, fear abandonment. “If danger strikes, will my parents run to save their lives and forget about me? Will my parents save one of my brothers or sisters instead of me (because the sibling is younger, older, smarter, more attractive, or perceived to be one of the parent's ‘favorites'?)”

Identify and list supportive others and institutions : relatives, neighbors, teachers, friends, police, firemen, family doctors, nearby hospitals, and any other sources of support that exist. Make a list of these and give it to the child or put it on the refrigerator. Have the child repeat the list to you several times. If advisable, have these others speak to the child and show their support. Some children may benefit from visiting a fire department, etc.. and seeing helpers at work.

Religious beliefs : These are stable and the terrorists can't destroy them.

“ Grandparent therapy: Create a safe place or a safe atmosphere to talk. Hot chocolate, warm milk with honey and other traditionally soothing drinks are helpful.

Message: “This place is safe and loving. When you get scared, remember these moments in this room, the hot chocolate, etc...” For younger children , you can include safe and comforting items: crucifix, pictures, kids favorite things. Older kids may resist the idea that they need to be comforted. In this case, don't make a big deal out of discussing matters: just do it.

Role models : Courage is not the absence of fear but the ability to do the right thing and keep on keeping on despite the fear. If there was no fear, then how could courage be courage?

Being present when the child needs to talk or is anxious or unhappy is invaluable.

Limit exposure to the media. Watch tv with children and discuss what they observed and their reactions. Some children may distort what was presented on the news.

Practice anxiety management techniques ( deep breathing, muscle relaxation, visualization) if the child is anxious, especially after media exposure to frightening events but at other times also, so that they become well-learned, almost automatic.

Create and practice positive affirmations and self-talk : Have the child devise statements that counter ear and affirm his or her strengths and the support and strengths of others. For example, “This is scary but my parents (and ______________ ) love me and will do all they can to help me. Americans are smart people. If I pray to God, I will feel better and God can help me.”

You can suggest some of these affirmations to the child, but it's best if they come up with affirmations of their own that mean something to them.

Write them on paper, rehearse them out loud, draw them. Whatever works. Repetition is the key.

Positive Action: Focused Energy ; Put the anger, fear and other feelings to work. The opportunities to give are endless, from writing children in New York to contributing something to the community. Any form of helping others is a way of “fighting back.” and focusing the emotional energy of the negative emotions onto something positive.

6. Internal Safety

Thinking :

Disentangle Sept. 11 th from other events.

Reframe symptoms as normal: Nightmares are like a burp. Fear and anxiety are normal: we are supposed to feel this way (animal examples)

Combat all-or-nothing thinking

Teach child about feelings:

What are feelings? Feelings aren't facts. Being afraid it will happen doesn't mean it is happening now.

Label Feelings: See feelings list.

Discuss degrees of the feeling and mix of feelings

Anxiety Management

Teach child to comfort him or herself: Deep breathing, Counting to ten: Affirmations, Prayers, Exercise, Relaxation Exercises

Practice them with the child. Ask the child if they help. Teach child to come to you if these or other methods don't work then try something else.

Strengthen the child: Support the child's talents and interests; Encourage the child to become good at something in order to develop a sense of competency and mastery.

Spiritual strengthening

Other : Rituals, Music (Apollo was god of medicine and music), Singing, Reading a story over and over

Nonverbal Methods Not all children have the language to speak.

Draw or act out vision of the event; feelings, revenge, reams

Draw yourself or your house at time of trauma.

Play Therapy

7. External Safety: Make the child's world as safe as possible .

Children may have fears other than those related to the terrorist attack that perhaps they never mentioned before or were able to handle before Sept. 11 and the ongoing news about bioterrorism, etc.. Ask your child if he or she has other fears or if there's anything that he or she would WISH to happen to make his or her life feel better.

Young children may want a light on at night.

Children who are being teased or bullied at school may need intervention.

Children who are afraid of doing poorly at school or in sports may need support, additional instruction (tutors), etc..

Home Safety

If age appropriate or helpful, show child the smoke detector, fire extinguishers and other safety features you have in your home. If an additional bolt on the door or some other safety measure brings relief to the child, there is no harm in purchasing or installing such an item.

Emergency Plans

Just as schools and offices have fire drills, the family may want to have it's own “emergency” plan. You may not chose to have such discussions.

However, if you do or the child expresses a desire to talk about what to do in case of a future attack or need to evacuate the area, you can discuss such a plan. Some parents fear such discussion will create fear and anxiety, but the fear and anxiety is already there. Planning, as far as anyone can plan, can help allay anxiety.

Keep to schedule and daily routine as much as possible

 

Resources

Packets on Helping Children Handle Disaster-Related Anxiety; Coping with Disaster: Tips for Adults; and Facts for Families: Children and the News

Free from Mental Health Association, 1000 Twinbrook Parkway , Rockville , MD 20851 301 424 0656 info@mhamc.org

www.hellenist.org

Greek-American perspectives

www.matsakis.com

Articles on Terrorism; Issues of Newsletter “Growing Stronger” – Coping with depression, guilt, stress and related topics

The Parent Center : www.parentcenter.com/general/34754 .html

American Psychological Association

http://helping.apa.org/therapy/traumaticstress.html#children

American Academy of Child and Adolescent Psychiatry

http://www.aacap.org/

American Academy of Pediatrics

http://www.aap.org/advocacy/releasesdisastercomm.htm

Coping with Emotions After a Disaster

http://www.psychworks.com/PTSD%20response.htm

The Child Survivor of Traumatic Stress

http://users.umassmed.edu/Kenneth.Fletcher.kidsurv.htm

How to communicate and treat children and adolescents during crisis

http://www.aap.org/advocacy/releases/disaster.comm.htm

 

Feeling Word Vocabulary

Most Simple: Sad, Mad, Glad and Scared

(Weakest to strongest)

Sad: sorry, lost, bad, abandoned, isolated, alienated, lonely, distant, ashamed, distressed, discouraged, unappreciated, dismal, inadequate, disappointed, miserable, empty, rejected, uncaged for, worthless, crushed, helpless, crushed, exhausted, defeated, drained, hurt, wounded, depressed, sorrowful, hopeless

Mad : irritated, agitated, annoyed, offended, frustrated, disgusted, resentful, jealous, repulsed, betrayed, humiliated, hateful, abused, incensed, vengeful, hostile, enraged, seething, furious, murderous

Glad: hopeful, peaceful, satisfied, good, relaxed, content, admired, confident, grateful, assured, cheerful, proud, joyful, optimistic, encouraged, valued, loved, enthusiastic, energized, alive, jubilant, terrific, exuberant, elated, ecstatic

Scared: doubtful, concerned, timid, unsure, shy, impatient, relaxed, suspicious, apprehensive, insecure, defensive, uneasy, tense, vulnerable, terrified, frantic, desperate, intimidated, overwhelmed, shocked, fearful, panicky;

Confused : undecided, bothered, foggy, disorganized, puzzled, ambivalent, stagnant, demobilized, troubled, trapped, bewildered, disoriented;

Aphrodite Matsakis , Ph.D.

www.matsakis.com

“ The dignity of --- humans is to weep” Martha Nussbaum ( Introduction to Euripides: The Baccae , translated C. K. Williams, X, New York : Noonday Press, 1990

Grieving is Normal

Grieving is part of being a social animals. It has been observed in animals and is a universal part of the human experience.

Dealing with death is an unavoidable part of being alive. Many people cope with it by avoiding it, which leads to disrupted family relationships or medical problems. Unexpressed or unresolved traumatic grief is a fundamental contributor to many psychological disorders, including depression and anxiety disorders.

Grieving is Exhausting

It is not wise to take on additional responsibilities after a major loss. Lightening the load is best, for grieving requires a great deal of emotional and physical energy.

Dr. Kubler-Ross's Five Stages of Grief:

Denial, Anger, Bargaining, Depression and Acceptance

Denial: This isn't really happening. It isn't as bad as it seems. Others are exagerrating. I'm overreacting.

Anger: Why did this happen to me (us)? I (we) didn't deserve this!

Anger at the death may be displaced onto care givers, community, the self, God, or another family member. If the death involves trauma, then some of the anger at others or institutions may not be a projection, but appropriately directed outward to those people or institutions involved in betrayal, incompetence, or cruelty.

Bargaining: Making deals with God or the universe to prevent or mitigate the calamity; Reviewing the past for the “what if's” that might have prevented the calamity

Depression: Realization that neither anger nor bargaining can restore the loss

Acceptance: Not resignation, but an acceptance of the loss with accompanying sadness

Grieving is not a linear process : These stages are not necessarily sequential and a person can experience more than one stage at a time.

Can grief be abnormal?

Answering this question involves looking at the disruption of function rather than depth or length of grieving. It isn't how long or how hard you grieves but whether or not the grieving significantly interrupts your emotional, social, or vocational functioning.

Grief is expected to disrupt normal functioning for a while, the extent of this “while” being culturally determined. Grieving occurs in a social or cultural contexts where the expressions of and length of grief vary in what is considered “permissible.”

Some cultures or sub-cultures are characterized by denial of death and dying and subsequently those engaged in the grieving process may fear being seen as “weak” for seeing support, as “self-centered,” “overly dependent,” or “full of self-pity” if they grieve longer or deeper than what the culture or sub-culture permits.

They may also fear being ridiculed for crying or “losing” control and may fear they will damage or lose existing relationships by burdening others with their pain.

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#12 The Impact of the Abuse of Males on Intimate Relationships

By: Aphrodite Matsakis in The Abuse of Men: Trauma Begets Trauma : Barbara Jo Brothers (Ed.) The Haworth Press, Inc., New York 2001

“This edited volume addresses a topic that has been neglected in the literature: the abuse of men. It is unique in adopting a systemic perspective that focuses not solely on the males who have been abused but also on their partners and family members. The contributors convincingly argue that effective treatment must include not only the male survivor but also his spouse, partner, or other family members, because everyone intimately connected to the survivor will also have to cope with the effect of trauma in order for healing to take place. This volume will be of greatest interest to new clinicians who are looking for direction for intervening with the population of abused males, their partners, and their families. Most helpful will be the final chapter which gives detailed and specific directions for intervening with couples who have experienced multiple traumas.

-Joseph A. Micucci, PhD, Associate Professor of Psychology, Chestnut Hill College , Pennsylvania

“One of the major strengths of this book is the multidimensional examination of the abuse of men. Of particular note is the attention given to the trauma associated with men being abused, couple stress, systemic factors relating to abuse, and the secondary traumatic stress affecting men whose partner were sexually abused. The contributors to this book offer a compelling call for an examination of personal and professional issues relating to men as both victims and perpetrators of abuse. Through case study, personal narrative, and a review of research this informative book will undoubtedly promote discussion among practitioners, educators, and researchers concerned with family violence and couples.”

-Nicholas Mazza, PhD, Professor of Social Work, Florida State University , Tallahassee

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#14 : Counseling The Physically Challenged and the Chronically Ill

from Matsakis, A., 1998 Chapter 13 in Client Anger: What to do When Your Client is Angry with You. Oakland, CA: New Harbinger Publications COPYRIGHTED MATERIAL

A. Stereotypes and Generalization

Our culture idealizes youth and beauty. Our historical ethos includes the twin notions that people are free to shape their destines and that personal power and persistence can overcome all obstacles (Masur 1994). Consequently, in our culture, to be physically challenged can feel like, and be, an immutable curse. The more one's physical difficulties are visually apparent, the greater the risk of being considered inferior, incompetent, and, of course, unattractive and sexually undesirable (Duffy 1977, Saxton 1991). Even when the physical problem is not obvious (i.e., it is internal and therefore invisible), the stereotypes attending the physically challenged, like the stereotypes attending women, are often those of helplessness, non-assertiveness, dependency, and passivity (Daily 1979, Rieve 1989, Marinelli and Orto 1977).

One of the social consequences of being physically challenged is being labeled disabled. Once so labeled, there is a tendency for the disability to be generalized. In this context, generalization refers to three phenomenon (Taylor, Wood and Lichtman 1983, Matsakis 1996).

(1) the tendency for others to interpret most, if not all, of the physically challenged client's emotions and behavior in light of that label;

(2) the tendency for others to assume that because a person has one physical challenge, he or she is physically impaired in other ways;

(3) the tendency for others to assume that the physical challenge will remain constant forever and ever.

For example, the deaf may be assumed to also be blind and mentally retarded and the blind, physically weak and unathletic. For instance, Roger, who lost an eye in a chemical explosion at work, was not injured in any other way. When he returned to his job, he was offered a wheelchair and told that his company did not employ “cripples.” The more humane and logical response would have been to keep Roger on a job he was fully capable of, and to offer him any assistance he needed to adapt to his injury. Like persons with physical challenges, individuals with chronic illnesses, such as cancer, diabetes, and heart disease, are sometimes subject to the same forms of discrimination, generalization, and stereotyping as the physically challenged. Although individuals with these and other types of chronic illnesses may not be considered physically challenged in a legal sense, they may be treated by others as such (Shover and Jensen 1988, Crooks and Baur 1990).

B. Roots of Negative Stereotypes Of the Physically Challenged and the Chronically Ill

Added to the destructive stereotypes of physically challenged described above and to the tendency to generalize from one physical challenge to the existence of a host of other physical challenges, the physically challenged client must cope with the pervasive notion that those who are ill, disfigured, or otherwise physically challenged are somehow “bad” or “sinful:” i.e., that they somehow brought their problem upon themselves. A related notion is that such persons are dangerous and need to be avoided. The danger does not reside in their being violent, but in a primitive fear that being near a disabled or injured person will cause one to become disabled, injured, or diseased also.

The idea that illness and other physical problems are a “punishment” from God, or the gods, or otherwise signs that one is “bad” or “evil” stems back to pre-Christian days (Vash, 1982, Linveh 1982). For example, having deformed children was sometimes seen as a form of punishment to parents for their “sins” or as evidence of other forms of parental inferiority (Linveh 1982, Vash 1982, Richardson, Goodman, Hastorf and Dornbush 1961 ). Sociologists have found such notions to be nearly universal (Richardson, Goodman, Hastorf, and Dornbush 1961, Linveh 1982).

The idea that physically challenged persons should be avoided in order to protect one's health has also been found to be nearly universal ( Richardson, Goodman, Hastorf and Dornbush 1961, Ruiz 1996). Historians note that these notions became firmly entrenched in western Europe during the Middle Ages when the Black Plague or Black Death of 1348 was blamed on lepers (which included anyone with a skin rash or skin problem), other physically deformed persons, and Jews (Ruiz 1996). Unaware that the deadly plague was being transmitted by fleas carried by rodents, but very aware that almost half of the people around them were dying from the plague, people frantically sought for explanations. A popular theory was that breathing the air near a sick person or a suspected carrier of the plague (such as a leper) might cause one to become ill. Many felt they could save themselves by distancing themselves from plague sufferers and others who suffered from visible diseases, such as lepers. As a result, many victims of illnesses were abandoned by their families, the clergy, and the doctors of the time.

Anyone with a body sore was considered a “leper,” consequently even individuals who had minor skin rashes were considered outcasts and forced to join lepers in ceremonies in which lepers (or anyone who looked like a leper) were declared dead, forced to lay in empty caskets, and, if not killed, then forced to wear black and grey and clappers so that people could be warned of their approach and run away (Ruiz 1996).

C. Societal Rejection, Avoidance and Ambivalence Towards the Physically Challenged

In a parallel manner, today's physically challenged persons are often allocated low-visibility jobs (Marinelli and Orto 1977, Duffy 1977, Dailey 1979 ). This may hearken back to medieval fears of those with visible physical problems, or it may simply reflect our culture's preference for those deemed physically attractive (Duffy 1997, Dailey 1979).

Today legislation affirms the rights of the physically challenged persons and all around us we see physically challenged persons participating as productive members of society and the work force. Furthermore, modern medicine has shown us that physical disability and injuries are not contagious unless the physically challenged person's medical problem includes transmittable viruses or microbes. Most people in our society know they can not become ill ( or disabled, injured, or otherwise physically challenged) merely from being near a physically challenged person unless that person is medically contagious. Nevertheless, on a gut level, some people still fear the physically challenged, as if getting too close might contaminate them.

We therapists are not immune from cultural stereotypes about the physical challenged or their history of persecution (Daily 1979, Cecil 1985, National Working Group on Physically Disabled Vietnam Veterans 1988). An experienced therapist explains: “When my client told me she had cancer, I instinctively pushed my chair back -- away from her. For the first time, she seemed ugly to me, even though I had never thought her so.

“My client noticed my pulling away. I knew she was hurt, but her guilt about having cancer prevented her from saying anything to me.

“‘What's going on with me?' I wondered. Then I realized that I was afraid that if I was near her I'd catch cancer too. Maybe she'd breathe it on me or something.

“I have an advanced degree and my father is a doctor. I know better than to believe I can ‘catch' cancer that way, but somewhere in the back of my mind, something said, ‘Stay away, for your own safety. Be careful. Get away from her.'

“ ‘How could I be so biased? Where does this come from?' I wondered.

“ I've never been hurt by a physically challenged person and nobody in my family is biased against them either. I guess I learned it from the culture.”

Physically challenged clients are often extremely sensitive to the rejection of others and may therefore be especially reactive to any rejection or revulsion, real or perceived, by a therapist. Like many minority groups, they tend not to express anger readily towards anyone perceived of as a helper or as an authority figure (Daily 1978). Consequently, they may not be assertive enough to confront the therapist initially, but over time, any anger at perceived or real rejection or revulsion may build up and express itself in one large outburst (over a relatively trivial matter), in withdrawal, or in some form of passive-aggressive behavior.

In sum, the physically challenged clients on your case load must cope not only with the limitations imposed upon them by their particular physical disability or injury, but with the prejudices of the uninformed and uncompassionate members of their world, including certain physicians and health care workers (Wingfield, Healy and Nicholson 1994, Beckmann, Gittler and Beckmann 198, Rieve 1989, Marinelli and Orto 1977). In addition, the reactions of those in their more immediate interpersonal world, i.e., their partners, family members, neighbors, friends, physicians and medical workers, and co-workers may be mixed (Marinelli and Orto 197, Cecil 1988 ). On the one hand, these persons may be sympathetic and in many tangible ways, extremely supportive. On the other hand, they might also resent any extra work or burdens imposed upon them due to the client's disability. Indeed, one of the major causes of elder abuse is the degree of dependency and disability of elderly persons on their caretakers and friends (Kurrle, Sadler and Cameron 1991).

Furthermore, even when the physically challenged are accepted and cared for, they are not necessarily spared being seen as childlike (in needing extra help), inferior, vocationally and interpersonally incompetent and impaired, and physically unattractive (Daily 1979, Marinelli and Orto 1977). In a society where physical appearance is often equated with an individual's value or worth ( Dailey 1979 ), being deemed unattractive can become a major liability in achieving interpersonal goals, such as love and marriage, as well as vocational goals, and in receiving adequate health care.

The stigma of physical disability can sometimes spill over onto their family members and sexual partners. Parents of physically challenged might be blamed for or as seen as deficient parents for having a physically challenged child. Children of physically challenged parents may be ridiculed or seen as inferior (Marinelli and Orto 1977). There is also evidence that partners of physically challenged can be viewed as having “something wrong with them” because they have chosen a physically challenged mate, especially when that mate is a physically challenged woman ( Duffy 1977, Dailey 1979 ).

D. Shakespeare's Richard III: Internal and External Rage

The Shakespearian character, Richard III, illustrates the paradox of internal and external rage: i.e., harboring rage at the self, as well as rage towards others (Bevington 1980, Huston and Saccio 1994). In Shakespeare's tragedy, Richard III, the chief character, Richard III, is a deformed hunchbacked prince who is seen, and sees himself, as ugly. He grew up the object of disgust and loathing by his mother and others and, overtime, internalized the reactions of these others. By the time he is a young adult, he is full of self-hatred, self-loathing and other forms of extreme emotional pain. He is also full of hate towards others.

This anger he feels towards others, however, is experienced as a form of power. Furthermore, since he has been blighted by nature and segregated by others, he feels free of normal moral laws and societal rules. Inside, he is full of chaotic and self-contradictory feelings (Huston and Saccio 1994).

By discussing Richard III in this text, the author does not intend to perpetuate false or damaging stereotypes of the physically challenged as being evil or ugly. Rather, the dramatic character of Richard III is used to illustrate the prevalence of such stereotypes throughout history and the resulting negative impact on the psychological well being of the physically challenged. Furthermore, the classic figure of Richard III hardly typifies physically challenged persons. However, his internal dynamics underscore in an extreme way the internal and external rage which can be experienced by some physically challenged persons who have been excluded from the world of work and love (or who have had to struggle and overcome major obstacles in order to find social acceptance, close interpersonal ties, and appropriate work) and who have internalized societal negative stereotypes and societal rejection of the physically challenged. Internally Richard III hates himself because he feels ugly, inferior, and sexually and socially undesirable. Externally, he hates others (such as his brother) because they are not deformed like himself, because they look down on him and because they exclude him socially and reject him sexually. If a therapist had asked Richard III to apply the Serenity Prayer (“God, grant me the serenity to accept the things I can not change and the courage to change the things I can, and the wisdom to know the difference”) to his life, that therapist might have received a torrent of accusations, such as, “It's easy for you to talk. What do you know about being ......? You have love and companionship. You can do what you want, when you want, without having to take into consideration [a disability]. You don't have to spend all this time and money on doctors and medical help. You've never been rejected for a job because of [a disability]!”

Rehabilitation counselors and others who work with physically challenged populations strongly suggest that therapists avoid statements such as “I know how you feel” or “If I were in your shoes, I would.....” Even if you, the therapist, are physically challenged yourself, you can avoid considerable client wrath by speaking from your own experience, strength, and hope rather than by implying that you “really understand” how the client feels. Responses which are less likely to evoke client anger include: “I can't say I know how it feels to suffer from [ ] or to have to deal with [ ]. How has that been for you?” or “What has [ the disability or physically challenge] done to your life?” or “How have you managed to do all you do?” or “How have you managed to endure so much emotional and physical pain for so long?”

E. Internal Rage Compounded by Survivor Guilt

In sum, all too often, the physically challenged client has internalized some, or all, of the negative and self-limiting stereotypes about physical disability. This internalization can result in low self-esteem, depression, and anger at the self and, in some case, anger at the therapist. The physically challenged individuals may be haunted by the questions of, “Why me?” or “Did I somehow cause my illness or injury?(Cecil 1985, National Working Group on Physically Disabled Vietnam Veterans 1988). This is especially the case when the physical challenge was the result of a traumatic incident for which the client feels responsible (to one degree or another) or if this traumatic incident involved the injury or death of others.

When a physically challenged client with such a history becomes angry with the therapist (and the anger is not due to therapist error), possible sources of client anger may be survivor guilt and anger at the self for having made a “mistake” or somehow caused the traumatic injury (Cecil 1985, National Working Group on Physically Challenged Vietnam Veterans, 1988). If some individuals were not injured during the traumatic event (or injured less than the client) and the therapist is not physically challenged him or herself, the client may displace his or her ambivalent feelings about the uninjured or relatively less injured person involved in his or her trauma onto the person of the therapist. On the one hand, the client may feel “glad” that this person wasn't injured (or injured as severely as him or herself). On the other hand, the client may be angry at this person for being spared when he, or she, was not. (Chapter provides guidelines for working with trauma survivors who displace their anger about their involvement in such incidents onto the therapist.)

When the physically challenged client feels responsible for his or her condition, his or her depression, and anger, at self and at others, tends to be more intense. Any consequent anger at the therapist can also be more frequent, and more extreme, especially if the therapist proposes ego-enhancing interventions or encourages the client to be more self-rewarding through affirming self-talk or by putting more pleasurable and reinforcing experiences into his or her life. Deep down, some physically challenged clients may feel they do not deserve to feel good about themselves or make their lives better because they blame themselves for their physical condition. As with child abuse survivors, the sense of worthlessness and guilt can be very deep. Consequently, when therapists suggest planning rewarding activities, practicing positive self-affirmations or positive self-talk, or other such interventions, these clients may erupt in protest.

“That will never work!” or “That's too simple” or “Do you think that just because I'm disabled, I'm a moron too? What you're telling me to can't make me happy,” the client may shout.

Some of the client anger may arise from the fact that, unbeknownst to you, your suggestions may create medical or physical stress for the client and the client for one of the following reasons, or some combination of these reasons:

(a) the client is in denial about the extent of his or her disability;

(b) the client is too proud to tell you of the true extent of his or her limitations and consequently becomes angry when he or she is offered a plan or program he or she can not possibly execute without considerable strain or hardship; or

© as stated above, the client may react in anger to you because he or she doesn't feel he or she deserves to even try to make his or her life more pleasant, happier, or more productive.

He or she may feel doomed to a life of slavery to the disability, which, is perceived as a “punishment” for some misdeed or imperfection or for simply being an unworthy person. Due to such guilt, even the most gentle, benign, rational, or obvious comment, intervention or suggestion may be considered insulting, stupid, “dumb” or otherwise unhelpful and ignite the client's wrath towards the therapist..

F. Perceived Therapist Denial or Discounting of the Physical Disability

Clients may also become angry when you make suggestions or comments which they feel deny, discount, or minimize their disability (Cecil 1985, Daily 1979). For example, Susan, who lost the use of her legs in a car accident, was bemoaning her growing obesity. She had trouble getting dates and felt she had few pleasures left to her other than food. She complained that she could no longer walk and jog as she used to prior to the accident, which also contributed to her weight gain. When the therapist suggested swimming or upper body training, which did not require the ability to walk, Susan glared at the therapist.

“Stop pushing me!”

“I wasn't trying to push you. I was responding to what you said in our first session, that one of your treatment goals was to lose weight and to exercise more. If you can't use your lower body, you can still exercise the upper body.”

Susan glared at the therapist some more, then scowled and looked around the office, as if she was trying to block out what the therapist was saying.

“How are you feeing, Susan?” asked the therapist.

“Shut up! Let's drop it,” Susan replied.

During a subsequent session, Susan explained to the therapist that the exercise suggestions were “fine” and “good” and “just what a therapist would and should say.” However, Susan was so angry that she couldn't walk, she didn't want to engage in any kind of physical movement. Also, she deeply resented that the kinds of exercises she could do, for example, push-ups and upper body resistance training, were exercises she didn't like.

Being a “cripple” was so devastating to her, that losing weight and toning her upper body seemed like no compensation for all she had lost. One way she expressed her anger at her situation was by refusing to exercise at all and instead engage in “revenge eating.” Although such actions only contributed to her misery, they were two forms of control she felt she could exert and thus, in some way, take revenge on fate.

Susan felt the therapist was trying to turn her into an “overcomer,” someone who would triumph despite adversity and Susan resented it. Wasn't enough expected of her as it was? She was having trouble just getting through each day. Did she have to be a physically challenged heroine too?

As Cecil (1985) and Daily (1979) explain, positive coping suggestions for disabled clients may sometimes be experienced by the client as a lack of empathy or a form of denial or discounting of the extent of their disability. In working with the physically challenged, sometimes therapists have to walk an emotional tightrope and have to phrase their interventions with exquisite sensitivity. They must offer the client hope of some form of mastery, control, and life satisfaction, while at the same time acknowledge the toll the client's physical condition has exacted on the client's physical health and his or her emotional, spiritual, vocational, family and social life.

Therapists are bound to elicit client anger when they fail to appreciate that even the best medications and medical treatment have limitations, and often have side-effects, which can create new problems and dilemas. For example, medications can dampen sexual desire and abilities and certain medical procedures directly interfere with the ability to be mobile, to be sexually active, or to be able to function on a job (Crooks and Baur 1990).

G. Client Denial

While some clients may become angry with you if they feel you aren't respecting the degree of their disability and suffering, others may flare up when you, in fact, acknowledge their physical challenge. Such clients may not want to be see as “weak” or may feel you are defining them in terms of their disability, rather than in terms of their being a whole person with many attributes, only one of which is having a physical challenge. Alternatively, they may be in a state of denial (Cecil 1985).

Physically challenged clients who are still in a state of denial about their condition have yet to undergo the grieving process. Even if they say they have “made peace” with their hardship or reached a spiritual solution, unless they have undergone the grieving process, their acceptance of their physical challenge exists only on the intellectual, not the emotional, level. Until such clients have completed sufficient grief work and other forms of emotional processing of their physical challenge, they will probably harbor considerable repressed anger.

This repressed anger can easily be triggered in therapy session when the therapist offers empathy or compassion regarding the client's physical challenge or is supportive in other ways. “I don't want any pity. There's nothing wrong with me. I'm no weakling. I don't need your help,” is the stance of denial.

For some, anger may be disguised by an alcohol or drug addiction or by obesity. As Cecil (1985) and Hendrickson ( 1990) note, there is a high correlation between physical challenge and addictions, including eating disorders. When a client begins to exert control over his or her alcohol, drug, or food addiction, grief reactions to the disability (which include anger) are bound to emerge. Some of this anger can easily be displaced onto you, the therapist, especially if you are not physically challenged yourself. You can expect more anger to emerge at the self and at others (including helping professionals such as yourself) once the client begins to emerge from a state of denial

On the other hand, if clients are still actively using alcohol or drugs, or are overeating, then their chemical addiction or obesity (or binge/vomiting) can constitute yet another reason for them to disparage and be angry at themselves. These addictions and eating disorders can also give others reasons to reject them and see them as sexually undesirable, inferior, and interpersonally and vocationally incompetent. This additional interpersonal rejection can fuel the physically challenged client's internal and external rage. Some of this rage can be displaced onto you, especially if the client faults you for not being able to save him or her from his or her addiction or eating disorder.

H. Permission to Grieve

If a client claims that the disability is irrelevant, that client is in denial. Whatever issues that client is seeking counseling for are bound to be affected, to one degree or another, by the client's disability. As Cecil (1985) the disability becomes a part of the sufferer's self-definition and all of the sufferer's relationships and life issues are affected by that disability. Clients who minimize the psychological, financial, interpersonal, and other costs of their disability are more likely to become angry with you when something you do, or say, pierces that denial. Underneath the anger at you may be a deep underlying sense of grief at the loss of health.

You do your physically challenged clients a service when you permit them to grieve or vent their anger over their disability, no matter how many times they have grieved the loss already (Cecil 1985, Daily 1979). As Kubler-Ross (1969) so aptly points out, the grieving process is not a one time process. Permanent or severe losses can be grieved repeatedly. Furthermore, aging and life transitions, difficult for most people, are even more difficult for the physically challenged. For example, aging and life transitions may increase their physical pain and other hardships. These life stages also serve as reminders that any magic wish, that someday in the future they will miraculously be cured, will probably not come true, no matter how “good” they are or how hard they try, or pray, or give to others.

The anger over the renewed or deeper realization of the extent of their loss can easily find convenient (and safe) target in you, the therapist. If your physically challenged client seems particularly angry or irritable with you, despite your best efforts to be sensitive to him or her, you might inquire as to whether there are any changes occurring in his or her family or work situation or whether he or she is experiencing any additional medical problems or discomforts due to the normal process of aging.

As with Richard III, remember that anger at others can be experienced as a form of power and that the feeling of power can be a welcome relief, and diversion, from the profound sense of powerlessness and loss disabled clients must feel when confronting their disability or illness. Your challenge as a therapist will be to help the client uncover the feelings underlying the anger towards you: more specifically, the client's anger at his or her disability and the individuals and circumstances which may have caused it; the client's rage that he or she may be powerless to effect a cure or improvement in the disability; and the client's sense of betrayal and helplessness at confronting any interpersonal or societal stereotypes and rejections because of his or her physical condition.

I. Confrontations regarding dishonesty

Another challenge will be confronting the client regarding any dishonesty or abuse or misuse of others. If the client is like Richard III and feels “entitled” to lie, cheat, steal or injure others because he or she has been cheated out of much that life has to offer, that client may react angrily when you confront him or her with the dishonesties or discrepancies you have observed. However, your sympathy for the client and any guilt you may have that you yourself aren't physically challenged should not prevent you from treating this client as you would any other client exhibiting the same self-destructive or other-destructive behaviors.

J. Prevention Strategies

With the physically challenged, as with other populations, therapist ignorance is a frequent source of client anger (Cecil 1985, Dailey 1979). It is critical that you, the therapist, become acquainted with the exact nature of the physical challenge and the medical and emotional side effects of any medications or treatments for the condition which the client is experiencing. Clients themselves can be excellent sources of this information, or you can ask for letters from the clients' treating physicians or health care providers.

You also need to take a detailed history of the disability, illness, or injury. As Weinstein (1997) explains, unless the client was born with the physical challenge, the client was, at some point in time, almost totally healthy. The moment at which the client became physically challenged, especially if this involved a traumatic event, is most likely a defining moment in that client's life. You need to know as many particulars as possible about how and when the physically challenge became a part of the client's life and as much as possible regarding the client's experiences with health care and other providers. By being aware of the history of the physically challenge, you can be on the look-out for “anniversary dates” related to the client's physical condition, during which the client may evidence lower self-esteem, more depression, greater acting-out, and greater anger at others -- including you. By being aware of the clients' experiences with medical and mental health professionals, you will be better able to understand the client's anger at you when that anger is rooted in mistakes made by previous health care providers or in the client's disappointments with previous medical and mental health professionals.

References - Chapter 13

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