Thursday, April 30, 2009

National Crime Victims' Rights Week - Part II

by Lucy Puryear, M.D.

As evidenced by our readers' comments in Part I, my patient Elizabeth is not unique. There are many women who have been victims of incest, and other sexual assaults. As I see primarily women in my practice, I know their stories very well; but men are also victims of incest as well as victims of rape. Unfortunately their stories are often never heard due to shame and skepticism. It's been recently that we've come to know the darkness of priests assaulting young boys, revealing more about the impact of sexual abuse on men.

When I first began to see Elizabeth she was very anxious and depressed. Her depression was the primary problem and was potentially life-threatening. She was unable to eat and had lost a great deal of weight in a short period of time. She was tired all the time, felt guilty about all the trouble she was causing her mother, and believed that she had been a problem to her family for a long time. She thought that maybe they'd be better off without her around.

At the least, she said, "If I'm dead, the pain will stop. I'm so tired of trying so hard to be good enough, and always screwing up. I just don't want to be here anymore."

My first job in treating Elizabeth was to make sure that she was safe to be on her own and didn't need to be hospitalized for her own safety. I asked her, "Do you think about ways you might hurt yourself?" Fortunately, she said, "No. I just think about not being here anymore. Like if I could just go to sleep and not wake up, that would be great. But I couldn't do that to my mother. I think it would kill her."

Many people with depression have thoughts of death but no plans to actively hurt themselves. This is critical information in order to continue to treat someone as an outpatient. I started Elizabeth on antidepressant medication and recommended she see me once a week for therapy. I also referred her to the rape crisis center in Houston for support, and possible group therapy.

There are themes common to all incest victims and victims of sexual assault that I often hear in therapy. For Elizabeth, she had to deal with the shame and responsibility she felt for the abuse by her stepfather. She wondered, "Why didn't I tell him no, or run out of the room? Why didn't I tell my mom? She would have believed me and it would have stopped. He was mean to her too. Maybe there was part of me that wanted that? Is that possible? I always took the ice cream or candy afterwards."

As an adult looking back, a survivor of sexual abuse might find it hard to understand why s/he didn't say no . . . why s/he didn't run away . . . why s/he didn't tell someone . . . anyone. But a child's mind does not function like an adult's.

A child assumes that adults are there to protect them from harm. It's confusing when the stepfather you are told to love and trust hurts you. You want attention, but the attention is confusing. You are young and he is old; you do what you're told. And it doesn't stop because the person who tells you that he will kill your mother if you tell is more powerful than you and you believe him. You are small and he is big. And you're afraid that if you tell you might be taken away from your mother. So you pretend that there's no problem and you try to be really, really good. But as an adult you feel ashamed and guilty for your participation. You've forgotten how helpless you felt as a five year old. Elizabeth must learn to forgive herself for being five and doing the best she could at the time.

Women who are victims of sexual abuse often grow up feeling dirty and damaged. There is something broken in them that will color how others see them and treat them. It's why often women who have been abused will tolerate being partnered with another abuser. They believe that they are somehow worthless and when someone gets in close they will know how awful they truly are. The abuse, whether verbal or physical, makes sense.

Some women who are abused go on to lead ruined, damaged lives. Elizabeth was walking down this path with her promiscuity and drug and alcohol abuse. The unconscious belief is, If I treat myself this way I am making that choice, I am not powerless, what happened to me was not that big of a deal, I am in control.

If this behavior doesn't stop, lives become more and more desperate and sad. Many women though, like Elizabeth, tell themselves that they will not let the abuse ruin their lives, they will be successful and prove that they have value. But without therapy or some type of working through the abuse the feelings I have described remain. These feelings can have long-term effects on future relationships with friends and loved ones. They remain vulnerable and hurting.

Once someone has been through a traumatic event another traumatic event is much harder to process. It's as if the brain has been primed to respond to trauma. Elizabeth processed the rape in much the same way she internalized the sexual abuse. She believed that the rape was somehow her fault. That there was some flaw in her that made the rapist chose her. That if she hadn't been so stupid as to be walking alone at night, it wouldn't have happened. She had a hard time blaming the rapist for his actions; she was more responsible than he. The rape confirmed her fears that she was damaged and dirty. She didn't report the assault to the police because she was ashamed of herself.

Elizabeth and I spent many months together talking about how a child is not responsible for an adult's abuse. She didn't run away because she was confused and scared and didn't have the maturity to process other choices. She was a child, she was blameless. We talked about the sexual assault on campus being similar to what happened to her as a child. A man bigger and more powerful than she took control and abused her. At the time she was helpless to stop him. We talked about her allowing herself to be angry at her stepfather and the rapist for hurting her. She even allowed herself to express anger at her mother for not realizing what was happening to her as a young child and stopping it.

I am still seeing Elizabeth. She is no longer depressed and has graduated from law school. She is employed and volunteers as a child advocate at the court. We are working on her acknowledging her worth and value and allowing her to have a close relationship with a man who respects and cherishes her. That is still hard for her.

All stories are different and people react differently depending on earlier life experiences. But victims of sexual crimes are left with a particular set of feelings about themselves and their worth as women. There is healing for those feelings and women can recover and lead healthy and productive lives. It is an honor to work with these women and to help them to heal.


Burl Barer said...

As a victim of crime more than once as an adult -- robbed at knifepoint, beaten and robbed, defrauded, identify theft, bank fraud, etc - and also sexually molested as an adolescent -- I have mixed feelings about about this whole crime victim "thing."
There is a strong temptation (or is it tendency) to redefine one's identity as "victim." This self-labeling and self-concept can become a stifling role, and an alternately suffocating and self-exalting identity. I reminds me of people identifying themselves by their disease, injury, sex-act preference, or whether they prefer Spock or Kirk on Star Trek. Do I see myself as Burl Barer, molestation victim, fraud victim, violence victim, head injury victim, or, worse yet, true crime writer and professional braodcaster? I'm sure there has been research on VIS (victim identity syndrome) but I am not familiar with it. It is one thing to survive trauma, it is another thing to retain it and have it become the essence of your identity. You folks are the experts, and I would really appreciate your insights into this topic.

Thank you,
Burl Barer

Lucy Puryear MD said...

I agree with you Burt. identifying yourself as a "victim" or "survivor" is indeed risky. It becomes who you are and not who you ARE, if that makes any sense. The goal for me is to help someone move beyond identification as a victim and identify themselves as someone who something bad happened to, that was beyond their control. I don't want my patient's to see themselves as being defined by what happened to them, but incorporate it into all the stories of their lives. Thanks for you comments.

Leah said...


I hope you'll let Elizabeth know that there are many of us who are very proud of her. Not only for getting the help and support she needed and for finishing her education but also for being a victim advocate. Not every incest, molestation, and rape victim is able to go on and lead a productive life and she is a testament to all victims.