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In the last section, we discussed ways for a client to better understand
his or her emotions regarding feeling awareness, thoughts vs.
feelings, and writing out the trauma.
Many times, a survivor of traumatic events experiences
feelings of guilt and shame even though he or she was not responsible in
any way. As you know, this syndrome
is known as survivor guilt.
In this section, we will examine
survivor guilt and other self-destructive behaviors arising from it such as: self-mutilation,
substance addiction, and eating disorders.
3 Self-Destructive Behaviors
♦ #1 Survivor Guilt
First, we will discuss the various causes of survivor guilt. I
have found that many clients contract survivor guilt to counteract their
feelings of helplessness that they experienced during the trauma. Because
clients do not like to think of their lives as being out-of-control, many are unwilling to accept the idea that they in fact had no power over the
crisis. As a result of this, they choose to view themselves,
rather than chance, as being responsible for the trauma.
use survivor guilt as a defense against the pain that they
feel upon seeing others suffering.
Haley, a seventeen
year old client had been in a car accident with four of
her other siblings. Of the five people in the car, Haley
was the only one who walked away from the accident with nothing
worse than scratches. Her younger sister, Stephanie, however, was permanently
paralyzed from the waist down, and her brother Mike was in a coma for seven
though Haley was not driving the car at the time, she suffered
from survivor guilt. Haley stated, "Every day I wish to God that
I had sat in the middle seat. Then I could be
the one in the wheelchair and my sister could still play lacrosse. I
don’t even like sports. I should
be the one forced to sit for the rest of my life."
As you can see,
Haley used her guilt to defend herself from seeing her loved
ones in pain. By overwhelming herself with shame, Haley
won’t have to face the more complicated emotion of grief.
♦ Technique: Identification of Self-Blame and Positive
I believe that in addressing survivor guilt and self-blame, the client
must first confront and recognize that he or she is having these
feelings. To help Haley with her survivor guilt, I asked her to try the "Identification
of Self-Blame" exercise. I gave Haley a list of questions
to consider about her trauma and asked her to answer those questions in detailed
The three questions I gave Haley included the following:
- In what ways, large or small, do you blame yourself
for the event’s occurrence?
- Do you blame yourself for the way you acted or didn’t act
during the trauma? If so, why?
- Do you feel responsible for the extent of the injuries
or the damage or other negative results of the trauma? In what
To respond to these questions, Haley wrote, "I blame myself for Stephanie’s
condition. We fought over who would sit in the middle because we all
hated the over-the-shoulder seat belts. I let her win the fight and take
the middle seat. It was the lap belt that snapped her spine. If
I had been more stubborn, I could have protected my little
sister because that’s what big sisters are for."
As you can
see, Haley has now put into writing her own feelings of self-blame. Because
self-blame so closely has a negative effect on self-esteem, I asked Haley to
try another exercise to counter these feelings called "Positive
Effects." I asked Haley to list all the positive qualities
that she discovered in herself as a result of the trauma. Haley listed, "emotional
strength, loyalty, supportive nature, listening and counseling skills."
Haley said it felt immodest, as she termed it, to list her
qualities, she felt less blame and more purposeful about her
devotion to her family once she had written them down. She stated, "I
guess I survived the wreck so that I could help my brothers and sisters survive
their recovery." As you can see, these two techniques, "Identification
of Self-Blame" and "Positive Effects" helped
Haley to reduce her feelings of survivor guilt.
♦ #2 Self-Mutilation
and Substance Addiction
Second, we’ll discuss the self-destructive behaviors that
some clients resort to as a result of their survivor guilt. The first
of these is self-mutilation. Often,
trauma survivors, and particularly teens, use self-mutilation as a means to
punish themselves or compensate for the fact that they survived the trauma
relatively unharmed. Because this is such a complicated behavior,
we cannot fully discuss self-harm in one section.
If you feel that a client
is in danger of harming themselves to the point of suicide, we strongly recommend
that you refer them for hospitalization. If you wish to learn more about
self-harm and treating clients who self-mutilate, refer to the Healthcare Training
Institute’s course "Physical Pain Stops my Pain!" Treating
The second type of destructive behavior
is substance addiction. Often, clients
describe using such substances as alcohol, cocaine, amphetamines or other drugs
to "escape" from their guilt. Also, this substance abuse
is a way to punish themselves for not taking action when they feel they should
have. To identify clients who might be abusing substances,
an investigation into their clinical or family history may reveal that substances
were used as a way of coping.
♦ #3 Eating Disorder Questionnaire
In addition to self-mutilation and substance addiction, a third type
of self-destructive behavior is eating disorders. Eating
disorders can include anorexia nervosa, bulimia, and overeating. Eating
disorders are more common in women, but can be found among male clients
as well. Often, clients with eating disorders are not aware they have
a problem. To help them identify any eating disorders that have resulted
from PTSD, I suggest trying the "Eating Disorders Questionnaire."
ask my PTSD clients whom I suspect are suffering from eating disorders to answer
the following questions:
- Is your body weight 15 percent below that expected for
your age and height?
- Are you intensely afraid of gaining weight or becoming
fat, even though you are truly underweight?
- Do you believe you are fat or overweight even though,
in reality, you are not? Do parts of your body "feel fat" to
you, even though the bathroom scales, other people, or your own eyes tell
you that those parts are very thin?
- If you are a woman, have you missed at least three menstrual
periods in a row?
- Do you frequently binge?
- When you binge or overeat, do you feel as if your eating is out
of control—that you can’t stop even if you wanted
- Do you regularly make yourself vomit, use laxatives or
diuretics, diet or fast, or exercise strenuously in order not to gain weight?
- Are you obsessed or overconcerned with your body shape and
- Do you often feel depressed, guilty, angry, or inadequate?
- Do you eat large quantities of food in a short period
- Do you eat in secret, hide food, or lie about your eating?
- Do you feel guilt and remorse about your eating?
- Do you start eating even when you are not hungry?
Next, I tell the client how I score this questionnaire. If
a client answers positively to the questions 1-4, I tell them that these
are the characteristics of anorexia nervosa. If he or she answered
positively to questions 5-8, I tell them that these are the characteristics
he or she answered positively to questions 9-13, I tell them that these are
the characteristics of a compulsive overeater. Do you
have a client who has made the PTSD food connect to cope with their disorder? Would
playing this section during your next session or providing them with the questionnaire
in the Manual be beneficial?
In this section, we discussed survivor guilt and other
self-destructive behaviors arising from PTSD such as: self-mutilation,
substance addiction, and eating disorders.
In the next section, we will examine the three levels of
assumptions, secondary wounding, and victim thinking.
Peer-Reviewed Journal Article References:
Bloom, C. M., Holly, S., & Miller, A. M. P. (2012). Self-injurious behavior vs. nonsuicidal self-injury: The CNS stimulant pemoline as a model of self-destructive behavior. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 33(2), 106–112.
Contractor, A. A., Weiss, N. H., Dolan, M., & Mota, N. (2020). Examination of the structural relations between posttraumatic stress disorder symptoms and reckless/self-destructive behaviors. International Journal of Stress Management, 27(1), 35–44.
Shapiro, D. (2014). Survivor guilt. Families, Systems, & Health, 32(3), 354.
What are three destructive behaviors that clients use in answer to survivor
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