The treatment of victims of violent crime presents particular challenges beyond those typically encountered with other patients. This article was written to illustrate some of the issues that frequently arise. It is a very abbreviated composite of several cases I have worked with. I chose this format in order to disguise the identities of the people involved and to elucidate a few of the treatment aspects.

Tom was a 34-year-old man who came to therapy about four months after having been assaulted at gunpoint by two men in his security parking garage. He had come home late at night after work. He had tried to be cooperative, fearing for his life, but he broke into tears as they laughed at and ridiculing him.

Before he came to see me, Tom had been trying to deal with the incident on his own and was "walking around scared." He had initial insomnia with mid-cycle awakening practically every hour, sometimes as a result of a nightmare in which the assault was being re-enacted.

Tom and his wife had been alcoholics for over fifteen years. Since the assault, he was drinking more, both to help him fall asleep and on the weekends when he was "feeling depressed," and arguing with his wife more.

He was now afraid while driving home at night. He was no longer willing to park in the garage, and he found his anxiety increasing as he got closer to home. In fact, he was staying out later than before and drinking more in order to avoid going home.

He finally called for his first appointment when he had been very disappointed in himself for continuing to have these reactions. He reported feeling anxious and depressed, with periodic episodes of uncharacteristic crying. Friends were tiring of hearing him talk about what happened, and a few were criticizing and ridiculing him because he was "not over it yet."

Our first task was to normalize his experience. He benefited greatly from learning that his reactions were typical. He had been feeling "a little crazy" at his heightened startle responses, his intrusive thoughts, his fears, and his lability. Once he understood these responses in the context of the assault and learned that they were common, he felt less crazy and less worried about them.

This improvement generalized to other aspects of his anxiety. He felt less "out of control" because he was able to talk with me, feeling accepted in his experience of the assault and his reactions to it, without fear of being criticized or judged by me.

He was concerned about his increased drinking. Though he recognized its interference with his recovery from the assault, he noted its defensive function in anesthetizing his fear and anger. He was not yet ready to deal with his alcoholism, though. He was afraid of attending an AA meeting, lest he have to deal with the feelings against which the drinking defended him.

After about 5 months of treatment, he eventually was ready to face his fears and began to attend AA. This sobriety helped him confront some of the issues he had been avoiding and which had been impeding his recovery from the assault.

His wife was also an alcoholic and had reached a point where she was ready to accept help. I was able to offer her a referral to another psychologist, so as to keep the therapeutic relationship between Tom and me unencumbered. She began treatment and started going to meetings herself.

Tom's isolation of affect and the defensive function it served permeated many aspects of the issues he faced. He grew up with an alcoholic father who became angry, volatile, and violent when drunk. As I connected these experiences with his responses to the assault, he discovered that he was perceiving the assailants as if they were his father, taking control away from him again, threatening his life, and ridiculing him for any show of emotion.

Tom was afraid of his own anger because he had no model for expressing it without violence or retribution. Historically, he either exploded or repressed it. He feared that he would not be able to control his anger if he began to allow himself to experience it. He also discovered that he was frightened of his anger because it reminded him of his father, whom he had vowed not to be like.

His intolerance of his own anger left him in a helpless, impotent, victim position in relation to his assailants and their treatment of him. He felt powerless to fight back, even in fantasy, because that confronted him with his experiences of himself in relation to his father, where he felt helpless, vulnerable, wrong, and in danger of his life as if he were still that child.

Without his being able to fight back in some way, he was defenseless in his efforts to face his fears regarding the assault. Once again, he felt like he was back in time, facing his father.

As we were able to identify the obstacles to his anger and his fears about it, he learned to separate his fear and anger with his father from those feelings with his assailants. As he was able to acknowledge and voice his protest against what they did to him, his sleeping difficulties diminished and the nightmares decreased.

With his increased ability to express his anger and fight back in more varied form and intensity, he felt less afraid of it and more able to express it without violence or explosion. Similarly, he felt safer being among people, driving at night, and parking in his garage. He also came to accept how he did respond to their assault.

At the close of treatment, after about a year, Tom had remained sober for seven months. He felt "back in control" of his life and "able to deal with what comes at me." He recognized that he still had issues with his father and his mother, but he was consciously not ready to deal with them. He left feeling good about what he had accomplished and with the confidence that he would be able to return to address those issues at another time.

© Copyright, Carl H. Shubs, Ph.D., 1994.
Reprinted from LACPA News, May/June, 1994, 1.

Dr. Shubs is a psychotherapist in practice in Beverly Hills. He is a member of the Independent Psychotherapy Network.

back to article of the month