Numbing After Rape, and Depth of Therapy

Introduction

Rape is experienced always as a terrible trauma associated with terror, pain, and fear of death. It persists as a brutal common crime in all parts of the world. Recent estimates indicate 17 % of US women are sexually attacked during their lifetime (National Institute of Justice, 1998). Men constitute a small minority of its victims, and as yet there is a paucity of data describing their post-trauma symptoms. Most treatment specialists in regard to children distinguish rape from abuse, but the boundary between them is often indistinct. Psychological information about treatment of raped children and its effectiveness is sparse, because of moral, legal, and religious taboos. The hundreds of articles about the victims of female rape incidents recognize that male violence, power, and rage fuel assaults, more than sexuality. But a definition of rape as “a sexual relationship to which one party does not consent” captures a broad widely accepted contemporary meaning of this word with a quite different connotation than it had during medieval or classical eras. Despite progress in securing women’s welfare and rights during recent decades, amelioration of both the protean painful and durable psychological symptoms after a sexual attack continues to pose a difficult challenge. While I am now an older psychoanalyst specializing in addiction medicine, formerly I was a younger associate professor in an academic department of obstetrics and gynecology. I have treated and followed up with many rape victims some for decades. Many of the patients had had considerable psychopathology prior to the assault because of poverty or psychological mistreatment during childhood and adolescence.

At the outset of this article I need to summarize my concept of “severe emotional trauma”. I adopt much of the eloquent descriptions of Stolorow, 2007. Overwhelming emotional trauma represents and reflects the unbearable feeling that one’s inner world is unstable, unpredictable, and even dangerous. Individuals that have this shattering experience are “stripped of an internal presence of more powerful guardians unconditionally protecting them from harm.” (Prager, 2011, p. 429) Numbing and/or psychosis are psychological remnants and reminders of a shattered once safe, albeit illusory universe. Individual victims vary in their capacity to tolerate the external world’s horrific events such as torture, starvation, imprisonment, warfare and rape. The quality, duration, and intensity of external traumatic events are important determinants of traumatic states. But the inner subjective abiding solidity of relationships with other beloved humans such as parents, offers some protection and possibilities for repair and recovery.

I treated the four women in this report with psychotherapy and some medication for at least three years, all prior to the recent 2013 publication of DSM-5. The present contribution reconsiders psychodynamic psychotherapy methods with a focus especially upon more severe psychopathology. I emphasize, especially, the major importance of the symptom or feeling of numbing. I use most of the criteria of DSM-IV and DSM-5 to diagnose posttraumatic stress disorder in both the first patient, who had comorbid poly-drug dependence, and in the second patient, who had episodes of methamphetamine misuse. In the case history of the second woman, a victim of childhood rape with a co-morbid stimulant addiction diagnosis, numbing possibly may have been present during early life. But after being re-traumatized by adult sadistic, sociopathic male partners, and sudden abandonment by her children, her numbness had an intermittent presence.

The diagnostic features in both instances fit the rubric of “Complex PTSD.” I will summarize the salient features of this diagnosis, evaluate the symptom of numbness, and discuss their implications for therapeutic approaches. Several research studies cited below, published prior to 2013 considered numbing symptoms of considerable importance for prognosis as do I. For purposes of contrast and comparison, I present two other brief treatment summaries that describe emotionally healthier patients, also survivors of an attack incident. Their reactions to acute trauma were characterized by brief or only mild numbing symptoms and both had successful treatments. The first two patients’ histories are more detailed than typical examples in statistical research trauma articles. My descriptions of treatment interactions are intended to provide renewed stimulation for therapists to reconsider the role of the numbing phenomenon in the psychotherapy of victims of a rape crime.

The PTSD Diagnosis Applied to Rape Trauma

Most psychiatric research has studied the post-incident suffering and disability of raped patients using the PTSD symptom clusters found in the Diagnostic and Statistical Manuals (DSM) of the American Psychiatric Association. The World Health Organization’s (WHO), International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) mental disorders classification system is similar, though it has been used to a lesser extent in the United States. The WHO’s ICD–10, like the DSM-5, (both of these the current iterations of the publications), places an emphasis upon the defenses of dissociation and conversion. Both the DSM-IV and -5 contain a criterion for PTSD that states the patient must have been exposed to an event of threatened death, or dangerous threats, or sexual violence. The target population systematically studied to establish and validate the PTSD diagnosis in the DSM has been war veterans, and for the recent DSM-5 reliability research (2012–2013), the adult population was found mainly in the United States Veterans’ Administration hospital system. But the PTSD diagnosis also has been applied broadly to assessing the trauma of rape. Women have a greater risk of developing PTSD after physical assault than do men (Betts et al, 2013).

The validity of all the DSM has often been criticized, but particularly DSM-5. While I have contributed to this negative view especially with regard to the PTSD diagnosis (Barglow, 2011, 2013), I consider this nosology to be a comprehensive, quantifiable description of the consequences of traumatic experience. The Diagnostic and Statistical Manual criteria are the best current source of research data to compare alternative methods of treatment with many varieties of psychopathology including those specific to rape trauma. The psychiatric diagnosis PTSD first included in the 1980 DSM-III lists the symptoms of intrusive recollections, nightmares, psychic distress, or physical reactivity to reminders that leads to avoidance of some thoughts or situations, insomnia, irritability, and hyper-vigilance. There may be poor recall of disturbing experiences with a new “numbing of general responsiveness” or restricted affect. The description remained the same in DSM IV-R, and its nosology demonstrates very high reliability for the PTSD diagnosis after its transfer to DSM-5 (Freedman, Lewis, Michels et al, 2013). The DSM-5 with regard to PTSD mentions psychological symptoms and feelings often tantamount to numbing, citing decreased involvement in habitual activities, a new detachment from formerly important persons, and absence of habitual pleasures. However, it uses the term “numbing” as type of culture-related symptom. The DSM-5 classification of PTSD appends the presence or absence of coexisting symptoms of depersonalization or derealization, which are separately considered to constitute a Dissociative Disorder in the DSM-5. To qualify for inclusion, these two symptoms, often associated with psychotic states, must not be the product of intoxication or another medical condition. I prefer to consider them to be more malignant aspects of severe numbing, as they were in DSM-IV.

Typical post-trauma responses to rape comprise a Posttraumatic Rape Syndrome compatible with descriptions in the DSM-IV R of flashbacks, nightmares, startles, phobias, depression, avoidance, and numbing for PTSD. The relevant emotional defense process, extrapolating from concentrated combat exposure research, is “peritraumatic dissociation.” In a study of 251 male Vietnam veterans with high war-zone stress, “the greater the dissociation during combat stress exposure, the greater the likelihood of meeting criteria for later PTSD,” (Marmar, Weiss, Schlenger et al, 1994, p. 902. In the first two patients described here, besides numbing there were considerable symptoms of depersonalization and derealization, also emphasized as related to PTSD descriptions in DSM-5. Comorbidity with substance dependence, depression, and anxiety disorders other than PTSD is typical of a large portion of the population of women who have been raped. To introduce my effort to comprehend more thoroughly the numbing feeling, affect, defense or syndrome, I will start with a self-report of a young woman, for whom this condition was paramount among her disabling post-trauma symptoms.

Case Example I

On the day my patient, aged 25 years, was raped she had almost completed a PhD. On that Thanksgiving Day my patient was taken hostage and brutally raped by three strangers who broke into an abandoned house of a friend where she was living temporarily. She reported:

Numbing came soon afterwards, described as follows:

While having considerable derealization, and transitory depersonalization during the attack she manifested some immediate resilience shown by her odd politeness to an attacker. Perhaps strength was shown also in the capacity to retain a positive image of group safety shown in the family dinner fantasy. The patient during her post rape-trauma emotional life experienced the pervasive perception of numbness as her single most painful and disabling symptom. A few details of her childhood are pertinent to her strengths and vulnerabilities. More nuanced early emotional memories were almost entirely missing fully compatible with generalized dissociative amnesia. But I doubt if she had any emotional numbing then, an observation compatible with recollections of her parents when they were asked about this in a recent year. (In this regard she differs from the patient in Case Example II who suffered more extensive and chronic childhood trauma, and who did have early numbness, and “zoning out” periods.)

The patient was born on a small farm near Banja Luka, Serbia, and while her overall memory of the first years of life was quite poor, she remembered the sweetness of being sprayed with warm cow milk. She recalled that she seemed older and more mature, and disliked same-age playmates from Croatia (implying that even then, as a child, she knew of current political reality). She recalled little adversity or pain, but suspected that much turmoil resulted from her biological father leaving the family when she was a child of three. Her mother left the rural area and studied music at a local college, where she met the patient’s stepfather, then a student journalist. Her mother married the student, and when she was seven years old, the family moved to Belgrade during the onset of the Third Balkan War.

Her stepfather was hired by a Serbian media propaganda group and was successful as a writer. She liked the sound of his voice, adored his reading books to her, and recalled that he gave her a small diary, which she treasured, and now associates with her pleasure in writing. Frenzied political struggles engrossed her father, who rarely lived at home for more than a couple of days at a time, and who started having numerous sexual affairs with a series of younger women. Her mother suffered from severe migraine headaches and chronic back pain, making it impossible for her to be employed. The patient recalled her mother not so much as in motherly role, but more as a friend who protected her from her father’s malice and condemnation of female fragility. Her mother avoided any display of irritation and when confronted by adversity often played the role of clown or buffoon.

During most of her childhood my patient felt she had been mistakenly “trapped in the body of an adult.” She always felt compelled to avoid trouble (as her mother did) and to exercise control over both positive and negative feelings. Since her father wrote for a radio station detested by members of other ethnic groups, he felt (possibly correctly) that he and the family were being spied upon. Because the patient was “super-smart” (by her own description), peers bullied her as a “teachers’ pet,” and adults were condescending or ignored her. To survive emotionally she attached herself to a popular athletic girl, and maintained a secret unrequited love for an older boy. At the age of eight, her main relationship was to her diary, in which she shared her unhappiness, resentments, and hatred of her lonely life.

At age 17 she was sent to the United States with a full scholarship to an Ivy League college. But soon after matriculation she established social ties with school dropouts, town vagrants, troublemakers, and “druggies.” She began using euphoriants, leading to intermittent mild addiction over the first three years of enrollment. Miraculously, she performed well in classes and was considered a gifted, brilliant student; she particularly excelled in fiction and writing classes. She recalled no numbing episodes during these years.

Since being attacked, there were a few occasions she barely survived physically, and she contemplated suicide. Eighteen months after treatment started, she required two more hospitalizations both much shorter than the one she needed after being raped.

At the initiation of treatment, she totally avoided both sexual life and emotional intimacy, was plagued by various obsessions about food, doubts about her work capability, and physical attractiveness. She controlled these doubts through prolonged exercise activities and dieting, which she regarded as soothing distractions, but which often exhausted her emotionally and physically. Her parents helped her a little financially, but still lived in Europe, and mostly ignored her. She was unwilling to have contact with American relatives who tried to reach out to her, perhaps because she was too ashamed of her addiction problems.

At times she worked as an administrator and peer counselor in a “safe-habitat house” treatment program for people with addictions, where she lived in an unheated attic room. She attended Narcotics Anonymous meetings regularly and did not have cravings for illegal agents or suffer a drug relapse. Abstinence was supported by a daily high dose of buprenorphine (24 mg.), an opiate maintenance agent. The use of this legal agent prevented menstruation during the first three years after the rape. She was comfortable with this situation in spite of a slight risk to her ovaries because menstruation reminds her of sexuality and rape. She also took small doses of antidepressants and benzodiazepines. Often, magical thinking attracted her to alternative medicines that were promoted in partial hospitalization programs. I discouraged the use of these, if they posed a risk.

Discussion of Case Example I

The therapy strategy evolved not so much from her early history but from her more recent status, including illegal agent use just before the rape and from her precarious mental status post-incident. In this patient’s treatment, I chose an approach that was supportive of her surviving psychic defenses and deliberately avoided psychological depth. Her primary psychotherapist had a similar approach—we avoided deep psychological interpretations or reconstructions, and we rarely spoke of her traumatic past. Early in her treatment during a monthly medication checks, I often chatted superficially with her. When she found it too emotionally difficult to meet with me, she sent me extensive e-mails detailing her chaotic life. Sometimes I gave her direct advice about daily tasks of living. Also she had supportive therapy once a week or every two weeks with an empathic older woman. The patient’s creative writing was clearly a good way to remain emotionally connected, and was cautiously encouraged by both of us.

The distressing sensations of numbing were prolonged, paralyzing, and painful during the first year of treatment. It is possible their presence and duration were increased by the use of legal buprenorphine, even in the absence of illegal drug use.

During the second therapy year she suffered more bouts of anxiety, insect phobias, considerable anhedonia, and hypochondriasis. We noticed once that when she had a six-to-seven hour bout of numbness, triggered by a strong flashback reminder of the rape by a menacing man, she felt less agitated and fearful. But the simultaneous heightened derealization lead to serious temporary mistakes in judgment and decision making and lead to exposure to other real risks. Yet, the patient increasingly managed to feel safe and comfortable with both me and the other psychotherapist, an attitude gradually transferred over several years of time to her social life outside of treatment.

Using the description of ego growth phases outlined in the writing about trauma of James Chu (2010A), she attained “Phase II of Trauma Repair,” in which she could confront and work through some of her traumatic memories. Numbing symptoms diminished markedly during the second treatment year, while the dose of the opioid agent buprenorphine remained the same. Numbness was brief and rare during the third treatment year. At the end of this year her dose of buprenorphine was diminished by 20%, and she had more symptom-free days. She managed to establish durable non-sexual friendships with several men who were both protective and generous to her.

The diagnosis of Depersonalization/Derealization Disorder does match all of this patient’s symptoms and treatment course events. However, there was no numbing prior to the rape, and we were unable to verify that she was exposed to substantial abuse, violence, or neglect in childhood. Her many years of academic high achievement also speak against this diagnosis. Considering her history of drug dependence prior to the rape, my patient’s diagnosis met all the criteria for the designation, “Complex PTSD.” This term describes the pathology of trauma subjects with a background of repetitive and chronic traumas (Muenzenmaier, Spei, & Gross, 2010), or disorders of extreme stress producing major co-morbidity with depression, addiction, and Axis II Personality Disorders as described in the DSM.

Illicit drug use increases the risk of future sexual assault and assault increases risk of subsequent substance dependence (Kilpatrick, Acierno, Resick et al., 1997).

Could the patient in this case example have been helped more by intensive therapy or even psychoanalysis? Ullman & Brothers (1988) emphasized the benefit of analytic approaches for even severe trauma treatment. They consider the advantages of “insight” versus “supportive” therapy, and compare the “psychology of the self” understanding with traditional Freudian perspectives. Ullman and Brothers (1988) might have recommended that for this woman we should identify the archaic, narcissistic fantasies that were shattered by the sexual assault. (They acknowledge that some analyst writers have warned of risks associated with depth analysis of severely traumatized patients.) These fantasies they maintained, even if weakly restored can be “precursors of the more familiar dissociative symptoms of PTSD such as re-experiencing and numbing” (p. 118). This idea seems a little too speculative, but we could not identify such a childhood cognitive-affective nucleus in this patient anyway.

Localized dissociative amnesia was a tough impediment to efforts to reconstruct details of her early emotional infantile conflicts and injuries. This was not shown in regard to memory of details of the rape incident, but was manifested more in regard to her experiences as an addict. Her other therapist and I noticed loss of remote memory most dramatically in the blanket of silence covering early childhood: “I was never a child.” Years of illegal drug use might have impaired recall, but the influence of this factor was difficult to judge. Ferenczi (Gutierrez 2009) noted that unbearable trauma could destroy the self, through the mechanisms of “concussion,” “splitting,” or “atomization,” which may generate a psychosis. It is possible that therapists who fear to use classical psychoanalytic methods, such as transference interpretation and reconstruction of childhood narcissistic wounds, may be over-identifying with victims of injustice. The second summary of a treatment captures even more vividly the importance of transactional empathic timing, and the utmost caution required to treat a severely traumatized rape victim.

Case Example II

Alberta is a divorced 55 year-of-age teacher. She is physically small, with blonde hair, and a smooth doll-like face that at times is perturbed by twitches of tardive dyskinesia. She has two daughters and three grandchildren who are very important to her since they constitute almost her sole social contacts. At the beginning of her treatment the only medicine she used was aprazolam, an agent with the frequent side effect of memory loss.

Alberta’s early life was chaotic and dangerous. Her father was schizophrenic and alcoholic and resided more in mental hospitals and jails than at home. Her desperate impoverished mother abandoned her at the age of two, and after a year in an orphanage Alberta was placed into an unprotected foster home care situation. As the youngest of 10 children she was severely neglected by often-changing care providers. Half a century prior to my treating her, between the ages of three to four years, she was raped and badly bruised by a 19 year old mentally impaired foster-brother. She recalled that afterwards,

There were further episodes blurred by the fog of time. Unbearable repeated childhood terror, I speculate, was the progenitor and nucleus of later adult numbing.

She was married for a few years, and after divorce had some durable relations with men. But men tended to exploit, deceive and verbally abuse her. After her daughters left home as adults, Alberta reported some days of fogginess, disorientation, depression, and craving for stimulation. During her 40s she became addicted to crystalline methamphetamine and sometimes became paranoid during heavy use episodes. She almost recovered from this addiction, and had had many drug-free years during which she was assisted frequently by therapists and psychiatrists. Still she had periodic severe panic attacks, and sometimes cut her wrists after stressful life events. When numbing dominated her mood she would make errors of omission. She might not appear at her job, without offering an explanation before or afterwards. Antidepressant medication provided some relief, but she often stopped taking it because of various disagreeable side effects or because of “forgetting” to take it.

Treatment Issues and Problems

Once during a treatment session Alberta was talking of being abandoned by a man she had dated recently. Suddenly she recalled that a few days after her childhood assault experience, she had shut out awareness of her own external genitalia. Then she recalled a “disgusting” memory that she has not told her previous therapists:

I might have used this memory to talk about shutting out her embarrassment about having once again trusted a stranger without considering that he might turn out to be a selfish exploiting male or I might have further explored with her, feelings connected with her childhood rape. But I responded only with a terse comment, “you must have been very scared.”

At that moment I did not pursue the memory at all, made no interpretations, and did not try to use it for purposes of reality testing. Instead I chose to support the defenses of repression and suppression. My response may seem incompatible with the challenge of “recovery of dissociated emotion and knowledge … and restoring or acquiring personal authority over the remembering process,” by Courtois and Ford (2009, p. 90) as suggested for treatment of this sub-type of PTSD. But the abrupt revival of this undefended bizarre explicit graphic image seemed near to psychotic deterioration. The time was not ripe for efforts to counteract either dissociation or repression, and there might never be such a time. (Later while preparing this article, I searched for such an image in Life and Time magazines published during the specific years of her early childhood, but could not find any such photo of Siamese twins. I did locate a graphic image of thalidomide-deformed joined-at-the-hip female fetuses that the patient may have glimpsed as a child.) After this incident the patient had a sustained period of emotional stability.

But nine months later she had a relapse in crystalline methamphetamine use. This lead to the fierce angry criticism by one of her daughters and a several month long period of social rejection by the other, who herself felt more emotionally fragile after the birth of her own infant. This familial friction, reinforced by her insensitive ex-husband, was the precursor of a situation in which the patient’s daughters disinvited her from a planned family vacation. Alberta took this as a vicious rejection, and she had a near psychotic-rage reaction during which she yelled loud threats of violence. Alarmed neighbors precipitated a massive police intervention and involuntary psychiatric hospitalization. After I learned she had been discharged I scheduled an early therapy meeting with the patient.

She was still agitated and immediately directed her verbal fury toward me, to which I responded clumsily and inappropriately. Perhaps too quickly I surmised that she was not overtly paranoid or delusional. She tried to avoid exploring either the slight from her daughters or the details of the hospitalization. She insisted that she only sought a few-minute meeting to renew her sleeping medications (Alprazolam, 2.0 mg). I wrote the prescription, but I commented that I could understand how in light of her drug relapse, recent irritability, and work absenteeism, her daughters might not have wanted to expose themselves and their very young children to her unpredictability. My error reproduced in Alberta both the terrifying perceived abandonment by her daughters and the intolerable pain of her horrific early childhood traumas. She screamed invectives at me with intense vehemence. She suddenly bolted out of the room, almost smashing the exit door, jumped into her car, and drove away at such a high speed, I feared a serious auto accident.

Van der Hart, Nijenhuis, Steele (2006) would comprehend this behavior as a “maladaptive substitute for adaptive action” which revived earlier life hyperarousal while demolishing reflective thinking and realistic action (p. 27). Two days I phoned her to schedule a meeting. When we met, I referred to the recent traumatic situation only while entirely taking her side: “You were entirely justified to be outraged. But maybe you could use anger at such a rejection more in your behalf next time, and avoid going into the hospital”.

It appeared I could at least temporarily assist her to master recent events more calmly and realistically. But after three years, while she has improved in her capability to work at a job, participate fully in Alcoholics Anonymous, and develop new friendships, she remained profoundly impaired. She had not fully attained the completion of the first phase of Complex Trauma Repair (Chu, 2011). This partial failure may have been explained by periodic addiction relapses, my therapeutic mistakes, or by her inability to better master the extraordinary agony of her early continually childhood traumata, revived in her contemporary life.

The Importance of Numbing in Comprehending Aftermaths of Emotional Trauma

I find that numbness is the pivotal condition or symptom in selecting an optimal strategy for psychodynamic treatment. In the DSM-5, PTSD (309.81) and the Dissociative Disorders–Dissociative Amnesia (300.12) and Depersonalization / Derealization Disorder (300.6) attribute the proximal cause of numbness to the mechanism of dissociation. “For PTSD, dissociative processes manifest as emotional numbing” (Chu, 2010, p. 615). Deeper understanding, description, and elaboration of this symptom might further clarify the prognosis for rape victims, and might even provide a guideline for selection of a type of psychodynamic treatment–”supportive” versus “uncovering.”

Persuasive evidence shows that the important psychological defenses of avoidance and numbing are distinct (Asmundson et al., 2005; Pruneau 2008). Clinically viewed, those patients who actively avoid perceptions and environments reminding them of a specific severe trauma manifest considerable control and mastery. The former defense seems healthier and more mature than the latter. Those suffering from pervasive numbness appear to suffer more from sensations of helplessness and being overwhelmed by a distressing void of emotion as described in the first two subjects in this article. This observation is aptly captured by the summary quotation by Feur, Nishith, and Resick (2005) of the assertion of Taylor, Kuch, Koch et al, 1998 that “Numbing is an automatic consequence of uncontrollable physiological arousal whereas avoidance is an active means of coping with trauma-related intrusion” (p. 166).

Severely traumatized patients with preexisting psychopathology, as illustrated by the above first two case examples, may be characterized by a specific dissociative subtype of PTSD that involves disruptions in the functions of memory, identity, body awareness, self-perception, and relation with the environment, When this PTSD category is considered from a neurobiological perspective it implies “emotional over-modulation mediated by midline prefrontal inhibition of limbic regions” located in the dorsal anterior cingulate, and medial prefrontal cortex, (Lanius et al, 2010, p. 640). Flack, Litz, & Hsieh et al (2000) proposed that emotional numbing is the result of chronic hyperarousal in male combat veterans. Amnesia, detachment sensations, lowered emotional responsiveness, reduced awareness of inner feeling nuances, conviction of a foreshortened future, and suicide wishes characterize a corresponding psychological numbing condition after rape.

Studies of combat veterans find that numbing often predicts an increased incidence of future anxiety and psychotic disorders (Kashdan et al, 2006) and predicts chronic PTSD, (Marshall, Turner, Lewis-Fernandez et al, 2006). Numbing symptoms in disaster workers predict future intractable PTSD (Malta, Wyka, Giosan et al, 2009). Also, it has considerable predictive importance for the employment of specific treatment modalities (Foa, Cashman, Jaycox, Perry, 1997, and Pietrzack 2009). Nishith et al, (2002) found that exposure therapy works better to reduce avoidance than it does to ameliorate numbing. Numbing seems to be more associated than does avoidance with major depression syndromes and implies a worse long-term prognosis. Holowka, Marx, Kaloupek &Keane (2012) reported that Vietnam war veterans with simple PTSD reported more numbing/restricted affect symptoms that did those with PTSD and comorbid disorders. Of course the frequency that numbing is reported may differ between male war veterans and female rape victims.

The symptom of numbing is incorporated in two quantitative scales of Psychological Test Instruments that measure improvement in the PTSD clinical condition. One is a Clinician-administered PTSD Scale ([CAPS] Blake, et al., 2006) and the other used patient self-report (Foa, Cashman, Jaycox, & Perry, 1993). Both scales to a large extent mirror the symptom categories from DSM-III-R, in which numbing is included in “Avoidance-Numbing criterion C.” These psychological test instruments in subcriteria (C3-C7) capture aspects of numbing in documenting odd and vague recall of rape details, estrangement from loved ones, absence of pleasure, pessimism, and loss of all hope.

The Treatment of Emotional Traumata after Rape

The first two case examples raise questions about the various approaches to the treatment of rape victims in general and the importance of the numbing symptom in particular. The best therapeutic response for the emotional short- and long-term consequences of this worldwide epidemic of sexual trauma remains doubtful and even controversial. For example, even the benefit of immediate “debriefing” after a rape is uncertain since it may produce retraumatization (Barbosa, 2005; Gist & Devilly, 2002). Regarding the severity of rape trauma after effects: A community study of crime victims (Kilpatrick, Acierno, Resick et al, 1997) demonstrated that after nine years the group of 100 women who had been raped made suicide attempts (19.2%) than other groups. The rates were comparable to those of combat veterans with PTSD (Hendin & Haas, 1984). Studies of combat veterans with PTSD find that numbing often predicts an increased incidence of future anxiety and psychotic disorders (Kashdan et al, 2006) and chronic PTSD (Marshall, Turner, Lewis-Fernandez et al, 2006;).

Careful assessment of medication and treatment efforts for the entire post trauma spectrum of symptoms characterizing PTSD found that there was sufficient scientific evidence only for the efficacy of Prolonged Exposure Therapy ([PET] National Academy of Sciences, 2008). Cognitive-behavioral Therapy (CBT) more recently has displayed effectiveness in treating PTSD. There are excellent guides to techniques for PET and CBT for PTSD in general by Taylor (2006) and Foa, Keane, and Friedman (2009). There is also a comprehensive book by Foa and Rothsbaum (1998) about rape treatment with detailed instructions and techniques for therapeutic interventions. Several of their described patients did have numbing sensations and even some perceptual distortions similar to those that were depicted in my Case example I. But more serious symptoms implying alterations in the sense of self, like depersonalization or derealization as found in my Case example II were not noted by these authors. This suggests that members of their study sample may have had less severe psychiatric disturbance than my first two patients. But numbing was often an important condition in this population, requiring special therapeutic intervention.

Numbing also has considerable predictive importance for specific treatment modalities (Foa, Cashman, Jaycox & Perry, 1995; Pietrzack, 2009). Nishith et al (2002) found that Exposure Therapy worked better to reduce avoidance than it did to ameliorate numbing. Numbing seemed to be more associated with major depression syndromes than did avoidance, and it (numbing) implied a worse long-term prognosis. This symptom, affect or condition is almost ignored in the largest research study of treatment of rape PTSD treated with Prolonged Exposure Therapy (PET) or Cognitive Behavioral Therapy (CBT). Their research evaluated the outcome of intervention with 171 rape victims treated in a research setting (Nishith, Resnick, & Grifin, 2002). Major symptoms showed considerable amelioration of symptoms with both interventions when compared to thos in a “Minimal Attention” control group. I surmise that the symptom of numbing was was largely ignored because it may have characterized the large group of 63 subjects that dropped out of the research study. This sub-group of research participants was not assessed.

Numbing Considered Within a Psychodynamic Context

Judith Herman in her superb classic, Trauma and Recovery (1992) emphasized the use of both psychiatric research and psychodynamic depth understanding for trauma treatment. The treatment strategy approach toward the four patients described in this report is informed most overtly by her contributions. The psychoanalytic perspective appears to use the language of everyday experience more than the more abstract, abstruse words of Psychiatry’s discourse. But then“what’s in a name?” Most of us have shared the experience of a tooth’s physical numbness from a trip to the dentist. If we have had surgical anesthesia our memories vary little, and dental patients can communicate readily about the experience. But the words, numbing or numbness have multiple meanings, definitions, and connotations many of which are related to the experience and aftermath of trauma. In psychiatry, subjectively regarded, our patients’ numbness is captured by colloquial concrete adjectives such as “zombified,” “spaced out,”, stunned,” “deadened,” “lifeless”, “empty”. Emily Dickinson’s poem at the beginning of this paper conveys the deathlike condition of numbing with the beauty of poetry. By contrast, Keats, in his “Ode to a Nightingale,” (1819) captures its idealized association with nature.

Objectively, the condition is described though abstract terms, such as “affect,” “anhedonia.” “depersonalization,” “derealization,” “dissociation,” “blunting,” “flattening,” “aporia,” “alexithymia” or even as a “defense against affect”. But further conceptualization and clarification of emotional numbing is complex. Its definition encompasses a broad variety of feelings with multiple nuances, comparable to what the term, “white” can connote in the Japanese language or what it may mean in Herman Melville’s analysis of “whiteness of the whale” in Moby Dick (1851). Numbness can imply an avoidance of the hyper-aroused acute state of a devastating flashbacks or the blurred awareness of diminished pain without euphoria that a sedative produces in a mind’s grasp of physical injury. But the sensation may occupy totally the vast sphere of consciousness, quite unlike the perception of a conversion symptom of hysteria that is usually appears to be localized to a specific body part.

Numbing conceptualized while using only psychological constructs is most compatible with psychodynamic therapy. Freud (Breuer & Freud, 1895/1995) compared mental trauma to a wound inflicted not upon the body, but on the mind. He recognized that a profound traumatic experience could not be fully assimilated as it occurred and hypothesized that in the face of trauma an innate barrier against dangerous stimuli could be threatened with rupture. The mind could split in two, yielding an altered state of consciousness in which some events could become dissociated, unreal, and repressed. Later unconscious material could surge back against repression thereby generating anxiety, different symptoms (hyperarousal, avoidance, obsessions, numbing) and recurring nightmares. Freud’s interest in dissociation soon was subordinated to his absorption with fantasy, repression, and the Oedipal complex. But Janet (1907) restated Freud and Breuer’s insights by asserting that severe trauma could be managed only through the emergency mechanism of dissociation. Carl Jung, his student, a few years later explicated both favorable and damaging aspects of dissociation. Dissociation Disorders in 1980 were included in DSM-III, the same year that PTSD made its formal debut (McFadden 2012). Janet’s contributions inspired the clinical insights of Van der Hart, Nijenhuis & Steele (2006).

It is valuable to contrast aftermaths of rape with prolonged numbing with those instances where it is transitory. Numbing in the first two case histories above was profound and persistent. I consider its essence to be a primitive affect, split off from its ideational content. The genesis of this particular primitive affect is well expressed through the concept of “structural dissociation”. Apparently healthy but vulnerable mental structures strongly inhibit agonizing affect, leaving a severely traumatized person, “numb, depersonalized, and avoidant of conflicted painful” feelings and sensations (Van der Hart, Nijenhuis, & Steele, 2006, p. 285).

The absence of ideation and memory of the traumatic incident can be encapsulated by the insight that “some early childhood memories are at the same time unremberable and unforgettable” (Frank & Muslim, 1967, p. 48). In the light of their formulation, a too severe trauma marked by later prolonged or refractory numbing generates a regression to a primary process ideational state that is pre-linguistic or even “unlinguistic” (my neologism). They name the process, “passive primal repression.” Applied to pervasive numbing a rape victim is unable to recall cognitively or forget the trauma. Only the split off painful affect may remain. Such a deficit constitutes a profound challenge for repair, which patients can accomplish through only through sharing the heavy emotional burden of the trauma with a therapist (or with a unique loved one). During this process, capacities for self-care, self-comfort, and self-regulation require much monitoring and support.

Rape Victims with Less Virulent Psychopatholgy

For purposes of contrast and comparison I present two other treatment courses that describe far healthier psychiatric patients. Their PTSD symptoms include short-duration or moderate numbing sensations during their gradual, but progressive, recovery from a rape trauma. Their therapy may include transference interpretations, or other therapeutic “uncovering” activities as illustrated by the following two case examples demonstrate.

Case Example III

Connie is a 40-year-old, successful private detective in a good marriage for many years. When I met her both her mother and sisters were having major emotional and drug addiction crises, and they frequently sought out her help and interventions. She over identified with their distress. During her childhood her dictatorial father was physically abusive to female members of the family; it was severe enough to bring about his incarceration. When she began the psychotherapy, contemporary family turmoil was absorbing her attention excessively, diverting her focus from her job performance. She was late in completing projects and found it difficult to complete investigations. Clients found fault with her performance.

A decade earlier while serving in the U.S. Army in Iraq, she was raped by a male senior military officer. Another woman soldier was also assaulted (almost a quarter of female military veterans have been raped (Steinhauer, 2013), but their joint complaints to authorities elicited an inadequate legal response. Sensations of numbing, and fantasies during which she could escape magically from an unjust, hostile male-dominated world lasted only for a few days. She felt anger more than despair and felt supported by her intense friendship with the other woman who had been attacked. Deeply disappointed by the military system, she took the active step of soon resigning in protest.

In later civilian life Connie had bouts of depression and though she had nightmares and insomnia that made it hard for her to hold a job, numbing did not recur. At times she experiences some symptoms of sexual inhibition, but these subsided after she married a kind, loving man who was a judge. Working in a criminal assessment system, her husband was often required to provide compensation for injustice. With his support and her keen intellect, Connie retrained and obtained remunerative, creative employment.

Sometimes during treatment sessions she would protest small signs of some of my compulsive rigidities and insensitivity to the nuances of a feminist’s challenges. There was a kernel of truth in her criticism, although its intensity might have been amplified by a mobilization of transference attitudes related to childhood images of her father or rage against her attacker, both authoritarian males.

After several years a major challenge to her stability suddenly emerged; she was assigned by her boss to investigate a crime in which she had to partner with a colleague, whose ethnicity was the same as and whose face resembled that of her attacker. In one therapy session she noted that his type of baldness reminded her of me. She had already firmly decided to resign from her position, and retrain for a different career. The obsessional intrusion and reliving of her past pain with her colleague was interpreted, and her excessive, frantic efforts to assist floundering family members were terminated through my urgent advice. She acquired the understanding that excess energy devoted to solving family-member problems might be connected with unwitting efforts to undo her traumatic experience many years earlier. Now fully aware of the transference meaning of working with this particular assigned partner, she surmounted this crisis with the help provided by insight psychotherapy.

She vigorously pursued legal remedies through the Veterans Administration clinical administrative system for compensation that she deserved. Her career path took an upwards spiral.

Case Example IV

Betty is 49 years of age, an athletic police officer with a good career. She is conventionally attractive enough to work part-time as a clothing model. But her beauty and competence has not been sufficient to lead to prolonged relationships with men or a happy marriage. A violent assault probably contributed to this. At age 27 Betty was gang raped and sodomized by a group of intoxicated professional athletes, one of whom she had dated for several months. “I was horribly hurt, sad, disgusted but my spirit was not taken away. I was determined to survive, and continued to think about what happened and if I had been careless.” Feelings of numbing in the form of unreality sensations, memory loss, and fainting spells lasted only a few months.

Although she had close ties both with her many siblings and her parents, with whom she shared devout Catholicism, she did not reveal the incident to anyone until 14 years later when she phoned the “hotline” of a local woman psychic. That same year she tried to tell her parents about the incident, but while “they suspected what had happened to me they didn’t want to hear any details.” However, she thinks her father was especially kind to her when he sensed “something awful was hurting in me”.

Perhaps because the rape left her with shame and lowered self-esteem she married a sociopathic man for a few years with whom she participated in minor illegal frauds, and drug thefts from pharmacies and medical offices. The couple had a child who after a period of adolescent turmoil became a model citizen and achiever.

Decades after the rape she began a decade of psychotherapy with me, precipitated by her difficulty in having durable intimacy with a series of males. Betty’s most recent involvement was with a former college hockey player notorious for on-ice fights. Although he later became a model father, he had a persistent wild streak that included promiscuous relationships outside of his several marriages. After his most recent divorce, he had multiple exploitative relationships with younger partners, including my patient. She terminated this self-defeating situation after she was able to understand that her attraction to him might be related to working through her rape experience decades earlier.

Her therapy demonstrated that a past rape incident revived in the present can be interpreted, mourned, assimilated, and used as an emotional growth experience.

Conclusions

The psychic aftermaths of traumatic rape with profound numbing differ importantly from instances in which numbing is transitory. The subjects of Case Examples III and IV were healthier, more resilient persons with only minor numbing. Neither of the two women used illegal drugs or required the transitory protection of hospitalization. They survived the trauma of rape with a more benign prognosis and were able to resume a near-normal life. In their psychotherapy, depth psychological interpretations and uncovering procedures were both appropriate and helpful. But the women in Case Examples I and II required the noninterpreting supportive therapy promoted by J. A. Chu (2010A) because they manifested severe emotional symptoms of numbing, and had powerful proclivities toward psychic dissociation and regression. Both patients had prolonged episodes of addiction, and repeatedly required hospitalization. The symptom of numbing was profound and persistent. Its basic essence in such an instances I conceptualize as a primitive affect split away from its ideational content.

Its genesis is captured well by the concept of “structural dissociation.” During later adulthood, seemingly healthy personality systems and structures become so endangered by primitive raw emotions that these must be extinguished leaving behind a chronic numb state (Vanderhart, Nijenhuis, & Steele, 2006) often with near psychotic depersonalization or derealization. The concomitant absence of ideation and memory can be psychoanalytically considered a form of “primal repression,” (Frank & Muslim, 1967). Possibly a patient can construct a new interpretation of the event through the use of naming and language. The numbing affect or defense against other hyper-aroused affect may diminish with time. But amelioration of such a deficit requires prolonged sharing of the emotional remnants of this kind of severe trauma with a cautious empathic therapist.

Numbing and avoidance make it difficult for patients to trust a therapist and to profit from complex interpretations or scrutiny of pretraumatic personality configurations and early memories. A therapist in the face of severe “complex trauma” with a prolonged regressive response and persistent numbness may need simply to help the patient hold together and prevent further regression. Repeated life-threatening crises inevitably damage the capacity for introspection and looking deeply within. If a treating professional detects a terrifying primitive terror during diagnosis or treatment of the aftereffects of being raped, there may be a risk of psychotic deterioration. In such instances, a therapist needs to soothe and support, or prescribe medication. Past trauma memories and interpretations of revived memories should be avoided. After psychological stabilization, severe traumatic memories must be approached with utmost caution and respect.