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Section 6
Self-Destructive Behaviors

Question 6 | Test | Table of Contents

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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. 

Also, clients 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 days. 

Even 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 Effects
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 paragraph form. 

The three questions I gave Haley included the following:

  1. In what ways, large or small, do you blame yourself for the event’s occurrence?
  2. Do you blame yourself for the way you acted or didn’t act during the trauma?  If so, why?
  3. Do you feel responsible for the extent of the injuries or the damage or other negative results of the trauma?  In what ways?

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." 

Although 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 brother and sister 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 Teen Self-Mutilation.  

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."   

I ask my PTSD clients whom I suspect are suffering from eating disorders to answer the following questions:

  1. Is your body weight 15 percent below that expected for your age and height? 
  2. Are you intensely afraid of gaining weight or becoming fat, even though you are truly underweight?
  3. 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?
  4. If you are a woman, have you missed at least three menstrual periods in a row?
  5. Do you frequently binge?
  6. 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 to?
  7. Do you regularly make yourself vomit, use laxatives or diuretics, diet or fast, or exercise strenuously in order not to gain weight?
  8. Are you obsessed or over concerned with your body shape and weight?
  9. Do you often feel depressed, guilty, angry, or inadequate?
  10. Do you eat large quantities of food in a short period of time?
  11. Do you eat in secret, hide food, or lie about your eating?
  12. Do you feel guilt and remorse about your eating?
  13. 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 of bulimia. 

If 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 victimization:  shattered assumptions, secondary wounding, and victim thinking.
Reviewed 2023

Peer-Reviewed Journal Article References:
Assink, M., van der Put, C. E., Meeuwsen, M. W. C. M., de Jong, N. M., Oort, F. J., Stams, G. J. J. M., & Hoeve, M. (2019). Risk factors for child sexual abuse victimization: A meta-analytic review. Psychological Bulletin, 145(5), 459–489.

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. 

Boysen, G. A., & Prieto, L. R. (2018). Trigger warnings in psychology: Psychology teachers’ perspectives and practices. Scholarship of Teaching and Learning in Psychology, 4(1), 16–26.

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 guilt? To select and enter your answer go to Test.

Section 7
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