8

Difficulty Regulating Emotion

(Complex PTSD, Category 1)

In chapter 1, we gave you a proposed description of a new diagnostic category of trauma called complex PTSD or disorders of extreme stress not otherwise specified (DESNOS). Why might a different diagnosis be necessary? As we said previously, you can be exposed to different types of traumatic events. The first type, type I exposure, means that you have experienced a single distinct traumatic event or, over the course of a lifetime, a few distinct traumatic events. Many persons experience only a few traumas in the course of a lifetime.

Judy was in a car accident when she was thirty. She was driving when a car came out of nowhere and hit her car on the passenger’s side. Judy had several broken bones from the impact but her injuries were not life-threatening. Her boyfriend died when he was thrown through the windshield. He had refused to put on his seat belt. She watched as he flew out of the car and hit the pavement in front of other cars that then ran over him.

Ted was walking down a quiet street about 10 P.M. when three young teenagers approached him and demanded his money. Ted noticed that they were carrying weapons: one had a knife, another had a gun, and a third had what looked to be a sawed-off shotgun. When he saw the weapons Ted handed the boys his wallet. However, they wanted his jewelry, too. When Ted was unable to get his ring off his finger, the boy with the knife suddenly grabbed Ted’s hand and cut the finger off. The boys ran. Bleeding heavily, Ted screamed for help and then collapsed. A policeman found his finger two blocks away but doctors could not reconnect it.

In both of these cases, the victims developed PTSD. However, neither Ted nor Judy had a lifelong history of trauma that suddenly roared up and needed to be treated as well. After a few months, both Ted and Judy returned to a new sense of normalcy, forever changed by what happened, but able to function. Judy now insists that every passenger in her car always wears a seat belt and Ted will never walk alone down a relatively dark city street at night again. He also has begun karate instruction and is learning to defend himself physically.

But what if Ted and Judy had had a lifetime of trauma prior to these events? What if Ted had been severely beaten by his father for the first fifteen years of his life, or if he also had witnessed the beating of his mother, brothers, and sisters while his father was drunk? What if Judy had been regularly molested by her brother between the ages of five and nine, had been physically attacked by her father, and had been told by both parents that she was never wanted and it would be better for everyone if she would just die. Do you see yourself as a Judy or Ted in the first situations (involving type I trauma, or a single, serious trauma) or in the second situations (involving type II trauma, or years of serious trauma)?

Do you feel as if you have lived in a war zone for most (or all) of your life? Do you have a hard time even thinking that you have a sense of self? Do you generally feel unsafe and untrusting, and believe that personal power is an illusion? Do you lack good self-esteem and positive intimate relationships? Are you isolated, without connections to others except perhaps in the work environment? Do you find it hard, if not impossible, to attach to others? Do you find it difficult to monitor how you act or to stop yourself before you act in an impulsive way that sometimes hurts you? If you answered “yes” to any one of these questions as you read this paragraph, you may have symptoms of complex PTSD. You may refer to chapter 1 of this workbook for a description of the seven dimensions of complex PTSD. If you want to, turn to the appendix to find a questionnaire that identifies the various symptom clusters of complex PTSD. You may complete it now. The higher the numerical response, the more likely you are to exhibit the characteristic of complex PTSD. However, there are no criteria yet that set the number of characteristics for each of the seven symptom categories that you need to have an actual diagnosis.

This and the following six chapters will examine each of those dimensions in some detail and will provide techniques and exercises to help you bring your symptoms under control. Not everyone has difficulties in all of the seven dimensions. As you read through this workbook, choose which of the seven dimensions apply to you and work on those chapters.

Trauma and Emotional Health

An emotionally healthy person is able to enjoy intimacy as well as being alone. A person who has experienced type II traumas (which lead to complex PTSD) tends to either be too dependent on others in an intimate relationship or is so terrified by any intimate connection that he or she flees from a relationship to aloneness. However, when alone, the survivor often feels an unbearable sense of abandonment and again longs for connection. So the survivor tries to connect and again becomes terrified of rejection and abuse. His or her relationships begin to take on a pattern of being too close and running away.

Does the previous paragraph describe you? Can you keep a clear sense of who you are when you are with others or with a partner or spouse? Can you self-soothe? When you feel very emotional, can you still make good decisions? Are you able to keep distance emotionally when others are overreacting; can you still make good decisions in such a case? Do your behaviors and your words match each other? Can you tolerate some pain if the pain means you will grow stronger in the end? If you have answered “no” to any or all of these questions, you might also find it helpful to look at the seven categories of complex PTSD symptoms in chapter 1, turn to the chapter that deals with each of the categories that applies to you, and practice some of the techniques found there. Even if you are not a type II trauma survivor and have answered “yes” to these questions, you may still find some of the exercises helpful.

Bloom (2000) writes that people start with a normal potential to grow. You started life with the potential to be a healthy, happy human being, within the context of certain genetic and bodily predispositions. However, if you were traumatized early in life, the effects of trauma soon interfered with your physical, psychological, social, and moral development. If you were repeatedly traumatized, you may have developed learned helplessness in order to endure abusive situations; that is, you learned that it was useless to try to get away. Later, even if you could have escaped, you may not have done so, or you went from one abusive situation into another (e.g., from a violent family situation to a harmful dating or marriage relationship). If you continued to have positive feelings toward an abuser, you may have also experienced what is known as traumatic bonding (you have a deep bond with the person who abused you).

Exposure to repeated trauma, type II trauma, may prevent you from attaching in a healthy way to others. It may cause you to be unable to control your emotional arousal. In a matter of milliseconds, you might go from being okay to being in a rage. You may also find that you do not have enough trust in others or yourself to allow yourself to develop a stable relationship. Instead, you may become aggressive toward others (either outwardly or in a more subtle, passive form), as well as toward yourself when things don’t go your way.

Your capacity to regulate your own internal emotional states, your body sense, and your response to external stress helps to define who you are (Cole and Putnam 1992). If you were a victim of type II trauma, you may lack a predictable sense of yourself, have a poor sense of separateness from others, have a disturbed body image, have poor impulse control, and become suspicious and distrusting in social situations.

Does this description sound familiar to you? Are you able to be emotionally upset without hurting yourself? Are you able to be emotionally upset without becoming aggressive? Are you able to stay present when you are emotionally upset, without dissociating? Are you able to find words to identify bodily sensations that occur when you are upset? Are you able to find words to name emotional states; that is, are you able to name how you feel, and do those feelings match the situation?

Exercise: What Type II Traumas Have I Experienced?

The following lists describe type II traumas and their symptoms. Check which characteristics of Type II trauma that you have experienced:

• _____ chronic, extremely invasive experiences
• _____ long-standing, repeated exposure to extreme events
• _____ ongoing physical abuse
• _____ ongoing sexual abuse
• _____ chronic neglect combined with other abusive experiences
• _____ ongoing horror that never seems to end
• _____ living in a world that is unpredictable and at times terrifying
• _____ having persons supposed to protect me show little regard for me

How many of these did you check? What do you think this says about your earlier experiences?

___________________________________________

Now, which of the following symptoms of type II trauma do you experience now?

• _____ massive denial
• _____ self-anesthesia in parts of my body
• _____ dissociation
• _____ self-hypnosis
• _____ continued attachment to those who hurt me
• _____ aggression turned toward myself through self-mutilation
• _____ absence of feelings
• _____ sense of overwhelming rage
• _____ unremitting, chronic sadness
• _____ loss of memory of a large part of my childhood
• _____ indifference to pain
• _____ lack of ability to empathize with others’ feelings
• _____ inability to name my emotions or recognize emotions in others
• _____ uneasiness with intimacy
• _____ serious emotional distancing
• _____ desire to remove myself from the possibility of pain and hurt in any way possible (adapted from Kelly 1999)

*****

Alterations in Your Ability to Manage Emotions and Impulses

As we have stated, there are seven categories of impact or symbols that make up what is now called complex PTSD or disorders of extreme stress, not otherwise specified (DESNOS). The first category involves alterations in your ability to manage emotions and impulses. This includes difficulties managing your expression of emotions (including anger and rage), the tendency to harm yourself through self-mutilation, problems from dangerous risk-taking, preoccupation with self-destruction or suicide, and sexual risk-taking and inappropriate sexual behavior. The goal of working through this chapter is for you to learn to modulate and control your emotion and regulate your emotion-driven responses.

Feelings generally can be associated with joy or with pain. Each feeling of pain has an opposite feeling associated with joy. For example, the opposite of fear is hope; of sadness, joy; of hate, love. Painful feelings that result from exposure to trauma frequently are denied and avoided. Many trauma survivors have a hard time keeping their feelings under control. Many times, people with complex PTSD are also not aware of the range of feelings that exists and have only limited emotional responses to most situations. Having feelings or recognizing having certain feelings may make you want to hurt yourself. Examples of feelings that may lead to self-hurt include anger, sadness, shame, emptiness, guilt, and betrayal. But if you do not know what many different feelings are like, you also cannot use them either positively or negatively.

Are you able to name the feelings you have at different times? Do you know the difference between dislike, disregard, anger, frustration, rage, and hostility, among others? Learning how to name feelings and then recognize (them both in yourself and others) are the first steps in trying to bring the feelings under control.

If you cannot find words to identify your emotions and if you are not able to know what you feel, then it is very difficult to plan how to cope with those emotions. When you name and then learn to tolerate your emotions, you gain the ability to “own” them and you become more in touch with yourself.

Exercise: Recognizing My Emotions

Which of the following emotional states do you personally know, and which have you felt in the past two weeks? Please circle those you have felt in the past two weeks and underline all those about which you can say that you know how they feel.

These are only a small proportion of the words that are associated with feelings. Were you able to identify and imagine or remember having most of them? What has completing this exercise taught you about yourself?

___________________________________________

*****

Using Feelings Appropriately

Learning to use feelings as ways to guide appropriate behavior is a second step in working on these symptoms. If your goal is to develop a self that has some personal power, it is important that you are able to experience both pleasant and unpleasant emotions without over- or under-reacting and, if things really get rough, that you are able to self-soothe. The goal is for you to be able to look at possible ways to express your emotions and then make choices.

Exercise: How Do I Regulate My Emotions?

If I get very, very sad, how do I express that sadness? Do I become extremely depressed or do I cry and grieve and then go on?

___________________________________________

If I get very, very happy, am I able to keep that happiness contained, or do I seem to get out of control?

___________________________________________

*****

Linehan (1996) encourages the development of mindfulness, or the ability to observe, name, and describe your feelings and reactions without judging yourself or seeking escape or relief from them immediately, if not sooner. Sometimes the emotions that you feel are ones you associate with past traumas. For example, anytime you feel the slightest bit of fear, it may take you back to an abusive situation in which you felt terror. Learning to know when the fear is truly due to something in your present and not something from your past helps you lessen the power of the past over you. If you were abused in childhood, it is possible that you may find it very difficult to contain your emotions, regulate your aggressive acting out toward yourself and others, and feel empathy for others.

One technique for controlling an emotion (adapted from Schiraldi 1999) has the following steps:

1. Allow yourself to feel enough of a certain emotion (joy, sadness) to get in touch with it without either going out of control or detaching yourself from it.
2. Use the experience of feeling the emotion as a way to learn more about yourself. What other emotions are present as well? Do these other emotions grow from the original emotion? You can look at each of them separately.
3. Identify the source of the original emotion. Go as far back as is necessary, often to a trauma.
4. Say or do what you need to in order to get a sense of closure on the situation that led to the emotion.
5. Look for a way to find an outcome to the emotion—perhaps writing a good-bye letter to someone who has left or died, organizing a ritual (see the section “Healing Rituals” near the end of chapter 7), or doing something for someone else.
6. Move on, away from the emotion; don’t allow yourself to be stuck in it. Return to the activities of daily life.

Exercise: Practice Controlling an Emotion

Can you think of a situation in which you have had an overwhelming negative emotion? Describe it here and name the initial emotion that arises from it.

___________________________________________

___________________________________________

Now apply the six steps just described to that emotion.

1. ___________________________________________
2. ___________________________________________
3. ___________________________________________
4. ___________________________________________
5. ___________________________________________
6. ___________________________________________

Was this exercise helpful? What did it teach you about that emotion? Can you think of another situation in which it might help you bring emotions under control?

___________________________________________

___________________________________________

If you are not able to write about your emotion, you might consider drawing that emotion or collaging it in your journal or notebook or on a separate piece of paper.

*****

Expressing Emotion

What are some other ways you might learn about, deal with, and express emotion in appropriate ways? You may go back to chapter 6 and look at the ways to deal with anger that are given in that chapter. Other techniques to help you with your emotions include:

1. learning to identify cues and triggers that lead to emotions, then writing down the differences in what you feel with possibly different emotions (anger, fear, etc.)
2. rehearsing ways to deal with emotions ahead of time when you are not sure how to handle a situation (e.g., saying out loud, “I need some time to think over what it is I need to do.”
3. role playing situations that involve emotion with others, including your therapist if you are in counseling
4. discussing emotions with others
5. practicing expressing emotions with those you trust and then asking for feedback
6. using relaxation techniques to combat arousal when emotions become too intense
7. monitoring your beliefs about situations: looking at what happens to those beliefs to lead to emotional reactions, and then attempting to challenge and change the beliefs so they do not lead to what Meichenbaum (1994) lists as the most damaging kinds of self-talk:

   catastrophic interpretations of events (”this is sooo awful; I just can’t stand it anymore”)

   demanding and coercive language involving shoulds, oughts, have to’s, need to’s

   overgeneralizations using never and always

   negatively labeling yourself as stupid, impossible, and so forth

   categorical thinking: calling yourself labels like asshole, shithead, S.O.B., and others

   black and white thinking—a situation is either all good or all bad with no gray in between

In chapter 11 we will discuss problem-solving techniques. You may turn to that chapter for additional ideas. It is also important that you look at exactly how you feel about feeling your feelings. In order to know how you feel, you might complete the following exercise (adapted from Miller et al. 1989).

Exercise: Feeling My Feelings

1. List any feelings that you enjoy having.

   ___________________________________________

   ___________________________________________

2. List any feelings that you may not enjoy having but that you at least are willing to accept having.

   ___________________________________________

   ___________________________________________

3. List any feelings that you find unacceptable to feel.

   ___________________________________________

   ___________________________________________

4. When you have the feelings you listed in question 3, what do you do with them?

   ___________________________________________

   ___________________________________________

5. List any feelings you may be embarrassed to feel.

   ___________________________________________

   ___________________________________________

6. If you have those feelings, what do you do with them?

   ___________________________________________

   ___________________________________________

7. List any feelings you may be ashamed to feel.

   ___________________________________________

   ___________________________________________

8. What do you do with those feelings if you have them?

   ___________________________________________

   ___________________________________________

*****

Being Afraid to Have Feelings

Being afraid to feel and show feelings may really be related to your beliefs about your unmet basic needs for safety, trust, personal power, esteem, and intimacy (Rosenbloom and Williams 1999). You may be more afraid of being rejected, abandoned, punished, or criticized than of the specific emotion itself. What really would happen if you allowed yourself to show an emotion you feel?

For one day, try to express your emotions honestly (without hurting yourself or others). Record what happened in the space provided below.

Emotion I expressed	What happened when I expressed it
_____________________________________	_____________________________________
_____________________________________	_____________________________________
_____________________________________	_____________________________________
_____________________________________	_____________________________________
_____________________________________	_____________________________________
_____________________________________	_____________________________________
_____________________________________	_____________________________________
_____________________________________	_____________________________________

Expressing emotions means taking a risk. Taking that risk can be productive; it can lead to emotional development and self-improvement. This type of risk-taking is in contrast to risk-taking that is not productive and that may occur just for thrills or an adrenaline high. Nonproductive risks often involve hazardous actions that can jeopardize health, career, relationships, and other major areas of life—or life itself (Ilardo 1992). Expressing emotions honestly can bring about gratification either immediately or over time, as you become more honest with yourself and others and as you let go of emotional baggage that has collected over time. Expressing an emotion means taking a chance; however, the end result of release from being a hostage to your emotions is worth that risk.

More on Self-Harm and Self-Mutilation

Self-mutilation is a special type of self-harm. It is direct, controlled, and repetitive, it does not have the intent of suicide, it is not related to being impaired mentally or cognitively (e.g., being retarded or autistic), and it is socially unacceptable (Suyemoto and Kountz 2000). Self-mutilation generally happens when you feel a deep loss that leads to feelings of tenseness, anxiety, anger, or fear, and you express those feelings by harming your body in a very controlled manner. The most common form of self-mutilation is self-cutting. Cutting (and self-mutilation in general) is:

• a way to manage painful emotions that you can’t express in words by doing something that is concrete and active
• a way to stop feeling feelings and therefore control them
• a way to prove you are alive
• a way to reenact trauma and abuse
• an addictive action that can become compulsive
• a boundary violation of your body
• an expression of self-blame
• a way to self-soothe
• a way to communicate an emotion
• an expression of self-hate
• a way to resist taking care of yourself in a positive way
• a way to maintain a stable sense of self if you are threatened with the loss of your identity
• a way to escape the pain of a perceived rejection
• a way to have physical evidence of emotional injury
• a way to distance yourself and set boundaries between yourself and others who will reject you for self-mutilating
• a way to stop, induce, or prevent dissociation (see chapter 9)
• a way to release endorphins so you do not feel pain
• a way to self-punish for doing certain behaviors or having certain thoughts or feelings that were punished in childhood by others

(Suyemoto and Kountz 2000; Alderman 1997)

As Alderman writes, “most self-inflicted violence is the result of high levels of emotional distress with few available means to cope” (2000, 7). You may use or experience self-mutilation as a way to get control over your body, challenging those around you to care enough to notice and do something. Do you see hurting yourself as a way to express your rage toward powerful others through hurting yourself? Self-mutilation of any kind can be a substitute for anger toward another as well as a desire (unconscious or conscious) to inflict pain on that person. Sometimes, the desire to hurt yourself is a way to fight depression and anxiety or a way to numb yourself out through a type of self-medication. Sometimes self-mutilation is a way to show how much you hate yourself. Eating disorders involving self-starvation and purging yourself to the point of physical pain can also be a form of self-mutilation. You also may self-mutilate as a way to reconnect your body and mind. Some people say that they are able to believe and recognize that they are real and alive if they see blood. Self-mutilating, to them, may calm their intrusive trauma-based thoughts by giving them the endorphin release that brings calming and lessens their arousal.

If you self-mutilate, complete the following exercise. Above all, it is important for you to go to a qualified therapist to get help. No self-abuse is okay; it is a way of revictimizing yourself. There are other ways for you to communicate your pain and anguish without taking it out on your own body. When you have very strong emotions of any kind, you do not have to act on them. Setting up a plan of alternative reactions to strong feelings is one way to bring self-mutilation under control.

Exercise: My Reasons for Self-Mutilating

1. List ways you self-injure here:

   ___________________________________________

   ___________________________________________

   ___________________________________________

2. Now answer the following questions about each of these behaviors (do the first behavior here in the workbook and do the others in your journal):

   How does the behavior help me survive?

   ___________________________________________

   How does the behavior give meaning to my trauma?

   ___________________________________________

   How does the behavior give me a sense of mastery and control and power?

   ___________________________________________

   How does the behavior release endorphins and make me feel better?

   ___________________________________________

   How does the behavior give me revenge?

   ___________________________________________

   How does the behavior reinforce my feelings of guilt, shame, and self-blame?

   ___________________________________________

   How does the behavior punish me?

   ___________________________________________

   How does the behavior reenact what I learned earlier in life?

   ___________________________________________

   How does the behavior bring me affection, care, and emotional closeness?

   ___________________________________________

3. Check all the items that you feel apply to you in the list below.

   _____I mutilate myself because

   _____ I want to show that I own my own body.

   _____ I want to express my rage at myself.

   _____ I hate myself.

   _____ I want to distract myself from other pain.

   _____ I want to numb out my feelings.

   _____ I have a message to give that I can’t say directly.

   _____ I am asking for help.

   _____ I want to be rescued.

   _____ I believe my body is a battleground.

   _____ I want to cleanse myself.

   _____ I want to somehow atone for my sins.

   _____ I want to express my shame.

   _____ I am trying to express my pain.

   _____ I am taking over where my abuser left off.

   _____ I am retaliating against myself for telling secrets.

   _____ I am doing what my abuser brainwashed me to do, if I told.

   _____ I am trying to connect my mind with my body.

   _____ I am trying to make sure I am real, through bleeding.

   _____ I am trying to bring my emotions under control.

   _____ I am trying to prove that I am alive.

   _____ I am trying to get a “high.”

   _____ I am trying to manage my flashbacks or memories.

   _____ I am trying to release intolerable emotional tension.

   _____ I am trying to buy myself time by focusing attention on physical rather than emotional pain.

   _____ I need a release valve.

   _____ I need to get into a “neutral zone.”

4. Now take each of the reasons for self-injuring that you checked and think of five other things you might do to express that emotion or action. For example, if you checked “I want to cleanse myself” as a reason for self-mutilating, what are five other things you could do to cleanse yourself that do not involve self-mutilation? They might be to take a bubble bath, take a sauna, go to a day spa, use herbs to purify my body, or do some other form of cleansing ritual. You may think of others that might apply to you. There is space below to write your reactions to one of your reasons. You may do the others in your journal or notebook.

   My reason for self-mutilating:___________________________________________

   Five things I could do instead:___________________________________________

   ___________________________________________

   ___________________________________________

   ___________________________________________

   ___________________________________________

5. What did completing this exercise teach you about yourself?

   ___________________________________________

   ___________________________________________

   ___________________________________________

*****

Beliefs Leading to Self-Mutilation

You may also have a belief system that allows you to mutilate yourself. These beliefs frequently are distorted and may even have come from your abusers (as introjects you have taken into your own brain and now experience as your own beliefs). These beliefs are generally black and white or all or nothing beliefs.

Exercise: My Beliefs about Self-Mutilation

Check which of the following statements you believe, if any:

• _____ Self-mutilation doesn’t hurt anyone but me and it really doesn’t hurt me.
• _____ It’s my body, I can do what I want with it.
• _____ It’s no big deal and shouldn’t upset anyone.
• _____ If I don’t hurt myself this way, my pain will be worse.
• _____ The scars are there for a reason; they remind me of (telling, needing to be punished, my shame, etc.).
• _____ No one knows about it, anyhow.
• _____ I need to be punished for what I did.
• _____ It just shows how bad a person I am.
• _____ It keeps people away.

*****

None of the statements in the preceding list is accurate or true. Each is a distorted belief. Self-mutilation is never a healthy way to express pain or hurt. If you checked any of these statements, it’s important that you work with a therapist to help change these beliefs. Other things you might do with that therapist include developing an impulse control log (write what, when you felt the urge to harm yourself, you did instead), and think of ways to express your feelings that are not harmful to you. In the impulse control log, you may want to identify any triggers that led you to self-mutilate. Other techniques to control self-mutilation include:

• Try to focus your attention on something other than the need to self-mutilate, e.g., focus your attention on doing a crossword or jigsaw puzzle or some other intellectually stimulating challenge. This minimizes emotional pain.
• Make a list of alternatives to self-harm.
• Write or draw the abusive intent rather than act on it.
• Substitute physical activity to get the same adrenaline high, if that is the motivation.
• Make a collage of acceptable methods of self-expression.
• List the introjects that lead to self-harm.
• Develop a safety contract with your therapist or some other significant person and agree not to self-mutilate for a specified period of time; include rewards for following the contract and consequences if you break it.
• Develop a collage of each emotion that you find difficult to handle or express including ways to release that emotion without self-harm.
• During a period of time that you don’t feel self-destructive, prepare a list of reasons why you don’t want to self-mutilate. Then, when you feel the urge to hurt yourself, go back and review this list and try to add another one or two reasons to it.
• Prepare a list or photo gallery of positive accomplishments in your life. When you feel the urge to self-mutilate, look at that list or album and then tell yourself, “I’ve accomplished all this good in my life and don’t deserve to suffer more; I’m a good person.”
• Learn to identify the early warning signs that a feeling is becoming intolerable and then self-soothe or do something else. This technique involves identifying patterns of self-injury as a first step to changing those patterns. How often do you self-injure (daily, weekly, sometimes, rarely)? Then look at what you were doing, thinking, or feeling both right before the self-injury happened and right after it happened (Trautman and Connors 1994).
• Look at the backlash that happens after you harm yourself—from others and from yourself. Do you: feel crazy, hurt physically, feel shame, try to hide from others? Use memories of that backlash as reminders why you do not want to hurt yourself.
• Create a safe toolbox that includes a non-harm agreement, an impulse control log, a list of your self-harm alternatives, writing materials and art materials so you can get out your feelings and thoughts in other ways, and a life plan (Alderman 1997).
• If you must see blood on yourself, get a tube of fake blood and use it to visualize the effects of self-mutilation without actually carrying out the act.
• Use affirmations to change your beliefs about why it’s okay to harm yourself (see the exercise near the end of chapter 6).

The Cutting Edge (P.O. Box 20819, Cleveland, Ohio 44120) is an excellent resource: a newsletter for those who self-injure.

Changing Your Beliefs Through Affirmations

As we discussed in chapter 6, regular use of affirmations can change your beliefs about yourself and your emotions and actions based on those beliefs. This kind of real change has six stages, and it does not happen overnight. These stages are:

1. Precontemplation (My negative beliefs about myself are right; I don’t need to change them.)
2. Contemplation (Well, maybe I do need to make some changes.)
3. Preparation (I guess I can begin to focus on what I need to do and what affirmations I might write or say.)
4. Action (I will do and am doing this; I am saying or writing the affirmations on a daily basis.)
5. Maintenance (I am beginning to believe the affirmations. I don’t need to say them as often and I sort of believe them; I am beginning to see things in a different way and feel better about me.)
6. Termination—the ideal end (Wow, I actually am okay and don’t need to see myself so negatively. Sometimes I forget that I am okay, but I recover quickly. The affirmations really are acceptable ways to describe myself—they work even when I am in crisis. I am able to do what is best for me.)

Exercise: My Affirmations around Self-Mutilation

In the space below, write three affirmations that you want to say to yourself or write to yourself that you eventually hope to believe. Remember to put them in present tense and use the word “I.”

1. ___________________________________________
2. ___________________________________________
3. ___________________________________________

Now write each affirmation five times to begin to get familiar with it.

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

Are you willing to write or say each of these three affirmations twenty times a day for the next month? If so, fill in the blanks below:

I am willing to commit to saying or writing each of these three affirmations twenty times a day for the next thirty days. At the end of that time, I will return to this page and write how I feel about the exercise and my beliefs.

Your signature________________________(sign) Today’s date__________________

Thirty days from that date is __________________(fill in date). In the last thirty days, this exercise has:

___________________________________________

___________________________________________

___________________________________________

*****

Modulation of Feelings and of Sexual Involvement

Schiraldi writes that some studies “have indicated that males and females with PTSD are more likely to experience sexual problems than those without PTSD…[including] sexual disinterest, aversion, dissatisfaction, performance difficulties (including painful intercourse and impaired arousal)” (2000, 318). If you were a victim of any type of sexual abuse or sexual assault, you may feel shame if you have sexual feelings, and sex can become a trigger that is associated with humiliation, danger, and the need to keep a secret.

You may have flashbacks during sexual relationships. If so, it is important that you ground yourself in the present as soon as you become aware of the flashback, perhaps by focusing on your safe place and on relaxation. It is important to stop any sexual response or activity you might be having until the flashback is done. It is also important to let your sexual partner know immediately what you are experiencing, asking him or her to reassure you and comfort you that you are in the present (Dolan 1991).

Some trauma survivors believe that they must self-injure if they have sexual feelings or arousal. Learning to substitute pleasure-oriented touch and imagery for self-injurious images and actions can be a long, hard process. Trauma may have impacted your ability to express yourself sexually to the point that you either ignore your sexual needs and wants or act out your sexual needs and wants aggressively, impulsively, or non-intimately. The next paragraph contains questions about your sexual feelings and behaviors. You can read and think about them, or write about them in your journal or notebook.

What behaviors are involved in any sexual behavior you have? Are there specific triggers that lead to your having or wanting to have a sexual encounter or relationship? When you want to be sexual, what thoughts motivate your behavior? Do you expect a negative outcome from any sexual experiences you have?

When you are sexual, how much control do you feel you have over what happens? If you feel out of control in a sexual encounter, what feelings do you have? Do you get confused, do you feel pain and shame, do you feel anger toward yourself or your sexual partner?

Then what do you do? Do you continue to have sex even though you don’t enjoy it? Do you get angry toward your sexual partner? Do you try to manipulate the situation? Do you stop the sexual act itself? Do you physically leave?

If any of these things happen, then how do you feel? Do you feel vulnerable and powerless? Do you believe that your partner will no longer care for you or love you? Then what do you do? Do you seek to protect yourself through distancing from your sexual partner? Do you use substances, numb out, sleep, or isolate yourself? Do you self-injure?

Physical Boundaries

A boundary is any type of division or separation that you set between what is permissible or possible and what is not. You have many different types of boundaries around you and within you. One type of boundary involves physical space. It is important for you to recognize the amount of physical space that you need around you in order to feel comfortable when you are with others.

Exercise: My Physical Boundaries

Answer each of your following questions, using your journal or notebook if you need more space.

How close is too close?

___________________________________________

If someone comes too close, how do you feel?

___________________________________________

Are there situations in your life at the present time in which persons come physically too close to you? What are they?

___________________________________________

What do you do when a person approaches you and you do not want to be approached? Are you able to be assertive and maintain your physical space?

___________________________________________

What is your definition of unwanted physical contact?

___________________________________________

How do you react if someone violates your boundary of physical contact? For example, how do you react if someone:

• brushes up against you

  ______________________________________________________

• stands too close to you

  ______________________________________________________

• touches you on your body in a nonsexual way when you do not want to be touched

  ______________________________________________________

• tries to touch you in a sexual manner and you do not want to be touched

  ______________________________________________________

• stares at you

  ______________________________________________________

• hits you

  ______________________________________________________

• talks too close to your face

  ______________________________________________________

*****

Body Language and Physical Boundaries

You can use body language (the way you position your body and the facial expressions you have) to say “stay away” or “come closer.” Such body language includes:

• folding your arms across your body
• turning your body away
• turning your head away if someone is talking to you
• staring back at someone in a positive manner
• staring back at someone in a hostile manner
• looking down and avoiding eye contact
• moving closer to someone
• making eye contact
• smiling

Think about what other types of body language you might use to say “stay away” or “come closer?”

___________________________________________

___________________________________________

Boundaries and Healthy Sexuality

Setting a physical boundary can invite in or keep away potential sexual partners. Appropriate boundaries are an important part of healthy sexuality. Healthy sexuality can be fun, playful, and authentic; it usually exists within the boundaries of a loving, respectful, giving relationship. It is part of relationship building and maintaining because it involves shared vulnerability and control. If you want to work on normalizing your sexual feelings, you might consider following the strategies suggested by Schiraldi (2000). These include:

1. Think of your genital area as a normal part of your body; use its proper name and acknowledge its unique functions.
2. Neutralize any feelings of disgust you have toward sex. Start by considering whether you think all sex is disgusting, or just certain aspects of it.
3. Look at any feelings of shame that you have about sex and then develop positive affirmations to shift your focus toward the positive aspects of yourself and your sexual being.
4. Develop your own description of what healthy sexuality is.
5. Follow Engel’s sexual paradoxes to develop a satisfying sexuality (1995):

   The harder you try to make good sex happen, the less happens, so relax and take your time.

   You can cure your sexual dysfunctions by not trying to cure them.

   The way to have sex when you want to is to learn to know when you do not want to have it and then say “no.”

   The way to please your partner sexually is to learn what feels good to you.

6. Before trying to have sex, learn to touch yourself and your partner sensually.
7. Learn the differences between sex, love, affection, and attention.
8. Be prepared for the inevitable flashbacks that will occur during sex (the techniques you have learned in chapter 4 should help).
9. Develop your own personal healing sexual imagery or stories to use if you need some fantasy during sex; these stories are typically built around what would lead to your safety.

Emotional Boundaries

A second type of boundary is an emotional boundary. Having an emotional boundary means that you are able to set limits without worrying whether or not you might hurt or disappoint another person. Asking for what you want or deserve is another way to set an emotional boundary. Asking without worrying whether or not you will be abandoned, disliked, hurt, or attacked occurs when you have good emotional boundaries. If you have good emotional boundaries, you can refuse to be sexual without fearing that the person who wants a sexual relationship with you will be so hurt or angry that he or she will abandon, reject, or punish you. You have the right to say “no” emotionally as well as physically.

Setting and Maintaining Boundaries

Part of setting boundaries is to create a personal “bill of rights.” This bill of rights can allow you to set boundaries and take risks. In one of the next exercises, you will have the opportunity to add to the rights listed below.

• I have the right to choose my own sexual partners.
• I have the right to say “no” to a request for sex.
• I have the right to keep others out of my personal space.
• I have the right to stop any sexual activity in which I am involved if and when I have a flashback.

If you say “no” in a firm manner when it is right to say no, you will be able to survive the reactions of those around you. It may feel very strange to think that you are able to say “no” to someone or something. You may find that saying “no” brings up many different emotions.

Exercise: How I Feel When I Say “No”

1. When you say “no,” which (if any) of these emotions have you felt in the past? Circle those that apply to you.

   I feel/scared/anxious/strong/ nervous

   ashamed/guilty/angry/ powerless

   relieved/empowered/rejected/ abandoned

   disliked/pressured/manipulated to/ change my mind

2. There are positive and negative ways to say “no.” Listed below are examples of each. Which have you ever used and when? Put a check in front of each that you have used and then write a sentence or two when you have used it. When I say no (or try to say no):

   _____ I become passive.

   _____ I shut down.

   _____ I get angry and turn that anger toward another person.

   _____ I explode in rage.

   _____ I escape through substances.

   _____ I withdraw.

   _____ I make clear statements.

   _____ I make good decisions.

   _____ I state what is good for me.

   _____ I negotiate if that is necessary.

   _____ I communicate what I want.

   _____ I listen to the wants of others.

   _____ I take a time out if necessary.

   _____ I keep my needs and safety in mind at all times.

   _____ I know I have the right to say no.

*****

Exercise: My Personal Bill of Rights

If there other rights you would like to add to those given earlier, write them here.

___________________________________________

___________________________________________

___________________________________________

What has completing the last few exercises taught you about setting sexual boundaries?

___________________________________________

___________________________________________

___________________________________________

*****

An Aside about Suicide

Many trauma survivors feel suicidal and have suicidal thoughts and plans. Some act out those thoughts when they are particularly stressed and triggered; some act them out on a regular basis. It is important to develop ways to cope with and control your suicidal impulses. In order to do so, if you have had these impulses, it is important that you ask yourself: What is the meaning and role of those impulses? Do the impulses and fantasies related to planning suicide lead to an adrenaline rush or a sense of calm and peace? If you have these impulses, what else might you use to bring you relief?

Learning to find ways to relieve any intolerable feelings you have through less destructive means is the first step to bringing suicidal impulses under control. Writing in the online newsletter Survivorship, Collings (2001) has created the following list of reasons not to kill yourself:

• Because you deserve to live.
• Because your life has value, whether or not you can see it.
• Because it was not your fault.
• Because you didn’t choose to be battered and used.
• Because life itself is precious.
• Because they were and are wrong.
• Because you are connected to each and every other survivor and so your daily battle automatically gives others hope and strength.
• Because you will feel better, eventually.
• Because each time you confront despair, you get stronger.
• Because if you die today you will never again feel love for another human being…or see sunlight pouring through the leaves of a tree.
• Because you have already won…no one can take that away.
• Because the will to live is not a cruel punishment, even if it feels like that at times; it is a priceless gift.
• Because we need survivors to offer testament against this horror and despair.
• Because no one knows better than you the meaning of suffering, and agony deepens the heart.
• Because you deserve the peace that will come after this battle is won, and it will be won, but only minute by minute.
• Because I am furious that we have to suffer the pain of another’s evil and filth.
• Because you, too, will one day feel fury.
• Because it is critical that you survive.

How do you relate to this list?

___________________________________________

___________________________________________

___________________________________________

Exercise: What I Learned from This Chapter

What have you learned about yourself and your ability to modulate your emotions and actions from working on the exercises in this chapter?

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

• abandoned
• accepted
• aching
• affectionate
• alone
• aloof
• amused
• angry
• annoyed
• anxious
• apologetic
• at peace
• aware
• betrayed
• bitter
• bored
• brave
• calm
• capable
• caring
• cautious
• cheerful
• composed
• confident
• conflicted
• connected
• content
• courageous
• cranky
• crazy
• crushed
• curious
• defeated
• dejected
• delighted
• dependent
• deserted
• desirable
• desperate
• devastated
• different
• disappointed
• discouraged
• distressed
• dominated
• doomed
• eager
• easygoing
• ecstatic
• elated
• embarrassed
• enraged
• excited
• exposed
• foolish
• frantic
• friendly
• fulfilled
• full
• furious
• giving
• glad
• grateful
• grouchy
• grumpy
• guilty
• happy
• helpless
• hopeful
• hopeless
• humiliated
• hurt
• impatient
• inadequate
• incompetent
• innocent
• insecure
• interested
• irate
• irked
• irritated
• isolated
• jealous
• joyful
• loyal
• lucky
• mad
• mean
• miserable
• patient
• peaceful
• pleased
• powerless
• preoccupied
• proud
• regretful
• rejected
• remorseful
• responsible
• revengeful
• safe
• screwed
• serene
• shamed
• shocked
• shy
• sorry
• stimulated
• stunned
• stupid
• sweet
• sympathetic
• tense
• terrified
• thrilled
• tired
• tolerant
• tortured
• trapped in time
• troubled
• trusted
• ugly
• unappreciated
• unaware
• understood
• unfriendly
• unhappy
• upset
• useless
• valued
• victimized
• violated
• vulnerable
• warm
• weary
• whipped
• wiped out
• withdrawn
• wonderful
• worthwhile