One of the more consequential mistakes on my quest to recover from sexual trauma was my lack of discernment about the type of care I needed. Instead of guided by clear objectives, I was driven by a panicky urgency to escape anxiety and despair. I accepted the first appointment I could get, which was at a mental health clinic that embraced the biomedical model and relied almost exclusively on medications to treat patients. There was simply no talking about sexual abuse as the origin of my suffering. When once I tried to broach the topic and share with my psychiatrist the nature of the abuse in my childhood home, he bracketed my efforts as evidence of genetic inheritance. “Of course there was chaos [the word he chose to replace my word abuse]. Everyone probably had a mental disorder.”
Long after I left that psychiatrist, the healthcare company running the clinic was fined millions of dollars because it failed to offer services for the treatment of sexual trauma. Although I felt vindicated, I lost almost a decade of my life to being misdiagnosed and mistreated with medications for a chronic, lifelong condition I never had. I learned the hard way that when the goal is self-repair following sexual abuse, biomedical psychiatry may hinder more than help. I devote this article to discussing this point because I hope to spare you the long detour I took on my way to recovery.
If you have been a client or patient of the mental health field, perhaps like me you not only encountered practitioners who had no idea how to support your recovery from sexual trauma, you also worked with people whose methods aggravated your problems. It’s tragically common to have histories of sexual abuse minimized or ignored. Perhaps like me, you relate to “Rita”:
The director of the institution where I was placed had been trained as a counselor. What I resent about her now is that I lived there for four years, and even though she knew what had happened to me, she never once took me aside and said, “Would you like to talk about it?” From age fourteen to eighteen I had nobody to help me work out my feelings. I cried myself to sleep every night.1
These omissions of compassion redouble the shame and alienation that seem to occur naturally in response to being sexually abused. They also cause many of us to stop seeking the support we need and deserve.
Ultimately, I was able to jettison the medical model because of courageous practitioners and patients who over decades of collaborative work developed and advocated for trauma-informed care. For those of us who make the shift from the biomedical model to the trauma model, trauma-focused treatment can be an antidote to both our symptoms and the unhelpful (if not harmful) therapies we once received. The trauma model’s success is derived in large part from its reliance on compassion combined with research in neurobiology — along with feedback from early utilizers — which has led to numerous modalities that markedly improve well-being (although it too has had its failures). Equally important, the focus on actual events as the source of mental suffering creates opportunities to openly speak about traumatizing experiences rather than be silenced by a diagnosis that blames genetics as the origin of mental illness.
The trauma model not only liberates from unnecessary shame and stigma, but also drastically alters the objective of treatment. Unlike the biomedical model that focuses on identifying and minimizing pathology (much like any medical field), trauma-informed care focuses on integration as the overarching goal of treatment, which includes resolving the inner fragmentation and dysregulation that commonly occur following traumatic experiences. With this shift in focus, trauma symptoms like flashbacks, nightmares, and high activation have been reinterpreted as attempts to integrate fragmented memories rather than as evidence of psychopathology.
Some trauma-focused researchers have even called into question the use of commonly prescribed medications for mental disorders because they block the natural integrative process following trauma. For instance, sleep medications are commonly prescribed to dampen nightmares, benzodiazepines to suppress overwhelming emotions, and Selective Serotonin Reuptake Inhibitors (SSRIs) to inhibit flashbacks.2 Whereas these drugs may feel helpful, especially when overwhelmed by traumatic stress, they can also interfere with resolving the fragmentation caused by trauma.
Both the biomedical model and the trauma model significantly advanced their respective paradigms during the last several decades of the twentieth century. Yet the profit margin for medications has been exponentially higher than compensation for trauma-informed care. A plethora of new medications also helped boost biomedical psychiatry’s reputation as a rigorous medical field. Yet rather than a commitment to resolving mental illness, biomedical psychiatry has focused primarily on treating metal illnesses as chronic conditions. A visit with a psychiatrist is a lot like seeing a general practitioner: a fifteen-minute appointment during which symptoms are discussed and medications reviewed.
In contrast, trauma-informed care typically requires ongoing psychotherapeutic support, and most insurance providers limit the number of visits well below the two to three years on average required to resolve the most troubling reactions to sexual abuse. Trauma-focused psychotherapy can also be difficult to find, leaving many consumers with no option but to rely on medications to manage their symptoms. There is hope, however, that as the trauma model receives the attention it deserves, it will be easier to access trauma-informed care.
Whereas I personally was opposed to reliance on psychoactive substances to deal with my natural reactions to having been subjected to sexual abuse, I also understand the power of medications to treat symptoms and support daily functioning, especially when you lack opportunities and resources to work through trauma. Furthermore, because so many of us go decades without appropriate treatment, medications can seem to be the only solution to seemingly intractable neurobiological states like flashbacks and depression.
Recently, substances like cannabis, ketamine, and psychedelics have been introduced as treatments for trauma. I have used both cannabis and psychedelics outside clinical settings and understand their appeal, especially for unrelenting symptoms of anxiety, shame, or alienation. They can also tap into the sense of feeling part of a greater whole — whether a god, nature, or something else — which I perceive as a cornerstone of self-repair due to the profound alienation that sexual abuse causes. However, looking back, I would have preferred to use these substances in a supportive setting that could have controlled for some of the negative reactions that unfolded when I used them on my own.
Clinics throughout the United States and in other parts of the world are developing protocols that combine these substances with psychotherapy. Prior to deciding your course of action, I recommend thoroughly researching both pros and cons, including seeking testimonies of people who benefitted as well as those who felt harmed by them.
It is tragic so many with histories of sexual abuse lack professional support or receive inadequate or inappropriate treatment. If you are like I once was, medications may have been, or continue to be, the only assistance available to you. They may also lessen symptoms, and thus make possible daily functioning, if not sleeping through the night. Depending on your circumstances, going off your medications may not be a wise choice.
If you are currently on medications for the treatment of a mental disorder, typically it is unsafe to stop these powerful drugs without supervision. It took me almost two years to end my use of psychoactive medications. During that time, I worked with a trauma-informed psychiatrist as well as an EMDR psychotherapist, slowly going off medications as I developed self-regulation skills and worked through my flashbacks of sexual trauma. If you are planning to stop medications, at the very least find a qualified mental health professional who can support you through the process, which at times can be destabilizing.
In general, I have come to think of the use of medications in recovery as like stakes surrounding a young tree. Eventually, you grow strong enough that you no longer need nor desire them to manage the disruptive and distressing effects of trauma. At least this is my hope for everyone, and it has been true of my experience.
Power Dynamics
Receiving an incorrect diagnosis and treatment with psychoactive substances were not the only adverse effects during my time as an outpatient in a psychiatric clinic. Power dynamics also stood in the way of my recovery, a problem that some believe is so entrenched in psychiatry that the only solution is to eliminate its role in treating people with histories of trauma. Antipsychiatry scholar Bonnie Burstow asserted, “severing our relationship with psychiatry is particularly critical, for psychiatry is a threat to vulnerable clients.”3 Burstow drew attention to psychiatrists’ near absolute power as the final arbiter of the mental status of their patients. She also pointed out the potential for retraumatization that can occur when a diagnosis of a mental disorder replaces recognition of the roles trauma and oppression play in mental suffering. Burstow recommended a complete reworking of the relationship between client and provider: “I am advocating that trauma work move more in the direction of critical adult education, with counselor and clients co-exploring the traumatizing and oppressive situations and structures together and clients take up real tasks.”4 This latter suggestion to “take up real tasks” — such as becoming a peer counselor, writing or making art about experiences, advocating for better care, etc. — is reparative of the alienation and helplessness that often plague those victimized by perpetrators and revictimized by insensitive, hierarchical institutions.
Many of us have difficulty seeing ourselves working collaboratively with mental health professionals. Instead, the tendency is to approach the beginning of treatment with the belief that we are damaged, perhaps forever, and destined to feel different from “normal” people, if not always on the margins of society. A diagnosis of a mental disorder can aggravate such attitudes. It can leave us feeling more isolated and yet nevertheless finding community in people who share our diagnosis and the mental professionals devoted to managing our symptoms. Having a sense of belonging is a fundamental aspect of recovery, yet I believe it is most restorative and enlivening when anchored to the whole of humanity, if not all life. I know from experience that in states of low self-worth, we tend to limit our horizons and put too much confidence in the methods and opinions of those we hire to assist us in recovery.
Early in the development of trauma-informed care, researchers expressed concerns about how to maintain collaborative dynamics between mental health professionals and their clients if the mainstream psychiatric community took the helm, which often pursues scientific status at the expense of patient outcomes. Tom Insel, the former director of the National Institute of Mental Health (NIMH), openly admitted:
“I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs — I think $20 billion — I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.”5
Furthermore, most psychiatrists tasked with revising the latest version of the Diagnostic and Statistical Manual of Mental Disorders, the text guiding diagnosing and treatment of mental disorders in the United States, received payments from pharmaceutical companies. This has led to questioning the biases of this supposedly objective resource. As one writer noted: “The descriptions of disorders and diagnostic criteria in the manual influence which drugs get approved, prescribed, and covered by insurance.”6 The difficult yet necessary work of teasing apart how much the manual is influenced by research and how much by potential profits for the drug industry has not yet been done.
In contrast, trauma psychologist Judith Herman wrote the following of the process through which trauma-informed care developed: “Early investigators often felt strong personal bonds and political solidarity with trauma survivors, regarding them less as objects of dispassionate curiosity than as collaborators in a shared cause.” Yet she cautioned: “This kind of closeness and mutuality may be difficult to sustain in a scientific culture where unbiased observation is thought to require a distant and impersonal stance.”7
Certainly, there are psychiatrists qualified to support recovery from sexual trauma and who embrace trauma-informed care. Yet even the most compassionate providers may fail to recognize the inherent power dynamics present in the relationships they have with their patients. Furthermore, those of us who had to submit to sexual abuse often have heightened awareness of the subtleties of power, which can interfere with taking risks to express ourselves authentically. I appreciate psychiatrist Bessel van der Kolk’s honesty and his courage to share how his own disregard of power in the therapeutic encounter was pointed out to him. He wrote:
Kathy [his patient] turned to me. “You know, Bessel,” she said, “I know how important it is for you to be a good therapist, so when you make stupid comments like that, I usually thank you profusely. After all, I am an incest survivor — I was trained to take care of the needs of grown-up, insecure men.” 8
Given that most of us resist telling people about the abuse, there is a deep need to be heard, to feel accepted, and especially to feel as if we belong irrespective of our histories. We often need encouragement to discover our unique ways of narrating our experiences, which may include rejecting the discourses used by the professionals willing to listen to us. We need all the help we can get, yet we also need collaborative providers to hear our truest voices. We also must, like Kathy, learn to be our own advocates. At the end of this article, I share some suggestions for how you might develop a collaborative approach with the professionals you employ to support your recovery.
The Normal Versus the Pathological
Simply changing diagnoses and treatment modalities was not enough to secure my path to self-repair. I also had to relinquish distinctions between the normal and the pathological I relied on when working within the confines of the biomedical model.
The medical model’s dependency on distinctions between the normal and the pathological, like ages-old distinctions between the rational and irrational, has the impact of instilling the belief that some parts of the self are acceptable, while other parts must be rejected. For me, this meant biomedical psychiatry amplified the shame and alienation I already felt in relation to parts of myself I associated with sexual abuse. Granted, there was much about these aspects of myself that seemed irrational, especially overwhelming emotions in response to seemingly innocuous circumstances that is the hallmark of flashbacks — and how my “symptoms” would have been accurately interpreted.
When I began seeing the psychiatrist mentioned above, I was in graduate school and reading the philosopher and social historian Michel Foucault, including his reflections on the panopticon-style prison developed by Jeremy Bentham.9 The panopticon was designed such that a guard could potentially witness the behaviors of every inmate from a central vantage point. Rows of prison cells stretched out from a viewing station like spokes of a wheel. The effect was that prisoners anticipated always being watched. Over time, they internalized the perspective of the guard and created an inner sense of being constantly observed that supposedly increased the likelihood they would self-discipline their own thoughts and behaviors. This is how I came to perceive psychiatric treatment: an internalized guard of my thoughts, emotions, and behaviors that supposedly helped me discipline myself so that one day I might become “normal.”
Yet this sense of surveillance already existed within me and felt much like the dynamics I had with my abuser, except then my objective had been to avoid further harm. Reflexively, I interpreted the medical model as a masculine way of perceiving the world, one that had power over me. This masculine presence was critical and judgmental and how distinctions between the normal and pathological contributed to my shame and self-stigma. It did not help that my psychiatrist was tone-deaf to how his power silenced my authentic voice, desires, and needs.
The Swiss psychiatrist Carl Jung shared an interesting distinction between the masculine and feminine in which he identified the masculine approach with concern for reaching states of perfection, such as making distinctions between the normal and the pathological in the quest for perfect health. With a masculine approach, we use techniques to manipulate ourselves to reach a pinnacle state of being. In contrast, Jung associated the feminine way of perceiving and being as directed toward reaching states of wholeness and inclusivity. With the feminine approach, all aspects of ourselves have value, and the meaning of parts is found in relation to the whole.
According to Jung, both the masculine and feminine attitudes are necessary for integrative states of mind. Each has its advantages and disadvantages. Jung wrote: “Perfectionism [by itself] always ends in a blind alley, while completeness by itself lacks selective values.”10 Rather than relying on one perspective, we need to continually examine ourselves from these two different approaches, clarifying the best options for reaching integration while making adjustments and corrections as we adapt to ever-changing situations.
Some reject distinctions between masculine and feminine because this dichotomy fails to fit their experience of gender. Others see such distinctions as promoting heteronormative values that can be used to pathologize sexual differences. I acknowledge the truth of both these objections. Nevertheless, I would like to momentarily bracket these concerns. For me, the distinction was necessary to reclaim what have been considered feminine ways of knowing and being, such as wisdom obtained through intuition, emotions, reveries, and the body. I want to suggest the benefit of seeing so-called masculine and feminine qualities as mental capacities, potentially part of anyone irrespective of gender, while noting the masculine drive for perfection, or getting things “right” (e.g., normal), has been overvalued by patriarchal cultures, including the culture of medicine. In the spirit of trauma-informed care and fostering integration, rather than eradicating one approach or the other, recovery rests on radical self-acceptance and discerning right actions given each unique person and circumstance.
Because of the prominence of the masculine point of view in patriarchal societies, the feminine approach has been routinely devalued or ignored. For instance, modalities such as art therapy and body-focused psychotherapy that work with the whole person without reliance on categorical distinctions between the normal and pathological have been perceived as adjuncts to treatment rather than core experiences of self-repair. Psychiatry has also been regarded as superior to psychotherapy in part because of its association with medical science, despite studies that show many clients find psychotherapy, rather than medications, lead to better outcomes, which was the situation for me.
Feminine Approaches to Recovery
Developing a relationship with what traditionally have been considered “feminine” ways of being is central to recovery from sexual abuse. Instead of self-disciplining through an introjected guard, like Bentham’s panopticon — one that is prone to inner states of bullying when you don’t get something “right” — there must be opportunities to foster a “feminine” perspective of your inner life, including trusting your capacity for growth and believing the wisdom you need to heal already resides within you.
Sexual abuse breaks more spirits than it does bones. Consequently, recovery cannot only address broken brains but must also mend broken spirits, or what is more commonly referred to as souls. Increasingly, practitioners and researchers are examining what is referred to as soul death or soul loss following sexual abuse and other devastating traumas like war. The idea of soul is phenomenologically associated with the awe-inspiring feeling of being whole and integrated. When regaining soul is the goal of recovery, we begin to look for opportunities to create restorative shifts from being soul-lost to living soul-full. This does not require disciplining mental life and behaviors, but rather relies on our attitudes toward, and how we relate through, our emotions, body, intuition, imagination, and beliefs. Through “feminine” ways of dwelling within ourselves we respond to what C. Michael Smith associated with the needs of the soul: “consideration, support, and space, to stir, breathe, come alive, move into the world more deeply and solidly.”11
It would be revolutionary if all women fully recovered from sexual abuse. One inkling of how this might look comes from the poem “Our Deepest Fear” by Marianne Williamson. You may be familiar with this poem, which South African President Nelson Mandela read in his inaugural address. Williamson begins:
Our deepest fear is not that we are inadequate.
Our deepest fear is that we are powerful beyond measure.
It is our light, not our darkness
That most frightens us.
She ends the poem:
As we’re liberated from our own fear,
Our presence automatically liberates others.
When you have been oppressed and view the world through the lens of possible threat and potential subjugation, standing strong, trusting all of yourself, and living soul-centered can feel frightening. Yet anyone who takes on the task of recovery from sexual abuse will ultimately have to turn toward trusting themselves and their inner wisdom, accepting they are complete even as they desire perfection.
I have had difficulty with this inner trust. Despite feeling I was successfully recovering, I sometimes held back. I retained a part of myself capable of inhabiting my body, imagination, emotions, and thoughts as if oppression by the power of another was still possible. How could I not? I might have changed, but the world had not. Thinking I should try to be the “right” sort of person sometimes resurfaced as defense against fears of judgment and revictimization. It is hard trusting feminine wisdom in a patriarchal world.
Ultimately, recovery means being liberated from such fears. Too often, however, we remain stuck in attitudes that contribute to playing small because we fear reprisal for inhabiting our power. Since we once experienced power as destructive, feeling our own power may be difficult without anticipating danger or fearing our own aggression.
Power is also identified with seeking justice — something we have every right to exercise but which, if we are not alert, can lead to thinking largely in terms of right and wrong, which although important for creating safe and ethical societies does not necessarily support recovery and can inhibit the process. A different, feminine power is necessary for regaining soul and connecting to our deepest humanity — one that is phenomenologically distinct from the mental states of judgment on which justice rests.
When in crisis, learning to observe one’s mind and body — and identifying certain behaviors, emotions, and beliefs as evidence of need for intervention — is wise. Yet if we are to recover, we must move away from being vigilant for the possibility of another crisis or pathological state of mind and instead begin to put faith in the power of integration. Rather than investing in distinctions between the normal and pathological, recovery requires creating conditions for living with greater calm, connection, and creativity. With this shift, we begin to harness a different kind of power, one that sustains the greatness of our souls.
Suggestions for a Collaborative Relationship with Your Healthcare Providers:
Seeking care and advocating for yourself can be anxiety-provoking. Many of us want to avoid confronting our health care providers. Unfortunately, simply trusting their decisions won’t always lead to the best outcomes. Here are some suggestions for how to receive the care you deserve when you see your psychotherapist, psychiatrist or other medical provider:
1) Write down your concerns prior to your appointment along with any medications you are currently taking. If you feel it will support your treatment, email this information to your provider prior to your appointment. Have this list with you at your appointment in case you need to refer to it. Consider writing down your provider’s responses, especially any new diagnoses, treatments, or tests. You may also want to ask if you can record their replies using your smartphone. Always ask before recording anyone, as taping a conversation without a person’s permission is illegal in many states. If your appointment doesn’t allow enough time for your concerns, ask your provider if you can have a telehealth visit or email the rest of your concerns for their reply. In general, it is a good idea to know how best to reach your provider in case of complications or an emergency.
2) Have someone attend the appointment with you if you are having difficulty expressing your needs on your own or remembering after the appointment what was discussed. Typically, mental health providers appreciate an email or call letting them know you will bring someone with you.
3) Ask for an explanation of why you are receiving a specific form of treatment and/or medication(s). Similarly, ask why you are receiving a particular diagnosis. Ask what outcomes your provider is seeking with your treatment. Ask if there are other ways to treat your condition. Ask what outcomes you could anticipate if you choose not to utilize the treatment they provide.
4) Let your provider know the reasons you are seeking help (e.g., intimacy with your partner, doing well in school or work, becoming a more attentive parent) and ask how they can help you reach your goals.
5) Let your provider know the symptoms you hope to relieve (e.g., flashbacks, insomnia, rage, depression) and ask if and how their treatment is directed toward those symptoms.
6) If you are taking medications, ask why the medication(s) is being prescribed, how it is intended to help you, and the side effects you might experience. Make sure the provider knows other medications you are taking and ask them to research any contraindications (he or she should have an app that easily performs this function).
7) Ask how long they anticipate you will need the medications. You may also want to discuss with your provider if they have ever supported clients as they went through the process of stopping or reducing medications.
8) Ask if any studies have been done on the effects of long-term use of the medication(s) prescribed for you.
9) If pregnant, could become pregnant, or breastfeeding, discuss with your provider if the medications are safe for a developing fetus or infant, and alternative forms of treatment if they are not safe.
References
1 Judith Herman, Father-Daughter Incest (Cambridge: Harvard University Press, 1981/2000), 181.
2 John Briere, “Reconsidering Trauma: Treatment Advances, Relational Issues and Mindfulness in Integrated Trauma Therapy,” Institute for the Advancement of Human Behavior, San Francisco, CA, January 23, 2009.
3 Bonnie Burstow, “Toward a Radical Understanding of Trauma and Trauma Work,” Violence Against Women 9, no. 11 (November 2003): 1316.
4 Burstow, 1313.
5 Stephen T. Casper, “The History and Future of Neurological Care,” Science 364, no. 6437 (19 April 2019): 243-44.
6 Jeffrey Brainard, “Is Psychiatric Guide Tainted?”, Science 383, In Brief, no. 6680 (January 19 2024): 244.
7 Judith Herman, Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror(New York: Basic Books, 1997), 240.
8 Bessel van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (New York: Viking, 2014), 128.
9 Michel Foucault, Discipline & Punish, trans. A. Sheridan (New York: Vintage Books, 1979).
10 C.G. Jung, Answer to Job, trans. R. F. C. Hull (Princeton: Princeton University Press, 1958/2011), 33.
11 C. Michael Smith, Jung and Shamanism: In Dialogue (New York: Paulist Press, 2007), iii.
