First Person Singular: A therapist at OSH explores betrayal and voice-hearing

By Pamela Birrell, PhD, Psych Central, Oct. 2, 2013

voice-hearing graphicNote: This story is based on what actually happened in one instance of psychotherapy. Names and details have been changed to protect identities.

It was 25 years ago. I was a relatively new intern at a busy inner city community health clinic and working at the Oregon State Hospital. I had already had my eyes and heart opened by the many stories of tragedy that surrounded such a place — poverty, racism, sexual assault, child abuse — and above all, the incredible power of the human spirit. I was already learning the limited power of the standard mental health system in addressing such injustices and trauma, and often did not feel up to the task.

Nancy was diagnosed with schizophrenia and major depression. She was incredibly suicidal, heard voices and was on a cocktail of psychiatric drugs. She had been arrested for assault and spent time in the state prison. The prison had quickly seen that she did not belong there and transferred her to the state hospital. I was able to see her first in the hospital and then at the clinic when she was released.

She was a mess. I didn’t know how long I would be working with her before she committed suicide. She had extremely lethal plans for it and was alone and isolated.

Nancy’s sad and violent history was recorded in the large file that came with her. She had a history of being sexually and physically violated by her father, who was, thankfully, on the road much of the time as a truck driver. Nancy’s mother was extremely depressed and unable or unwilling to adequately mother and protect her child. There were hospital records of her many visits to the emergency room starting from age 4. It was and will always be a mystery to me how and why Nancy was left in these circumstances with no intervention from the state.

Nancy trusted no one. She had not ever had a good experience with relationships and was extremely wary of me. It was difficult to get her to talk to me in our early sessions. Slowly, she told me a little of her story, primarily how she had been put in prison for assaulting people on city buses because her voices told her to. Her voices had ruled her life since mid-adolescence, telling her how worthless she was and about the dangers surrounding her. She was cut off from feeling for the most part, so her fear of others manifested as paranoia: Her voices told her others wanted to hurt her and that she had to lash out first or be attacked.

It was at one of these early sessions that Nancy turned her head slightly and seemed to tune me out.

”Are you hearing voices?” I asked.

She looked at me as if in a trance, not sure who I was, but managed to answer, “Yes.”

“What are they telling you?” I asked, not sure of what to say in this situation — my first demonstration that there are many, many situations that occur in therapy with traumatized people that no one ever prepares you for.

After a short pause, Nancy answered, “They are telling me to hurt you.”

I was taken aback. The clinic had emergency procedures to use if we felt threatened by a client, but I was reluctant to use them for some reason. I looked at her gently and fearfully and asked, “Are you going to listen to them?”

Nancy stared at me in a way that told me that she had never been asked that question. She was silent and thoughtful for a while. Then she said to me, “I guess not.” It was the first time ever that she had the idea that she didn’t need to do everything her voices told her to do. It was also an opening to begin to believe that she didn’t have to always believe them when they told her how worthless she was.

That moment opened things up for us. Nancy was able to have a little more freedom in what she could think and say. She began to have some feelings of grief and loss for all that had happened in her life, and began to understand the depths of the betrayals that had happened to her. She was still reluctant to trust me and the voices reminded her from time to time to push me away, physically and emotionally.

Somehow we hung in there. Since we had known from the beginning of our relationship that it would only last the year (the time of my internship), we had to set limited goals. Nancy decided that what she really wanted from our relationship was a hug at our last session. She had never touched or been touched by anyone in a way that was nurturing rather than destructive and she was frightened by the very idea. I agreed that one final hug would be a worthy goal.

We worked at it for months, through the fear and voices and self-destructive thoughts. We talked about what it might be like for her, what it might bring up, how it could affect her. She was willing to take the risk and so was I.

When the time of our last meeting came, we were both nervous. We had worked through the ending process and how it was difficult for both of us, as we had become attached to each other. We talked about her assignment to a new therapist and Nancy had met that person and felt it was someone she could work with. We couldn’t put that last moment off any longer. As she walked toward the door she took a deep breath and reached for me. We hugged briefly, both with tears in our eyes and she walked out of my life forever.

Twenty-five years later I remember Nancy with fondness and sadness. She had experienced great betrayals, yet possessed great courage in her search for loving human contact. As Jennifer J. Freyd and I wrote our recent book, Blind to Betrayal: Why We Fool Ourselves We Aren’t Being Fooled, I thought again of Nancy. She showed me the power of the human spirit as well as the devastation of betrayal and trauma. Her voices were not merely the result of a disease process, but a mechanism to prevent her from further hurt. Her rejection of herself and close connections was a result of her blindness to the betrayals of her parents. Since she couldn’t bear the knowledge that those who were supposed to take care of her and love her had so badly abused her, she pushed others away and punished herself as being to blame for the abuse.

In the book, we discuss how to heal from betrayal and overcome betrayal blindness. Nancy and I were not able to work together long enough to get to that point, but we were able to get to the point where she could allow a caring touch. And maybe that was enough. I hope Nancy was able to go on and develop more trust and find a sense of safety in others. I hope that she learned that she was not crazy or stupid, but the profound betrayal had damaged her sense of trust in herself and others. Betrayal blindness is actually not stupid or crazy at all. It is a survival mechanism that is quite clever and one which keeps children in Nancy’s circumstances from losing what little they have — but it comes at a great cost.

Betrayal harms us at the deepest parts of ourselves, and yet it can be possible to reach those dark places that hide our inmost fears and deepest longings if approached carefully with gentle love and profound listening.