Betrayal trauma, dissociative experiences and dysfunctional family dynamics: Flashbacks, self-harming behaviors and suicide attempts in post-traumatic stress disorder and dissociative disorders

Abstract

Abstract
Betrayal trauma consists of negative life experiences in which the victims are close to the traumatizing people as well as institutions for which they rely upon protection, support, resources and survival. In most cases, it operates as a dynamic of dysfunctional families which are described as pathologically-structured patterns of thoughts, emotions and behaviors, which function as violence-oriented negative child-rearing styles and generate childhood traumas. Trauma-related psychopathologies frequently discussed with these notions tend to be correlated to a high risk of self-harming behaviors and suicide attempts. It is, thus, of great importance to comprehend, explain and approach suicide attempts in trauma-related psychopathologies such as post-traumatic stress disorder and dissociative disorders by taking the dysfunctional familial dynamics and succeeding betrayal trauma both in clinical and forensic settings. Thus, in this review, betrayal trauma, dissociative experiences and dysfunctional family dynamics were discussed in terms of the dissociogenic reactions directed to them as well as flashbacks, suicide attempts and self-harming behaviors.
Keywords: Betrayal trauma, dissociation, dysfunctional families, flashbacks, self-harming behaviors, suicide attempts, childhood trauma, trauma-related psychopathologies, intergenerational transmission of trauma

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INVITED REVIEW
Medicine Science 2021;10(4):1550-6
Betrayal trauma, dissociative experiences and dysfunctional family dynamics: Flashbacks,
self-harming behaviors and suicide attempts in post-traumatic stress disorder and
dissociative disorders
Erdinc Ozturk1, Barishan Erdogan2
1Istanbul University-Cerrahpaşa, Institute of Forensic Sciences and Legal Medicine, Department of Social Sciences, Istanbul, Turkey
2Istanbul Arel University, Faculty of Letters, Department of Psychology, Istanbul, Turkey
Received 13 October 2021; Accepted 28 October 2021
Available online 25.11.2021 with doi: 10.5455/medscience.2021.10.342
Copyright@Author(s) - Available online at www.medicinescience.org
Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Abstract
Betrayal trauma consists of negative life experiences in which the victims are close to the traumatizing people as well as institutions for which they rely upon protection,
support, resources and survival. In most cases, it operates as a dynamic of dysfunctional families which are described as pathologically-structured patterns of thoughts,
emotions and behaviors, which function as violence-oriented negative child-rearing styles and generate childhood traumas. Trauma-related psychopathologies frequently
discussed with these notions tend to be correlated to a high risk of self-harming behaviors and suicide attempts. It is, thus, of great importance to comprehend, explain
and approach suicide attempts in trauma-related psychopathologies such as post-traumatic stress disorder and dissociative disorders by taking the dysfunctional familial
dynamics and succeeding betrayal trauma both in clinical and forensic settings. Thus, in this review, betrayal trauma, dissociative experiences and dysfunctional family
dynamics were discussed in terms of the dissociogenic reactions directed to them as well as ashbacks, suicide attempts and self-harming behaviors.
Keywords: Betrayal trauma, dissociation, dysfunctional families, ashbacks, self-harming behaviors, suicide attempts, childhood trauma, trauma-related psychopathologies,
intergenerational transmission of trauma
Introduction
Betrayal trauma, rst introduced by Jennifer Freyd, is described
as a type of trauma consisting of negative life experiences in
which the victims are close to the traumatizing people as well as
institutions for which they rely upon protection, support, resources
and/or even survival [1,2]. It is emphasized that the violation of
the trust and/or psychological and physiological well-being of
the victims by such close perpetrators is a fundamental precedent
of dissociative experiences which are used for the purpose of
sustaining the original relationship with the caregiver. It is,
thus, proclaimed that an increased level of dissociative defense
mechanisms would be required in order to process the trauma
when individuals faced traumatization from those they are reliant
or dependent [3]. It is postulated that all human beings originally
possess an ability to recognize and dier such violations from
everyday life experiences and that when escape is not an option
in face of a traumatic experience (e.g. that by a primary caregiver)
the aforementioned ability may be withheld in order to survive
[4]. The breaking of the toxic relationship would otherwise mean
the lack of vital resources, primary support, care and protection.
Betrayal trauma can, in that manner, be told to describe the
conceptualization of the dissociative amnestic experiences which
function not only as the guarantors of survival but also the blockers
of traumatic experiences that would prevent one’s psychological
integrity. The best-documented type of betrayal trauma is most
probably child sexual abuse, while other types can be counted as
institutional and romantic betrayal. Due to the fact that it refers
to negative experiences perpetrated by those for whom one relies
upon, the most common perpetrators of betrayal trauma tends
to be one’s own family, or rather more precisely, one’s own
dysfunctional family.
The negative or positive child-rearing styles of the dominant family
structure in a certain time period determine both the prevalent
social structure and the direction of the transformation. Such a
*Corresponding Author: Erdinç Ozturk, Istanbul University-Cerrahpaa, Institute
of Forensic Sciences and Legal Medicine, Department of Social Sciences, Istanbul,
Turke E-mail: erdincerdinc@hotmail.com
Medicine Science
International
Medical Journal

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social structure and transformation towards either development
or regression can be told to be shaped in accordance with the
leading practices of child-rearing styles. Parents with the same
or related child-rearing styles tend to raise new generations as
similarly traumatized and pathologized as not only themselves
but also their own parents. This intergenerational transmission
of trauma is well documented especially by numerous studies on
the Holocaust. In her case history of a female patient who was
suering from parental traumas even though she was born after
the Nazi genocide of the Jews, Wilgowicz conceptualizes the
incarceration of children that have already been traumatized by
wars and other combats in their very own parents’ traumas as a
“vampiric” form of identication [5]. Prager also focused on the
fact that even generations that have not witnessed the traumatic
turning point themselves are most likely to be subjects of the
victimization due to this collective memory [6]. Öztürk, on the
other hand, promotes the suggestion by underlining the fact that
a traumatized individual has two life periods around the traumatic
turning point: one period before the traumatic experience and
the one afterwards. The traumatic turning point does not refer to
the rst trauma which the subject had experienced, remembers,
or realizes in time, but rather the most upsetting experience
that most likely to have happened in childhood. The traumatic
turning point refers to the most upsetting traumatic experience
which takes a major role in the development of trauma schemata.
After the traumatic turning point, the individual is most likely to
continue their life with a psychiatric diagnosis and as a case that
possesses a "trauma self" characterized by dissociative reactions
associated with this diagnosis. According to Öztürk, ashbacks
appear suddenly and rapidly after this traumatic turning point.
The frequency, severity and duration of traumatic experiences are
directly related to these ashbacks. After the traumatic turning
point, the negative life experiences of the individual in their
actual life will continue to be repeated in their inner world, almost
like a traumatic obsession. These repetitions, on the other hand,
constitute the main reason for self-harming behaviors and suicide
attempts, which are accompanied by feelings of shame and anger
in the traumatic case [7,8]. Parents with the same negative child-
rearing styles, thus, tend to raise a dysfunctional generation that
is characterized by the aforementioned negative feelings and
similar levels of traumatic and dissociative experiences [9]. It is
of high importance to refer to child-rearing styles in families -with
varying levels of functionality within a spectrum diering from
normality to psychopathology- as a medium of this transmission
in order to be able to operationally dene this intergenerational
traumatization. This review, thus, aims to evaluate the concepts of
betrayal trauma, dissociative experiences and dysfunctional family
dynamics as well as related ashbacks, self-harming behaviors and
suicide attempts in trauma-related psychiatric disorders, namely
post-traumatic stress disorder and dissociative disorders within a
psychotraumatological frame.
Family dynamics, which can be seen almost identical to the notion
of child-rearing styles, thus, gain vital signicance in evaluating
the characteristics of values, emotions, memories, behaviors and
experiences that are intergenerationally transmitted. In order to
comprehend these relationship dynamics varying from normal
to psychopathological within families, Öztürk underlines three
dierent family models: (i) “normal”, (ii) “psychopathological”
and (iii) “apparently normal” or in other terms, “dysfunctional”
families [9,10]. A “normal” family model refers to the involvement
of individuals without any psychiatric diagnoses; which is also
the only possible model to raise psychologically integrated
generations without psychopathologies. A “psychopathological”
model consists of members that are diagnosed with at least one
psychiatric disorder. An equally important model in-between is
called the “apparently normal” or “dysfunctional” family which
refers to children that are diagnosed with at least one psychiatric
disorder and parents with usually only subclinical diagnoses.
Dysfunctional family dynamics that are present in this last model
can be dened as pathologically-structured patterns of thoughts,
emotions and behaviors, which function as violence-oriented
negative child-rearing styles and generate childhood traumas.
These notions, i.e. childhood traumas as well as negative child-
rearing styles within dysfunctional families which not only
traumatize their own children but also fail to protect them from
external traumatic and/or negative life experiences, are among
the most signicant means of “intergenerational transmission of
trauma” and “intergenerational transmission of psychopathology”.
This intergenerational existence of traumatic experiences and
psychopathological processes bring dissociative disorders and
post-traumatic stress reactions into view [9].
Generating from chronical childhood traumas and dysfunctional
family dynamics, dissociative disorders are characterized by
suicide attempts, self-harming behaviors, dissociative amnesias,
bursts of anger and ambiguities in identity or identity confusions;
most commonly comorbid with post-traumatic stress disorder
(PTSD), somatoform disorders and borderline personality disorder
[11]. Research shows a wide range of the age of starting to self-
harming behaviors in dissociative disorders, varying from 5 to 14
with focus on the ages between 10 and 15 as the most common
period [9]. The etiology of deliberate self-harming behaviors is
likely to be multilayered, alluding to factors such as moments
of disappointment, physiological excitation, low tolerance, self-
punishment and problematic interpersonal relationships [12,13].
Apart from these, psychological traumas, precisely chronic
childhood traumas are likely to explain both self-harming
behaviors and suicide attempts. Dissociative experiences play a
mediating role in terms of the frequency, severity and duration
of self-harm behaviors and suicidality or suicide attempts related
to preceding childhood traumas [14,15]. Self-harming behaviors,
which are closely related to dissociation, are done in order to
control the negative eects of childhood traumas on emotion,
thought and behavior [16]. Under these circumstances, it is literally
of vital importance to scrutinize the eects of dysfunctional
family dynamics and betrayal trauma on deliberate self-harming
behaviors and suicide attempts especially in PTSD and dissociative
disorders, two of the most common psychiatric diagnoses related
to suicidal attempts.
Dysfunctional Families as a Dissociogenic Agent in Betrayal
Trauma
Bowlby, in his Attachment theory of which the most fundamental
tenet is that children in their early years need to form a relationship
with at least one primary caregiver for a healthy development both
socially and psychologically, was the rst author to emphasize the
fact that traumatizing experiences with one's primary caregiver
impacts a child's attachment security, stress, coping strategies, and
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the sense of self [17]. He mentions three types of internal working
models, i.e. internal representations with which individuals
can recognize which inner content is dominant. Bowlby denes
“securely organized internal working models”, “insecurely
organized internal working models” and “disorganized internal
working models” among which the latter two refer to possible
early childhood traumas. The last one, however, alludes directly
to unprocessed or unmetabolized negative life experiences
of the caregiver themself, which then aect the subsequent
attachment style with their own children. Hesse and Main [18]
suggest that disorganized attachment occurs when the caregiver
is ambivalently both a source of the child's fright and solution,
referring to a double bind. Individuals with this disorganized form
of attachment happen to experience altered states of consciousness
as well as dissociation more frequently. Insecure and disorganized
attachments also happen to form one of the main characteristics of
apparently normal families, namely the dysfunctional families as
dened by Öztürk and Şar [9,10].
Dysfunctional families are characterized by non-empathetic
violence-oriented child-rearing styles, inconsistent communication
styles, constant conicts, frequent child abuse and/or neglect,
and probable history of traumatic experiences of at least one
family member, resulting in dissociative defenses which is
accompanied by a “pathological conformism”, described as
the adoption of psychopathological actions. These families
manifest major impairments in the fulllment of basic family
functions and children that grown up in these families, with a
psychopathological eort to adopt and/or a conformist attitude,
perceive these dysfunctions in the family as a social norm [9].
There are certain common behavioral patterns that dysfunctional
family models develop as a result of negative life experiences
within an "internal social system" and that should be recognized in
the psychotherapy process. These particular common behavioral
patterns are instrumental in the emergence of dysfunctional family
patterns by enabling inconsistent communication dynamics.
Dysfunctional family dynamics are psychopathogenic dynamics
that are learned from parents but can be unconsciously acted upon
at certain rates. These psychopathogenic dynamics function as
a means of controlling individuals and traumatize them. Some
common characteristics of dysfunctional families are listed below
[9]:
•Distortions, dissociative defenses as well as denial are prominent
in dysfunctional families. Parents tend to reject the fact of abuse,
or even legalize it by believing its normality and/or ordinariness.
•These families consist of inconsistent individuals and there
are certain –mostly sub-threshold psychopathologies in family
members.
•Parental favoritism is common. Besides, parents lack the
necessary mutuality, or they may even manifest pseudomutuality.
Some members of the family are approached by over empathetic
attitudes while the others face the lack of empathy.
•Adjustment of personal spaces or interpersonal distances is often
problematic.
•Manipulation, envy, jealousy and rudeness are present in both
internal and external relationship dynamics of the family members.
•Bursts of anger, self-harming behaviors, inconsistent interpersonal
relationships and suicide attempts as well as addictive behaviors
are frequent.
•Family members frequently sabotage not only themselves but
also others.
•“Intergenerational transmission of trauma” and “intergenerational
transmission of psychopathology” is ubiquitous.
•Lack of privacy between the members is common.
•Children tend to experience processes of insecure attachment.
•A social isolation is mostly present.
•The members are controlled by traumatization, which continues
in an intergenerational dimension.
•Womanhood and childhood are internalized as negative notions.
•Negative and psychopathological child-rearing styles are adopted.
•A criminogenic structure is observed.
•Continuity of a dysfunctional generation is provided.
Traumatic experiences and the negative child-rearing styles
of dysfunctional families can cause adverse and permanent
psychological eects on the whole life of people from childhood
to old age. In a process characterized by normal and optimal
functional dynamics, the family is the most important and most
valuable agent of the society in which the strategies of knowledge,
kindness, merit, loyalty and overcoming the maladaptive eects
of negative life events are transmitted or taught to children
from parents. Intergenerational experiences and psychosocial
dynamics transmitted by parents can be both positive and negative.
Children's ability to eectively use their coping styles in the face of
negative life events in and outside the family, to provide empathic
reciprocity, to construct trust-oriented communication styles, and
to maintain the optimal stimulus level against excessive stimuli
or lack of stimulus are positive dynamics. Negative dynamics are
that violence-oriented negative child-rearing styles continue to
exist between generations without much change, the asymmetrical
internal system: polarization of the family structure, attachment to
the abuser, identication with the abuser, experiencing dissociative
chaos in close relationship patterns, and generally choosing children
as victims in the family with a dysfunctional orientation [9,19].
Intergenerational transmission of trauma and intergenerational
transmission of psychopathology, which are characterized by these
negative dynamics, make it possible to experience many psychiatric
diagnoses over generations, especially dissociative disorders and
post-traumatic stress disorder, which show the closest relationship
with chronic negative life events [7].
Although they were initially suggested to explain the etiology of
schizophrenia decades ago, such characteristics which are now
associated with apparently normal families still play a crucial
role in the comprehension of childhood traumas. Apart from
insecure and disorganized attachment among those characteristics,
pseudomutuality refers to the apparently happy members who in
fact restrain themselves excessively, which in turn generates a
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1553
mild psychological disturbance in at least one of the members due
to the lack of a eld of freedom in which individuals can be and
manifest themselves. Another typical characteristic, double-bind,
as mentioned before refers to multiple messages from parents
which are reciprocally conicting and visible in interpersonal
relationships and communication [20]. Parental favoritism refers
to an in-group schism or segregation and would most likely to end
in a split in the psyche of the ospring. All these characteristics
above can be told to be violating a child’s feeling of safety,
intimacy and trust, i.e. the betrayal trauma. Betrayal trauma, thus,
functions as a dysfunctional family dynamic in most cases.
As mentioned before, dysfunctional and pathological family models
serve the intergenerational transmission of psychopathology and
trauma in a society. Dysfunctional families are characterized
by the intergenerational transmission of contradictory and
psychopathogenic dynamics that they learn from their parents and
unwittingly apply to their own children. Dysfunctional families
use violence-oriented and unempathetic negative child-rearing
styles as a method of punishment for their own children, and in
fact, the traumatized or even victimized individual is stigmatized
as "sick" and easily controlled by both their own family and
those outside the family. In the formation of psychopathology,
dysfunctional family structure and dynamics come into play as
the most destructive internal systems. The basic reality here is
that both psychopathology disrupts the family structure and the
family is in an existentially dysfunctional structure. The traumatic
experiences of both the parents and children of individuals who
adopt the same child-rearing styles are close to each other and in
the same psychopathological pattern, and their revictimization
experiences on the intergenerational axis also happen to show
similarities in the same direction [9].
Negative life events that are repeated through the traumatizing and
negative child-rearing styles of parents, and psychopathologies
characterized by these negative life events show intergenerational
transmission on a dissociative basis. The traumatic experiences
of parents or caregivers are transmitted to their own children
through the negative child-rearing styles they adopt. While some
of the parents are active agents in dysfunctional communication
dynamics characterized by violence-focused, trust-insecurity
conicts, and negative child-rearing styles far from empathy,
some of the parents remain as recessive agents in the position of
an inactive spectator, thus ensuring the continuity of abuse and
neglect as well as ensuring the continuity of abuse and neglect
within the family. It hides traumatic experiences and even makes it
impossible for individuals outside the family to be noticed. Parents'
adoption of their traumatic experiences in their own history to their
own children through negative child-rearing styles may cause this
maladaptive process of intergenerational transmission of trauma to
be experienced by being preserved at certain or even major rates
for generations [19,21].
Basic Etiological Factors of Psychopathology: Dysfunctional
Family Dynamics and Betrayal Trauma
As a result of the increase in the number of studies conducted
within the scope of childhood traumas, these negative life
experiences and dysfunctional family dynamics have begun to
be evaluated in a common context. The ambivalent and insecure
relationship patterns that emerge between the parents, the
inconsistent and double or mixed messages given to the children,
and the poor communication skills constitute the basic elements of
dysfunctional families. Child abuse and neglect, among the most
visible forms of familial dysfunctionality, happen to be correlated
with numerous psychopathologies including alcohol and/or
substance abuse [22], as well as negative eects on the brain
and the hypothalamic-pituitary-adrenal (HPA) system; resulting
in psychiatric vulnerability in adulthood [23]. Dysfunctional
attitudes and behaviors that arise in the family and are directed to
children to a large extent can cause –mainly in guise of childhood
traumas- the development of many psychopathologies, especially
dissociative disorders, post-traumatic stress disorder, depression
disorders and anxiety disorders [9,24,25].
Betrayal trauma is documented as a signicant contributor to
symptoms in many trauma-related psychiatric disorders including
PTSD, personality disorders, dissociative disorders as well as
schizophrenia spectrum and other psychotic disorders. Thus, when
it comes to trauma-related psychopathologies, the presence of
dysfunctional family dynamics should also be considered as the
betrayal trauma functions as one. A traumatized individual may
experience a very limited or an absolute nonexistent amount of
awareness of the traumatic event. Especially early, chronic and
cumulative childhood traumas can be manifested psychosomatic
and psychological symptoms such as somatization, ashbacks,
disorientation and psychological symptoms such as somatization,
ashbacks, disorientation and dissociation. As dissociative
defenses cease the awareness of the traumatic experiences, major
negative life events such as childhood sexual abuse may well
create the dissociative reactions. Dissociative identity disorder,
likewise, is signicantly related with chronic and overwhelming
traumas such as childhood sexual abuse and/or neglect and similar
interpersonal injuries. Another case that is commonly associated
with dysfunctional families is alcohol and/or substance abuse
disorder. Current research found that childhood neglect and abuse
increase the risk for substance abuse [15,22,26]. Some authors
suggest that due to the fact that betrayal trauma happen to generate
a loss of control, this loss incorporates into the guise of substance
abuse while others claim that it is a form of coping mechanism
with post-traumatic negative aect traits such as avoidance, self-
medication or tension reduction [27]. Even though the preeminent,
long-standing and prominent way of treatment of hallucinations
that are present in psychotic disorders has been pharmacotherapy;
current research postulates that the treatment of betrayal trauma may
also be benecial in reducing hallucinations when accompanied
with a history of sexual abuse in childhood [28]. When it comes
to personality disorders, the most studied trauma-related case in
literature happens to be the borderline personality disorder. It is
a well-documented fact that borderline personality disorder has
roots in early abuse, neglect, insecure attachment and other forms
of traumas which may occur as a result of the emotional, physical
and/or sexual abuse by caregivers [29]. Strikingly, self-harming
behaviors and suicide attempts in guises of suicidal ideation;
dissociative (deep) memory and dysfunctional family dynamics
happen to be what all these trauma-related psychopathologies have
in common [7,9]. In order to comprehend, explain and work on
suicidal tendencies or suicide attempts, it is of vital importance
to scrutinize early childhood traumas and related dysfunctional
family dynamics that can most likely to be manifested as betrayal
trauma.
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Flashbacks, Self-Harming Behaviors and Suicide Attempts
with Regard to Dysfunctional Family Dynamics
Flashbacks can be dened as intense revisualizations of traumatic
experiences mostly reported by patients with PTSD [30]. Some
authors prefer to conceptualize them as completely distinct type of
memory [31,32] while some others tend to refer to a fragmented
and disorganized form of the autobiographical memory [33,34].
They were also found to be among the most common types of
dissociation [35]. While some studies tend to be skeptical about
the frequency of ashbacks as they tend to handle this notion
referring to comorbid substance abuse and related hallucinogenic
eects [36], others claim that many trauma survivors suer from
autobiographical memory disturbances (such as psychogenic
or dissociative amnesia) and intrusions (namely ashbacks and
nightmares) that would manifest powerful sensory characteristics
[37,38]. Another study focusing on forensic interviews with children
that have an abuse history suggests that such interviews were a
medium through which dissociative post-traumatic reactions were
activated and frequently manifested in sensory ashbacks [39].
Apart from their characteristics and neuropsychological roots,
ashbacks have been scrutinized in terms of their relationship
with suicide attempts and deliberate self-harming behaviors. In a
study conducted with suicidal women with borderline personality
disorder, it was found that suicide attempts were more likely to
be preceded by ashbacks or nightmares [40]. Some authors even
prefer the term “ash-forwards” to describe the imagery about a
future suicide attempt, risk-taking and/or self-harming behaviors
rather than visualization of a past traumatic event [41]. Mainly
focusing on war trauma that can have intergenerational eects,
literature draws a parallelism between post-traumatic stress
reactions, ashbacks as well as nightmares, self-harming behaviors
and related suicide attempts [42].
As mentioned before, dysfunctional and pathological family models
serve the intergenerational transmission of psychopathology and
trauma in a society. Dysfunctional families are characterized
by the intergenerational transmission of contradictory and
psychopathogenic dynamics that they learn from their parents and
unwittingly apply to their own children. Dissociative disorders,
which are frequently seen in adolescents and young adults, on the
other hand, are among the psychiatric diagnoses in which self-
harming behaviors and suicide attempts are seen most frequently.
Self-harming behaviors are one of the public health problems that
have signicant adverse psychological eects on all age groups
in the world and in our country. Self-harming behaviors, which
are characterized by decreasing the quality of life of individuals
and having negative eects on their physical and psychological
stability, are among the focus topics of clinical psychology and
psychiatry disciplines [7,9,43].
Self-harming behavior is dened as the whole of behaviors that
are mostly performed voluntarily, resulting in injury to at least one
part of the body, and directly disrupting the integrity of it [44].
Current research stresses the fact that 87% of dissociative disorder
cases manifest self-harming behaviors, while 78% of them report
suicide attempts and 1 to 2% of the cases result in death by suicide
[24]. Studies on self-harming behaviors emphasize that childhood
traumas are major etiological factors of negative behaviors in
psychiatric disorders associated with these traumatic experiences
[45,46]. Self-harming behaviors, which are closely related to
dissociation, are adopted to control the adverse psychological
eects of childhood traumas on emotion, thought and behavior
[16]. Connors described three basic functions of trauma-
related self-harming behaviors: (i) re-enacting real or symbolic
representations of the original trauma with self-harming behaviors,
(ii) trying to express feelings and emotional problems that are
dicult to share by self-harming, such as post-traumatic anger,
regret and shame (iii) restoring the physiological and emotional
balance, that is, homeostasis, by rearranging the self through self-
harming behaviors [47]. Various mental health experts in the eld
of dissociative disorders underline the fact that childhood traumas
are closely related to self-harming behaviors [7, 48-51]. Franzke,
Wabnitz, and Catani state that solely dissociation plays a mediating
role between childhood traumas and self-harming behaviors [45].
Brand, Loewenstein, and Lanius state that as a result of negative life
events experienced by individuals, especially childhood traumas
and that cannot be coped, self-harming behaviors occur on a wide
scale ranging from careless driving to physiological self-neglect
[52]. Brand et al. emphasize that 64-78% of dissociative identity
disorder cases harm themselves, 61-72% have suicidal ideation,
and 1-2% suicidal attempts result in death by suicide [53].
Conclusion
First introduced by Freyd, betrayal trauma is described as a type
of trauma consisting of negative experiences in which the victims
are close to the traumatizing people as well as institutions for
which they rely upon protection, support, vital resources and/or
even survival. Three distinct types were dened as: (i) child sexual
abuse which shows a direct correlation with dysfunctional family
dynamics, (ii) institutional betrayal trauma that can be observed in
academic, military, legal and healthcare organizations in guises of
mobbing, harassment, discrimination, sexual assault and brutality,
and (iii) romantic betrayal trauma which refers to a wide spectrum
of interpersonal relations varying from indelity to domestic
violence. In most cases, severe traumatic reactions are products
of prolonged childhood traumas in the early years of life, stressing
the fact that betrayal trauma happens to function as a dysfunctional
family dynamic. The dysfunctionality of the family in terms of
support, care, nutrition and protection of the child manifests itself
as a traumatized child most likely to suer from trauma-related
psychopathologies as an adult. Dissociation was found to be a
severe symptom of betrayal trauma; recent studies even underline
that hallucinations are linked to extreme cases of this type of
generalized trauma [28].
A grand majority of dissociative disorder cases states that they
tried to harm themselves because they could not cope with their
traumas in their rst interview, their desire to live decreased
almost to nothing and they were suicidal. In these cases, suicide
attempts ranges from moderate to severe death wish, and a case
without suicidal ideation is extremely rare to observe [7,24,54].
Öztürk refers to self-harming behaviors and suicide attempts as
“individuals’ last-ditch cry for help not only against themselves,
but also their abusers due to the fact that they were unable to
take traumas into consideration as a solid possibility and thus
they were left in the lurch [55]. The elimination of self-harming
behaviors and suicide attempts in cases of dissociative disorder is
successfully achieved by the application of trauma-centered and
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1555
structured psychotherapies including crisis intervention treatment
for this diagnosis group. It is a striking point that insecure
attachment, childhood separation, emotional neglect, sexual abuse,
and dissociation, all of which refer to betrayal trauma and related
dysfunctional family dynamics, were found to be signicant
predictors of deliberate self-harming behaviors [56]. Öztürk, also
suggests that traumatized individuals have a certain traumatic
turning point and thus two periods of their lives, namely the one
prior to the specic traumatic experience and the one afterwards.
The traumatic turning point refers to the most upsetting traumatic
experience which takes a major role in the development of trauma
schemata. From the traumatic turning point on, individuals are
most likely to continue their lives with a psychiatric diagnosis
and a "trauma self" characterized by dissociative reactions
associated with the diagnosis. According to Öztürk, ashbacks
appear suddenly and rapidly after this traumatic turning point and
the frequency, severity and duration of traumatic experiences are
directly related to them. After this aforementioned turning point,
the negative life experiences of individuals in their actual lives
will continue to be repeated in their inner worlds, resembling to
a so-called traumatic obsession. These repetitions can be told to
constitute the basic triggers behind self-harming behaviors and
suicide attempts accompanied by feelings of shame and anger in
the traumatic individual [7,8].
In this respect, in all trauma-related psychiatric diagnosis
groups, cases that continue psychotherapy should be supervised
in recurrent crisis periods, crisis intervention psychotherapy
approaches like Trauma Based Alliance Model Therapy developed
by Öztürk should be used, and these cases should be admitted to
a closed psychiatry service when necessary. Working eectively
in the psychotherapy process with chronic dissociative disorder
cases characterized by repetitive suicide attempts and self-
harming behaviors require fundamental knowledge -focused
on psychotraumatology and suicidology- specic to this eld,
cumulative professional experience and a novel perspective and
scientic approach. Working with self-harming behaviors and
suicide attempts of trauma cases is, in fact, a crisis intervention
psychotherapy [7,55].
Being able to terminate self-harming behaviors and suicide
attempts, which are the basic psychopathological and dissociative
characteristics of all trauma-related psychiatric diagnosis groups,
requires the development of short-term and trauma-centered
psychotherapy methods, which will be structured within the
framework of the paradigms of modern psychotraumatology. Since
childhood traumas constitute an important factor in the etiology of
self-harming behaviors and suicide attempts the prevention of them
should be undoubtedly prioritized [57-60]. To conclude, we found
the three quotes below from patients with dissociative disorder
encountered by Öztürk during their psychotherapeutic processes
very striking in terms of referring to their dysfunctional families,
betrayal trauma and ideation of annihilation (self-annihilation)
which would likely to be manifested as risk-taking, self-harming
or suicidal behaviors:
“I can no longer live in this situation. I wish I just disappeared, I
wish I became nothing, I wish I simply didn’t exist anymore.”
“They killed my emotions. Now I have so few emotions to give
that I want to become numb, and I want them to feel that I became
emotionless.”
“Not being able to feel even the numbness kills me inside every
day. When my traumatic memories invade every moment like an
obsession, I can only realize that I still exist by cutting my body.
The pain of injuring my own body drives my planned suicide
attempts away from me. The shame that my family inicted and
the anger I felt towards them distance me from all people and
from myself. The only thing that consoles me is my own wounds,
which are still bleeding, which I can endure as if I'm experiencing
someone else's pain. The never-healing wounds that both others
and the past inicted and that surround my mind at every moment...
I am now a dierent person watching the evil done to myself from
afar and watching every scene of my sacrice a thousand times in
my mind.”
Conict of interests
The authors declare that they have no competing interests.
Financial Disclosure
All authors declare no nancial support.
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