Op-Med is a collection of original articles contributed by Doximity members.
The most common presentation of a person who has been harassed is a loss of self-confidence and a feeling of helplessness regarding dominion over her/his own body now that someone else wants to tell them how it should be used. An experience of alienation from the universe occurs as if the individual’s place in it has been diminished. There is a withdrawal from social contacts and a retreat from emotional as well as sexual intimacy, perhaps for long after the harassment is over. Sex is now associated with shame.
A healthy person has what is known as “agency,” meaning an ability to influence environment and social contacts. Consensual sex is between equals, not quid pro quo (sex with a person in power exchanged for being advanced or retaining a position in the workplace/training program). A harassed person often loses a sense of agency. This may occur whether or not an actual submission to coercion took place. The person has been confronted with two untenable choices: lose a valued position, perhaps even a career, or submit to a loss of personal integrity, and thus to shame.
A major defense/coping mechanism is dissociation and compartmentalization of whatever indignity has been suffered. Dissociation means the event is suppressed from the mind as if it did not happen. Common psychiatric diagnoses of those sexually harassed are major depressive disorder, panic or generalized anxiety disorder, and posttraumatic stress disorder (PTSD).
Treating Victims of Sexual Harassment And/Or Assault
If intensive psychotherapy is accessible from a mental health worker, with perhaps medication from a psychiatrist, at least some of the distress can be alleviated, but never cured.
I provide psychotherapy and often work with victims of sexual harassment. I like to do cognitive restructuring, to emphasize positive accomplishments of the patient, and to resurrect a positive world view, and a future that has promise in it. Research recommends also that exposure therapy be used, which means revisiting the memories after engendering a feeling of support and safety with the psychotherapy and medication. About 50 percent of patients can tolerate, and thus benefit, from exposure therapy. Others require gentler methods, such as hypnosis.
For major depression and anxiety, serotonergic antidepressants such as sertraline and duloxetine are used. For the most serious diagnosis, PTSD, serotonergic antidepressants are primary also, as well as topiramate, an anticonvulsant, and prazosin, an alpha-antagonist.
Recent clinical trials feature use of 40mg of propranolol while retrieving harassment episodes from memory. Propranolol erases the fear, but not the memory. Beta blockers which do not cross the blood brain barrier don’t work, according to Clinical Psychiatry News February 2019 p. 1 and 11.
Looking Closer at PTSD
The first criterion is exposure to a traumatic experience in which you feel threatened. Consequently, symptoms include nightmares, flashbacks of the harassment, hypervigilance of the environment, panic attacks, emotional numbing, avoidance of remembering the trauma, difficulty sleeping, and poor concentration. There are permanent brain changes that underlie these symptoms. These include hyperactive neural transmission circuits, which involve the hippocampus and the amygdala.
The family lives of harassed persons may be affected if these people do not get help. The husbands or wives will need to be seen as part of the treatment. Sometimes divorces occur because victims are difficult to live with.
We should be aware of possible sexual abuse of children by family members, priests, doctors, and coaches. All of these have been in the news.
An Example Case
In one case of mine, a middle-aged woman who worked in the military was forced by her superior to leave her job after she refused his sexual advances. A coworker of hers committed suicide, another went on TV to discuss it, they went to their senator, but nothing helped.
I advised my patient to resign from the organization, which she did. This is one of the important decisions: Remove yourself from the situation despite loss of career, as it is not worth loss of selfhood or life.
She was given medication and psychotherapy. I quote from this patient's own words about the case: "I still have major psychiatric disability due to the diagnosis of PTSD related to a hostile workplace. The stressors continue as the agency continues to lie, and not be held accountable for their illegal actions against me." Examples: "I feel like a shell of my prior self. To go from a Federal Criminal Special Agent with a Top Secret clearance to an individual who is not fit for work still, 18 months after leaving my job, is disheartening, depressing, and at times debilitating."
The #MeToo movement has shone a spotlight on the universality of harassment, and has spearheaded consequences for the predator, but most workplaces are still male hierarchies, many of which have had a program for dealing with harassed persons that was not effective.
A case in point is that a new law was just passed in Congress dealing with improvement of procedures for those personnel harassed on Capitol Hill. Foremost consequence is the fact that lawsuits lost by the predator used to result in monetary damages being paid by the taxpayers, which must now be paid by the predator. Secondly, victims no longer have to wait 90 days and get counseling before going forward with the complaint, though counseling is still an important part of the healing process, and one that we should take seriously with every patient we meet.
Patient information has been altered to protect identity.