The Target of the Bully and the Effects of PTSD
by Marinah Valenzuela Farrell

© 2007 Midwifery Today, Inc. All rights reserved.

[Editor's note: This article first appeared in Midwifery Today Issue 82, Summer 2007.]

This third article in our four-part series on bullying focuses on the target of the bully, and the effects on her, including posttraumatic stress disorder (PTSD).

Drawing by Minhoon Kim

"Truth compels them."
—Drs. Ruth and Gary Namie

In a homebirth to hospital transport a few years ago, I witnessed the bullying of a new medical resident. I remember this incident quite well because the energy in the hospital was electric with what seemed like layers of hierarchy—new residents, more senior residents, doctors who were supervising and doing rounds and, finally, many layers of nurses and other support staff. This particular day had been wild in labor and delivery, with scheduled cesareans for one set of twins and three breech births, along with mothers coming in unscheduled at various stages of labor. Everyone was obviously tired and a homebirth transport just added to the workload and duties of the three residents we had been assigned. We were treated quite nicely, actually. One of the special things about residents is their curiosity about homebirth and hunger for new knowledge.

A nurse came in (my client seemed to have no specific nurse) and asked one of the residents to check my client. I had just done so about 10 minutes before and knew the assessment. The doctor checked and gave accurate effacement and dilation and smiled happily—I could tell that she was quite pleased that she was able to do this. The nurse then turned to her and demanded to know the baby's station, at which the resident stopped short. After a pause she made an estimate that, in my assessment, was correct. In front of me, her patient and her waiting family and friends, the nurse proceeded to tell her, with smoothly hostile words, that there was no way she could have known the answer (but did not verify that she was wrong). The resident, who up until then had been happily enjoying our company, left—ashamed and embarrassed. Another doctor poked his head in to inquire whether the check had been made and the nurse said, "Well, she guessed that it was this but I'm not sure she knew exactly what she was doing….," again in front of all of us. It was quite a sight and, sadly, the resident came back aloof and afraid to let her guard down.

I wondered how this resident would be in five years and whether she would, in turn, treat others that way. I felt sad that our obstetric model, with its hierarchy, made it so possible for disempowerment and humiliation to be a part of learning how to work with birthing mothers. This resident was clearly the perfect target for an aggressive and hostile nurse who was obviously burned out with the sometimes thankless job of working with residents in the obstetric ward and who felt a need to assert her standing and knowledge. Targets have certain qualities that bullies find totally irresistible.

Commentary from the New Physician: "Everyone in the healthcare field feels threatened these days. This disquiet accounts…for most of the tension, demoralization, aggressiveness, apathy and insecurity among trainees and their supervisors…. Very few perpetrators are boors or sadists. But many are out of date, ill-informed, awkward at teaching, socially inept and deeply insecure…."(1)

From a JAMA article: "To gain entrance and acceptance within the guild [of medicine] one has to go through a series of hidden, punitive rituals…. The use of humiliation, rejection, and alienation in these punitive hazing rituals is readily observed by…[medical students] during training."(2)

From the Journal of General Internal Medicine: "Psychological abuse, gender discrimination, sexual harassment, physical abuse, homophobia and racial discrimination are prevalent problems during… training."(3)

Most targets, by their very desire to help others, fill our medical system, which means that the system accommodates bullies and somehow benefits from the humiliation of targets. Sadly, our birthing mothers end up bearing the brunt of this behavior and our best healthcare providers leave the field, physically and mentally sick from being the target of oppressive and violent behavior.

Some of the myths about why targets get bullied include:

• Targets deserve or assist a bully's aggression.
• Targets are weak. In reality, bullies are weak! In our society we associate strength with the Machiavellian behavior of aggression to be the most competitive. Generally, targets are neither political nor interested in workplace politics but are invested in doing good work for others, usually for personal moral reasons.
• Targets are too sensitive, unstable and unhealthy whiners who have a problem with authority.
• Targets are only in it for the money (from a lawsuit, for example).

We need to move past stereotypes, as our society has taught us that weak individuals are worthy of scorn and disregard. Targets have qualities that are part of their personal make-up and history, e.g., midwives and other healthcare workers who have certain ideologies that made them pursue healthcare in the first place. Most of us get into this field out of a desire to promote wellness, to make the world a better place and to alleviate suffering or ignorance in those who are experiencing a major shift in their health, whether for the positive or the negative. So, why are such well-meaning individuals selected to be targets?

Targets are chosen as a result of a combination of circumstances (right person, wrong place) and personality traits. Targets tend to be individuals who bring themselves a lot of attention for being good at what they do or for having a personality that draws admiration. Targets unknowingly beget the ire of bullies who fear that their own inadequacies will be discovered or that attention will be taken away from them. Generally, targeted individuals are very intelligent, determined, creative and industrious. At work, they go the extra mile, learn jobs quickly, come to "big picture" understandings with other professionals rapidly and are trustworthy. Being trustworthy is especially enticing to a bully when choosing a target. Bullies do not know anything about being trustworthy and generally lack a true sense of integrity. Targets, on the other hand, have a very well-developed sense of integrity and honor. Often, targets will refuse to side with others on issues based on personal moral objections or out of a desire to improve an idea or a situation so that "justice" can prevail and so that the playing field is more equal to all involved. Not surprisingly, targets are usually sensitive to world politics that involve justice and goodwill. Targets' ideas are usually incorruptible and they share them easily, with humor, sensitivity and compassion.

Targets also have personal vulnerabilities. Targets usually think highly of outside evaluations of their contributions—such as performance appraisals, management assessments, etc.—yet neglect to give themselves personal credit and do not value themselves highly even when doing stellar work. Targets can't imagine that others would harm them, and they refuse to think badly of others even when faced with evidence that the other person's behavior is harming them. Targets have difficulty resorting to aggression and refuse to address painful situations by violently lashing out or taking legal action. They are forgiving in nature even when a bully obviously is taking advantage of this to further continue harmful behavior toward others or even toward the target who continues to forgive.

Many targets are perfectionists and want their co-workers or management to be perfect, too. Targets say "sorry" quite often even when they are not at fault and tend to feel guilty easily. These women internalize their anger instead of expressing it and can cope for a long time under extreme pressure—at times to the point of illness—before finally coming to terms with the extent of violence being done to them. Sometimes body mechanics, such as certain vulnerable postures (slumping, cowering, etc.), will attract the attention of a bully since they may indicate deeper insecurities and vulnerabilities.

Other vulnerabilities can include:

• being single and not having a support person on a regular basis
• having caring responsibilities at home, e.g., an elderly relative, a disabled partner or a child with special needs
• being unable to change jobs, e.g., limited job opportunities, being a specialist
• belonging to a minority group
• having a different sexual orientation
• having a different cultural background
• having a different religious belief
• suffering an illness or disability, whether work-related or not
• not having the national language as your first language
• being too old or too young(4)

Prior traumas also may make a person more vulnerable. Abuse as a child or similar trauma are deeply imbedded in the psyche, so these targets often have a lot more insecurity and reluctance when dealing with the actions of a bully.

Drs. Ruth and Gary Namie, in their book The Bully at Work, write:

"Targets have unpolitical, and therefore impractical, expectations about how organizations and people should treat each other with integrity. Whistleblowers take seriously the responsibility to see that schools funded to care for special kids not misuse the money. Tobacco industry insiders went public with information that belied the falsehoods the industry wanted the public to believe…. Justice is a principle that causes Targets limitless pain. The entire complaint-response system disappoints the person hoping to see justice done. When bullies are confronted about their misconduct, they lie. This outrages the Target who may have taken great risks to have the bullying surface in public. Targets make difficult clients for attorneys. Though it is the law that does not provide protection, Targets hold attorneys accountable for not being able to do more to achieve justice in their case.(5)"

"Targets have a strong sense of justice, hold others to that higher moral standard and find themselves disappointed in systems they have entered into that profess to have high ethical standards yet, in reality, do not follow what they espouse. This is true of the nurse who enters into a community hospital as a way to help women of color and finds that women of color are the most mistreated; the midwifery student who goes to her first meeting full of desire to help women and only hears gossip about other midwives in the state; and the doctor who sincerely enters the profession to help the elderly and finds that she can't even embrace a dying person out of fear of a lawsuit. These individuals begin to try to find better ways or to change the system. When changes are prevented, they begin using their amazing and seemingly limitless supply of perseverance and humor. This lasts until they get ill or begin to lose hope. Most of these individuals end up exhausted and emotionally depressed by the lack of follow-through in an environment where the potential and desire are there (such as in many hospitals or other health organizations), but the reality is vastly different."

"The foundation clearly has been established for the target to become the object of a bully's aggression: a workplace that supports bullying behavior and the person who has the traits that appeal to a bully's behavior. When does the shift happen and a target is selected?"

A bully usually will begin to resent a target once the target becomes known for having the personality and work traits already noted. However, other strong triggers come into play. If a target's performance draws attention to the bully by "comparison," the bully automatically will react. Any attempts by the target to help the bully or to assure the bully that she is not trying to malign the bully will only make things worse! This puts the bully on the defensive and, being fearful and insecure, she will lash out instead of attempting open and honest communication about these fears. If a person is singled out and noticed when previously the bully had been noticed, the bully will react with immaturity at the loss of attention. This also happens if the target gets affectionate attention from professional peers (gifts, hugs, cards, letters of thanks, respect in meetings, etc.).

Bullying also may start after these events:

• The previous target leaves.
• A reorganization occurs.
• A new manager is appointed.

Or when a target makes herself noticed by:

• refusing to obey an order that violates rules, regulations, procedures, or is illegal
• standing up for a colleague who is being bullied—this ensures that person will be next; sometimes bullies drop their current target and turn their attention to that person immediately
• blowing the whistle on incompetence, malpractice, fraud, illegality, breaches of procedure, breaches of health and safety regulations, etc.
• undertaking trade union duties
• suffering illness or injury, whether work-related or not
• challenging the status quo, especially unwittingly
• gaining recognition for achievements, e.g., wins an award or is publicly recognized
• getting promoted(6)

The foundation is in place and a person with high standards comes into the field with strong ideals and the energy to make changes in the profession and garner the respect and trust of her professional peers. The bully suddenly feels threatened and waits, like all predators, for the ideal moment to strike. When the ideal moment comes—even if the moment is as simple as a small error on the part of the target—the bully will use it to full advantage to begin negative and debasing actions and words against the target, as well as attempting to round up allies against her (preferably people who like and respect the target). The bully chooses the moment and from then on, the target will be faced with a hostile work environment or estranged relationships with professional peers. The bully has been able to create an environment of fear and hostility and most witnesses to this behavior will simply look the other way or excuse the bully's behavior in some way, as is usual in the cycle of violence. Suddenly, this woman's efforts are fraught with negative attention and either one of two things happen:

1. The target will deal with the bully's tactics until her mental or physical health is affected by the bully's aggression, the isolation from her peers and the disappointment of high ideals that will never be able to manifest in her current profession due to the hypocrisy of the profession; or
2. The target will suffer from all of the above but decide to take action. This action may be going to management and fighting for change, whistleblowing, taking legal and legislative action, or any other creative means that the target can find to gain acknowledgement and support.

Not many targets will assert their rights against a bully or leave the workplace. Many people will blame the target, questioning why she does not simply take action and assert herself against the bully. A target may not assert herself because she needs employment to continue caring for loved ones and fears losing her job—especially if the bully is in higher management or in the "circle" of those with more power. By the time she considers action, the target may have been completely humiliated or maligned by the bully(ies) to the point where she has difficulty finding support among peers even when they profess to be sympathetic and in agreement against the bullying behavior. Often peers look the other way out of their own fear and negative addictions to violence. "The target now has artificially high levels of shame, embarrassment, fear and guilt—all stimulated by the bully, for this is how all abusers control their victims."(7)

Other answers to "why don't you stand up for yourself?" include:

• A climate of dysfunction and fear makes people frightened to assert their rights.
• The target feels bewildered and often cannot believe what is happening; the target feels responsible in some way, as evidenced by the nagging thoughts "Why me?" and "Why did I let it happen to me?"
• Bullying is not against the law and the laws that do exist are difficult to apply to bullying.
• By this time the target is suffering a severe psychiatric injury, is traumatized and unable to articulate her circumstances—whilst the bully remains glib and plausible.
• Trauma and fear combine to prevent the target from being able to find the right words to identify, unmask and call to account the bully's behavior.
• The bully relies on compulsive lying, Jekyll and Hyde nature, deception, deviousness, evasiveness and charm, and uses denial, counter-attack, projection and feigning victimhood to evade accountability. Charm has a motive—deception.
• Many people are ignorant of or unenlightened about the nature of bullying.
• Bullies are encouraged and rewarded, often by promotion.
• The target naively believes that the system is there to protect her and will work for her (it isn't and it doesn't).
• The target naively believes that her loyalty and good service record will stand her in good stead (it won't and the employer is likely to ignore and dismiss it).
• Bullying is a betrayal; the target trusted and depended on the integrity of another (e.g., manager) and that person betrayed her; the target fears and anticipates that when she reports the bullying, she will be betrayed again (she often is).
• The target felt and continues to feel guilty about what happened, having been encouraged by the bully to believe she was responsible.
• The target may have been encouraged to withdraw from legal action by the bully feigning victimhood, playing on the target's forgiving chord and manipulating other people's sympathies.(8)

When the target goes to management and her peers and tries to express her situation, she generally will find a lack of support for efforts to have the bully reprimanded or to create a zero-tolerance attitude toward bullying behavior. Although many individuals in the US are making efforts to address the need for better laws to deal with bullies, an intricate part of the mesh of our current society is the belief that aggression and competition lead to better results in profitability. The truth is that bullying costs professions and workplaces a tremendous amount of money—not least because those individuals with the best ideas and work ethics will often leave the field.

Once the bully realizes that the target is going to take action against her, the bully moves into a different objective: elimination of the target. This is done with continued violence against the target as a means to termination or in hopes that the target will "just go away" either voluntarily or as a result of the malicious distortions of the truth by the bully. The fact is, if the target does not leave the profession, organization or workplace, ultimately she will endure the hostility to the detriment of her health and with the debilitating effects of posttraumatic stress disorder (PTSD).

PTSD is a wide and varied normal response to stressful situations that occurs to many individuals all over the world and for different reasons. Although some common events trigger PTSD (such as a violent death of one's child), many times individuals may experience PTSD based on isolated events of significance only to them, based on their life history, geographical location, politics or many other reasons. Targets are known to experience some degree of PTSD, with effects ranging from mild to very traumatic and debilitating, ending in death due to the physiological manifestations of stress, or suicide.

Some scientists now believe that the effects of PTSD may also be caused by a number of smaller incidents, causing what is known as Complex PTSD. Many individuals will have a breakdown (of which there are different types) and suffer severe fatigue from lack of true rest. Simply put: Stress does not allow the body and the mind to rest. Since this article is specific to bullying, it is difficult to encompass more than a general introduction to the effects of PTSD. However, it is crucial that people know that the end result of bullying (whether done to adults or children) is a compromised and traumatized individual.

In brief, people suffering Complex PTSD as a result of bullying report:

• fatigue with symptoms of, or similar to, chronic fatigue syndrome.
• anger, over injustice, that is stimulated to an excessive degree (sometimes, but improperly, leading to the application of the words "manic" instead of motivated, "obsessive" instead of focused, and "angry" instead of "passionate," especially from those with something to fear).
• an overwhelming desire for acknowledgement, understanding, recognition and validation of their experience.
• a simultaneous and paradoxical unwillingness to talk about the bullying or abuse.
• a lack of desire for revenge, but a strong motivation for justice.
• a tendency to oscillate between conciliation (forgiveness) and anger (revenge) with objectivity the main casualty.
• extreme fragility, where formerly the person was of a strong, stable character.
• numbness, both physical (toes, fingertips, and lips) and emotional (inability to feel love and joy).
• clumsiness.
• forgetfulness.
• hyperawareness and an acute sense of time passing, seasons changing and distances traveled.
• an enhanced environmental awareness, often on a planetary scale.
• an appreciation of the need to adopt a healthier diet, possibly reducing or eliminating meat—especially red meat.
• a constant feeling that one has to justify everything one says and does.
• a constant need to prove oneself, even when surrounded by good, positive people.
• an unusually strong sense of vulnerability.
• occasional violent intrusive visualizations.
• feelings of worthlessness, rejection and a sense of being unwanted, unlikable and unlovable.
• a feeling of being small, insignificant, and invisible.
• an overwhelming sense of betrayal, and a consequent inability and unwillingness to trust anyone, even those who are close.
• in contrast to the chronic fatigue, depression, etc, occasional false dawns with sudden bursts of energy accompanied by a feeling of "I'm better!," only to be followed by a full resurgence of symptoms a day or two later.
• an initial reluctance to take action against the bully and report him/her knowing that he/she could lose his/her job.
• that later, reluctance gives way to a strong urge to take action against the bully so that others, especially successors, don't have to suffer a similar fate.
• proneness to identifying with other people's suffering.
• a heightened sense of unworthiness, undeservingness and non-entitlement (some might call this shame).
• a heightened sense of indebtedness and undue obligation.
• an unusually strong desire to educate the employer and help the employer introduce an anti-bullying ethos, usually proportional to the employer's lack of interest in anti-bullying measures.
• a desire to help others, often overwhelming and bordering on obsession, and to be available for others at any time regardless of the cost to oneself.
• an unusually high inclination to feel sorry for other people who are under stress, including those in positions of authority and those who are not fulfilling the duties and obligations of their positions (which may include the bully) but who are continuing to enjoy a salary for remaining in their post.(9)

To be targeted is to suffer intense periods of isolation and illness and, in some cases, to make a decision to speak out against the sociology of our work culture. For survivors, it also means breaking away from the guilt of what has been unjustly done and moving on to a place of strength, self-respect and self-love. We have a long way to go toward better policies, affordable and local opportunities for healing our traumas and supportive environments for individuals who want to end abusive behavior in the workplace. However, I hope that individuals will begin an open discussion on how bullying has affected them and begin to envision better ways to end violence in local communities in ways that can lead to world applications.

"Targets driven by a strong sense of equity, justice and integrity do make life challenging for those who wish they would simply disappear. Maybe they make us uncomfortable because they remind us of how we should all be, of what we should aspire to become. It is that guilt that allows witnesses to the bullying to abandon the principled, passionate and driven Target. God bless 'em. They are the salt of the earth….

"Integrity is a very personal decision. Organizations get involved when someone in power wants to silence the one with integrity. The bullying starts small between two people. The entire organization enlists its goon squad when the morally superior whistleblower refuses to back down. Character assassination begins; the Target loses her job, family, friends and her health. Was the Target's decision 'worth it?' Whistleblowers would tell you they'd do it all again given a chance. Truth compels them."(10)

Marinah Valenzuela Farrell, LM, CPM, is a midwife with Sage Midwifery in Phoenix, Arizona.

References:

1. James, D. 1999. Deep Impact: Medical education can be cruel. New Physician 48(2): 16–25.
2. Lee, F.S. 1994. Membership Has Its Costs. JAMA 271(13):1048–49.
3. Van Ineveld, C.H.M., et al. 1996. Discrimination and Abuse in Internal Medicine Residency. J Gen Intern Med 11(7):401–05.
4. www.bullyonline.org/workbully/vulnerab.htm. Accessed 25 Feb 2007.
5. Excerpted from The Bully At Work, © 2003 by Gary and Ruth Namie, taken from www.bullyinginstitute.org/bbstudies/targets.html.
6. www.bullyonline.org/workbully/bully.htm.
7. www.bullyonline.org/workbully/standup.htm.
8. Ibid.
9. www.bullyonline.org/stress/ptsd.htm.
10. See Note 5 above.

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