What is ‘real trauma’?
Reflections on a current controversy within Psychiatry and Psychoanalysis[1]
Frederik van Gelder
Ladies and Gentlemen,
Allow me, if I may, in addressing an audience of psychoanalysts, psychiatrists and psychologists here in the Netherlands, and most especially at this venue, to start with a personal note. If I try to put into words what I feel in standing here before you, I find that I am moved – and this will not come as a surprise to an audience trained in the mechanisms of psychodynamic processes – by conflicting emotions. Awe is mixed with respect, gratitude with a feeling of home-coming, trepidation with a sense of being among friends and colleagues.
Awe and respect because I find myself in the company of specialists whose profession it is to grapple with that fearful desolation of the soul which strikes so many survivors of persecution; gratitude that you are prepared to listen to someone who has no practical experience in your own field of endeavour; home-coming, because this Dutch Jew proud of his proficiency in this, the English language, makes no bones about his terrible hankering after the sounds of his childhood, and that means: Nederlands. Home-coming also because institutions such as yours are, despite everything, an expression of hope: a tangible expression of solidarity with the victims of persecution, a lived determination not to abandon them to their fate. Trepidation and a sense of belonging because, the more I examine my own motives for wanting to be here, the more I realize that you – the work done at the Centrum 45 and similar institutions in this country – symbolises something for me which I’ve never known – a sense of home, an emotional reference point, a ‘significant other’.
But to turn now to the topic of this lecture. A few preliminary comments are perhaps in order, to explain the background to what you are about to hear. The problem I have is one which is, I think, familiar to most of us: the literature on trauma is large, it is confusing, it is approached from so many different angles (and from so many different disciplines) that it is not at all certain that it is meaningful to to try to say something about it in its entirety. One author speaks – with the multiplicity of views, therapies and theoretical approaches in mind – of a “crazy centipede”[2], and I think we know how he feels. In the face of this I adopt, in accordance with my own professional training, a typically philosophical procedure: that is, I take a complex literature and classify it, as a first step, on the basis of the implicit pressuppositions which are made, and then I try to say something about the conceptions of truth (and reality) which these presuppositions imply.
That all of this tentative, that it is ‘work in progress’, I need not emphasise.
The large literature on trauma of recent years, it seems to me, revolves around one central issue: can the objections raised against the DSM approach be met by a change of definition, or is there something misleading – even retrogressive – about the whole DSM approach as such?
Perhaps another way of formulating the same thing: are the traumas associated with the Second World War (in the various victim populations and their subgroups) so fundamentally different from everything which went before, that the therapist/patient model itself has become questionable?
If one sorts the literature according to the first question (is the DSM approach adequate?) the line of division becomes that between Psychiatry and Psychoanalysis. If one sorts according to the second question (Do we live in a ‘post-Holocaust’ world in which all traditional categories have become problematic?) the line of division becomes one between therapists on the one hand (i.e. those concerned with individual clients) and social theorists on the other; the debate is, at any rate, then pushed into a realm far removed from that of the consulting room and the clinic.
This leaves one with four positions which I would like to discuss, briefly, concentrating on the methodological presuppositions inherent in each of them.
1) Twenty years of DSM
To illustrate this position I choose a paper presented at the Amsterdam/Utrecht Trauma congress in May this year by Bessel van der Kolk and his associates, entitled “Dissociation, Somaticization, and Affect Dysregulation: The complexity of Adaptation to Trauma”. This is a report of the DSM-IV PTSD field trials, and the conclusions it reaches (based on extensive trails on a representative clinical population) is that dissociation, somaticisation and affect dysregulation are central to trauma and PTSD. (Both as individual conditions which can be tested by the appropriate scales, as well as the way in which they interact statistically). There seems little doubt that diagnostic criteria for PTSD spelled out in future editions of the DSM (as well as the ICD) will revolve around measurements of these three variables.
This would reflect, according to the author:
“the growing understanding that the experience of prolonged and/or severe trauma, particularly trauma that occurs early in the life cycle, can lead to complex characterological adaptations, as well as disturbed regulation of affective arousal, an impaired capacity for cognitive integration of experience (as in dissociation), and impairment in the capacity to differentiate relevant from irrelevant information, such as occurs in the misinterpretation of somatic sensations.” (p. 84.) ...
With the renewed interest in the role of overwhelming experiences in the origins of psychopathology, modern psychiatry is rediscovering the intimate relations among trauma, dissociation, somatization, and a host of psychological problems that can most easily be categorized as disturbances of affect regulation: unmodulated anger and sexual involvement, self-destructive behaviors, and chronic suicidality." (p. 85)
I do not want to go into the details of these trails, or the way in which the DSM definition of trauma has been modified in the different editions, but confine my remarks to some general reflections on methods.
The methodological presuppositions here can be called ‘empiricist’ or ‘Cartesian’, since the underlying epistemology is that of classical materialism as this was adopted by the medical profession in the nineteenth century: the world consists of things and processes related to one another in complex causal chains, and it is our task, as researchers and clinicians, to bring these to light in order to manipulate them to our (or our patient’s) advantage. The authors are not unaware of the disadvantages which such a return to pre-Freudian categories entail, but they regard these as inevitable:
“With the creation of the DSM-III system of diagnostic classification, PTSD was introduced as a new diagnosis. Simultaneously, hysteria disappeared from psychiatric nomenclature and was deliberately ‘split asunder’ into multiple different diagnoses: somatoform disorders, factitious disorders, dissociative disorders, and histrionic and borderline personality disorders.” (ibid.)
Or, in another passage:
“DSM-III, in an attempt to be atheoretical, has almost entirely abandoned the psychodynamic understanding of psychiatric phenomena that had dominated psychiatric thought for several decades. In the process they have .. discarded the empirical psychodynamic observations that had been accumalated over the course of a hundred years in favor of a purely descriptive, phenomenological sorting and classification of the symptoms of psychiatric illness.” (Nemiah quote, p. 90.)
That is, the approach here is to regard terms such as dissociation, somatization, affect dysregulation as entities which can be analysed, described, measured and treated in their own right, as if they were objects in the external world, as opposed to modes of ego-integration to which we can have access only via interpretive understanding.
The notion of ‘real trauma’ is, from the point of view of the DSM, a non-issue, since in the natural science approach – and that is what is meant by “in an attempt to be atheoretical” – there is an absolute break between the knowing subject (the observing psychiatrist) and what it is that is being described and observed. ‘Real’ is, from this perspective, that which is captured by the statistical methods and the standardised scales used, whereas the theoretical concepts come from the various biological sciences: from neurobiology, genetics, cognitive neuroscience, Neo-Darwinian conceptions of species-wide adaptive processes.
2. DSM is not OK.
The existence of unconscious mental processes, the recognition of resistance and repression, the importance of sexuality and object relations in the understanding of behaviours and utterances which would otherwise be unintelligible, the analysis of transference and countertransference reactions: these terms describe, as before, an understanding of mental processes and their development which is not easily reconcileable with the methods and procedures of the biological sciences, and which is not easily reconcileable with the DSM. In other words: even before we come to discuss the question of extreme trauma associated with the Second World War, there is already a very deepseated difference in approach and assumptions between psychiatry and psychoanalysis which predates this debate.
A Neurosis is not an organic disease which can be treated; it is a text to be interpreted and understood rather than a causal process to be explained and experimentally replicated. Between myself and my client there is an intersubjectivity of meaning (transference, countertransference) which in its asymmetrical aspects resembles that of parent and child, teacher and pupil; successful therapies are successful (re)socialisation processes which for one reason or other have been interrupted.
If one were to summarise the difference between the ‘natural science’ approach of organic medicine on the one hand (what I have called here the DSM approach) and Psychoanalysis on the other, then perhaps by means of a short description of a lecture by Jean-Martin Charcot:
“Though Charcot paid minute attention to the symptoms of his hysterical patients, he had no interest whatsoever in their inner lives. He viewed their emotions as symptoms to be cataloged. He described their speech as ‘vocalization.’ His stance regarding his patients is apparent in a verbatim account of one of his Tuesday Lectures, where a young woman in hypnotic trance was being used to demonstrate a convulsive hysterical attack:
CHARCOT: Let us press again on the hysterogenic point. (A male intern touches the patient in the ovarian region.) Here we go again. Occasionally subjects even bite their tongues, but this would be rare. Look at the arched back, which is so well described in textbooks.
PATIENT: Mother, I am frightened.
CHARCOT: Note the emotional outburst. If we let things go unabated we will soon return to the epileptoid behavior ... (The Patient cries again: ‘Oh! Mother’)
CHARCOT: Again, note these screams. You could say it is a lot of noise over nothing.”[3]
Perhaps, looking back now on the hundred years since Freud and Breuer’s Studien über Hysterie, one could say now that the history of psychoanalysis is the history of the interpretation of this one sentence: “Mother, I am frightened”.
The different phases in the psychoanalytic conception of trauma are too complex to deal with here – Martin Bergmann distinguishes five such phases[4] – but one aspect is clear: what distinguishes Psychoanalysis from the biological sciences is that it operates with at least a dual understanding of reality: that of the client and that of the clinician.
“Real” is the state of ego-integration which at the start of psychoanalytic treatment only the analyst has in mind; the latter knows that it is possible to integrate fragmented, somaticized symptoms of past trauma into a coherent ‘narrative’, a ‘story’, which the client will discover, peau à peau in the course of analysis – if all goes well.
“Real” is also the increase in autonomy which the client experiences when one day the flashbacks, the repressed memories of unbearable fear no longer causes attacks of disintegrating panic – and the associated archaic defense mechanisms – but can be ‘faced squarely’ and ‘consciously’ as events which can be mourned about.
To summarise this first section: the difference in approach between the biological and natural sciences on the one hand, psychoanalysis and the humanities on the other – which is large enough for philosophers to speak of “two cultures”[5] – is as real now, since the DSM, as it was before the war, and it is not helpful to pretend that this is not the case.
Not only is there no ‘unified theory’ in sight, but the belief that this is possible could be regarded as one of those self-immunising strategies employed by the empiricist to avoid contact with the hermeneutic disciplines.
***
To come now to the second of the questions I wanted to deal with in this paper:
Are the traumas associated with the Second World War so fundamentally different from everything which went before, that they demand of us a radical departure from the psychiatric and psychoanalytic thinking and praxis which existed before the war?
For Hans Keilson it is an open question “whether it is permissible to apply a theory like that of Psychoanalysis, which had been developed in times of peace, to situations of developmental disturbance caused by man-made disaster.”[6]
De Levita expresses something which is widely felt by many, especially European psychoanalysts and psychiatrists:
“Alle bekende regels van trauma en traumatisiering hebben hun geldigheid verloren. Wij weten uit onderzoek, dat trauma gevolgen heeft voor degenen, die het zelf hebben ondervonden en veel minder voor degenen, die er getuigen van waren. Voor Auschwitz geldt dat niet. Het heeft gevolgen gehad voor degenen die er waren maar ook voor degenen, die er niet waren. Voor het hele joodse volk, voor het hele Duitse volk, voor alle volken. Deze eeuw zal voor altijd zijn met een woord van de Duitse schrijver Zygmunt Baumann ‘de eeuw van de kampe’. Auschwitz is een soort ‘contra-openbaring’. Sindsdien weet de wereld, dat men alles ongestraft kan doen.
In het leven van de enkeling kan Auschwitz als onindenkbare en onverklaarbare realiteit daardoor ook niet anders zijn dan onverwerkbaar. Bij verwerking van een trauma ontwerpt de betrokkene steeds een theorie, waarin het hoe en het waarom van het trauma worden verklaard. Bij de Sjo’ah is zo een verklaring er niet, en hebben de overlevenden geen enkele steun van een verklaring tegenover de toch al onverteerbaar sterke emoties. Het is bijna onmogelijk, een dergelijke hoeveelheid emotie alleen te verwerken.”[7]
Similar views by Chaim Dasberg, Eddy de Wind, Elie Cohen, Jacques & Louis Tas, van Dantzig.
Or as Martin Bergmann put it:
“Studien über den Holocaust zwangen die Psychoanalyse, das Wesen des Traumas mit neuen Augen zu sehen. Eine der Fragen, die noch auf Antwort warten, ist, ob der Holocaust eine völlige Revision der psychoanalytischen Trauma-Konzeption erforderlich macht oder ob er einen qualitativ anderen Typus der traumatischen Neurose hervorgebracht hat. Krystal und andere Forscher auf diesem Gebiet haben die Ansicht vertreten, daß alle Traumen, gleichgültig welchen Ursprungs, für die Opfer denselben psychischen Effekt haben. Andere, und dazu gehöre auch ich, neigen eher zur Ansicht, daß es trotz grundsätzlicher Ähnlichkeiten einen Unterschied macht, ob ein Trauma durch einen Wirbelsturm oder einen Autounfall verursacht wurde oder ob es auf den Sadismus anderer Menschen – oder gar auf einen staatlich organisierten und sanktionierten Sadismus – zurückzuführen ist.”[8]
One aspect which is new is perhaps this: Mourning, existential demoralisation, the confrontation with death.
Allow me to illustrate this with two quotes which I brought back from the 1993 Hamburg Congress “Children – War and Persecution”:
“The survivor reminds the psychically ‘healthy’ (including the psychoanalyst) of his/her mortality, of the precariousness of all human existence, of the ignominity and barbarity with which ontold millions of innocents have met their death within the last sixty years. This reminder is intolerable, its suppression is a central function of all that which passes for contemporary culture, its presence is universal to a society which calls itself post-modern. Hence the victim is ‘sequentially’ traumatised (in a sense different from the one used by Hans Keilson), is once again ostracised and rejected: this time round not in the name of the racist madness of the Nazis, but in that of the sonorous terminology of official psychiatry. Upon the heads of those who have gone through a hell beyond the imagination of a Dante or a Breughel is heaped the final indignity: instead of the understanding and support which they crave above all else – for the lack of which they commit suicide with unfailing regularity – they are given to understand, with the full authority of modern scientific medicine to back it up, that they are not quite right in the head. The very witnesses of the pathology of modern society, whose testimony could shake us out of a once again dangerous complacency about the state of the world in which we find ourselves, are stigmatised as neurotic, are treated as a new field of research for the psychiatric PTSD specialists, (ie. as objects), rather than as as a group of people who have something of great importance to say to us all.”
(We, the ANGs, the Luftmenschen)
“What makes the difference is this: the feeling of being understood, ‘contained’. (Bion!) For our kind that means: crawling into a hideout, a hole, with another victim, crying outselves to sleep in each other’s arms. That is what makes our kind travel long distances to speak to people we’ve never met before. We go to these lengths to find others who share this feeling of desperation because we know that they too are chained for life to the same endless nightmares of mass graves and burnt corpses. We are tied together by the same emotional scar-tissue. It distorts, taints everything we do, touch, or say. In Poland – in Warsaw for instance – one has the feeling that one is literally walking on the skeletons of the dead. When one universalises this attitude one knows how we survivors see the world. The world-view of the ANGs jars mightily on that of a postwar generation for whom all this is little more than ancient history: that is the root of the problems we have with those who think of themselves as ‘normal’, whose psychic and intellectual development have allowed them to follow the conventional trajectory of family, career, material security and an old-age pension. The ANGs have their hands full just battling the nightmares, the anomie, the feeling of being in this world but not of it. We have no energy left to compete with the healthy monads around us, we stand at the roadside of life, watching the well-fed moffen in the large limosines race by. Wondering whether to put an end to it all right now, or whether to wait until tomorrow.”
The reactions from Psychoanalysts to this kind of “existential demoralisation” seem to be two-fold. At the practical level: to concentrate increasingly on mourning, on supportive strategies, on a form of recognition-giving in which the neutral stance of the clinician is replaced by that of the ‘lotgenoten’, the fellow-sufferer, the listener in a collective process of bearing witness to an incomprehensible past. At the theoretical level: a shift away from the idea that psychiatrically relevant symptoms are the result of an inner conflict between ego and id forces, to the idea that there was a real trauma whose (objective) recognition must be part of the therapeutic process. In psychoanalytic terms: a movement away from Object Relations and Traumdeutung to the original notion that neurotic symptoms are causally related to a real (sexual or other) trauma which has left only fragmented and dissociated traces in the consciousness of the client. Back to Freud and Breuer’s Studien über Hysterie, and away from childhood sexuality and inner conflicts.
A real trauma however, which is not an event in the concrete biography of this particular client, but a collectively shared historical event: ‘the Holocaust’, ‘combat neuroses’ – or even: ‘patriarchy’.
One gets the impression that many psychoanalysts and psychiatrists dealing with trauma victims feel a considerable tension between the theoretical and institutional framework of the medical profession and the moral/political realities they have to face when they listen to their clients – not for nothing the spate of publications on ‘vicarious traumatisation’.
Whether it is Keilson, or de Wind, Niederland or Eissler, De Levita or van Dantzig, Dori Laub or Grubrich-Simitis, Kogan or Dasberg, one feels that each one of them, even those whose professional training had little to do with psychoanalysis, that there is a productive tension between the cause-effect thinking of organic medicine on the one hand, and a mostly intuitive conviction that what trauma ‘is all about’ cannot be expressed within this terminology. Hence the plethora of titles which express paradoxes and antinomies: ‘over het zwijgen gesproken’, ‘confrontatie met de dood’, ‘spiritual murder’, ‘chronic existential depression’, ‘leven in een niet-bestaan’.
Perhaps one could define (psycho)trauma as a condition on the reality and seriousness of which the psychiatric profession since the war has left no doubt whatsoever – the defining characteristic is however that it cannot be defined in terms of the nosiology of organic medicine.
How do we deal with this paradox? One way is to make explicit what I have called the epistemological presuppositions.
Real, for the therapeutic paradigm, is some conception of psychodynamic processes – or, at the very least, of a conception of cause and effect with respect to the mental functions of an individual patient, client, or ego. This conception may vary all the way from the empiricism of the PTSD approach (which confines itself to a description of symptoms and the elaboration of scales and questionaires) to the hermeneuticism of the psychoanalytic approach in which there is a deliberate and controlled fusion of mental horizons between the therapist and client, but what they have in common are two assumptions:
a) a shared conception of an instrumental/therapeutic intervention with regard to this individual patient or client, (‘methodological individualism’) and
b) the assumption that a growth of knowledge with regard to the causes and treatment of trauma is not going to change the self-conception of the community of therapists/psychoanalysts/psychiatrists in any fundamental way, let alone the wider society. (‘Nominalism’)[9] (Put irreverently: this is the “the-world-is-basically-ok,-it’s-just-that-you-are-sick” school of thought.)
Real for the recognition paradigm, on the other hand, is a historical event: de oorlog, the war, le guerre, der Krieg. When we say that the events of 1933-1945 (or 1940-1945, 1914-1945) have shaped our lives, our institutions, the history of Europe, our emotional reactions, our political landscapes, our fears and hopes, our rights and obligations within contemporary society, our conceptions of international relations, these collective pronouns (we, our, us) signify a moral-ethical, practical-political, collective-historical dimension which they do not have when used from within the therapy paradigm.
Within the recognition paradigm this ‘we’ is all-inclusive, does not presuppose a hierarchy between therapist and client, is not one step in the elaboration and application of knowledge with regard to this one patient. It is a ‘we’ that has historical dimensions, and it can be expressed, I think, in two words which every European of my generation and older – not to mention the Jewish community – understands in an almost visceral way: de oorlog, the war, le guerre, der Krieg. It is what shaped the lives of my generation and the one which went before, it is the fixed point in the history of the century now drawing to a close, and it is the reality which brings us together this afternoon. Or to use an older terminology to describe this, a term from philosophy: the war was constitutive for everything which came after, shaping both the objective institutions which surround us as well as the subjective meaning-horizons of those who live within them.
Now, where does all this leave us? The widespread acceptance of trauma and PTSD as diagnostic categories has led to the paradoxical result that the theoretical insights of the discipline which first probed these phenomena – Psychoanalysis – are being forgotten. The most important insight of all: the ‘single-reality’ view of the empirical sciences is not adequate to an understanding of emotional states, and that means: the human psyche.
The debate about ‘real’ trauma is a reminder of this. But what is ‘real’ trauma? It’s one of those questions which does not admit of a definite answer. Whoever works in this field has to live with an ambivalence, has to put up with something which in Hegelian logic is called an ‘objective contradiction’. The therapeutic paradigm says: treatment is not possible without clearcut criteria of ill health, of nosiology, prognosis, diagnosis, and implicitly: an acting subject, namely that of the therapist. The recognition paradigm says: we are all part of a wider totality, of a group, a society, a historical epoch, in which the basic category is not the individual ‘I’ but a ‘we’, however one defines this.[10]
But, as I understand it, the history of the Centrum 45 shows that this dual mandate is not an impossibility, that it can be carried out, and it can be done sucessfully.
I thank you for your attention.
Notes:
[1] unpublished paper: Centrum ’45, Oegsgeest, Netherlands, February 1999.
[2] Pier Francesco Galli 1987: “Psychoanalyse: Der verrückt gewordene Tausendfüßler” in: PSZ (ed.) Between the Devil and the Deep Blue Sea (op.cit.)
[3] Judith Herman: Trauma and Recovery, p. 11.
[4] Martin Bergmann: “Fünf Stadien in der Entwicklung der psychoanalytischen Trauma-Konzeption” Mittelweg XXXXXXXXXXXX
[5] C.P. Snow: ref.
[6] Psyche 49, 1995, nr.XXXXXXXx
[7] “Redevoering van prof. De Levita tijdens de herdenkingsreünie” in: Auschwitz Bulletin vol. 42, nr. 2, p. 7.
[8] Martin Bergmann: “Fünf Stadien in der Entwicklung der psychoanalytischen Trauma-Konzeption”, p. 19.
[9] Not that, from within the empiricism of mainstream biology on the one hand, the hermeneuticism of Psychoanalysis on the other there is not a literature which ‘historicises’ – Freud’s Kulturkritik, Neo-Darwinism’s ideas on the adaptive functions of emotional processes, including traumatic reactions, but these ideas have remained inconsequential for therapy.
[10] Norbert Elias: ‘Wir-Schicht’