Wounded By Reality

Understanding and Treating Adult Onset Trauma

Ghislaine Boulanger

• Publisher: Routledge
• Year: 2011
• ISBN:
  9781136873041
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

The culmination of three decades of studying and treating survivors of adult onset trauma, Wounded by Reality is the first systematic attempt to differentiate adult onset trauma from childhood trauma, with which it is frequently confused.

When catastrophic events overtake adult lives, they often scar the psyche in ways that psychodynamically oriented clinicians struggle to understand. For Ghislaine Boulanger, the enormous challenge of working with these patients is unsurprising. Survivors of major catastrophe, whether a natural disaster, a life-threatening assault, a serious accident, or an act of terrorism, experience a near-fatal disruption of fundamental aspects of self experience. The sense of agency, of affectivity, of bodily integrity, the capacity for self-reflection, the sense of time, and the ability to relate to others - all are called into question.

1

Toward A Psychodynamic Understanding of Adult Onset Trauma

There’s no initiation either into such mysteries. He has to live in the midst of the incomprehensible, which is also detestable. And it has a fascination, too, that goes to work upon him. The fascination of the abomination—you know, imagine the growing regrets, the longing to escape, the powerless disgust, the surrender, the hate.

— Joseph Conrad (1902, p.7)

Recently, I was teaching a course on trauma and psychoanalysis to advanced candidates at an analytic institute. I asked the candidates if they could offer examples from their own practices to illustrate cases of adults who had been traumatized in childhood and cases of adults who had been traumatized as adults. Each of them readily volunteered examples of adult patients who had suffered physical, sexual, or emotional abuse as children. Much of the time, the abuse in question was cumulative and consistent. There were also examples of sudden and horrifying violations of the trust between a caretaker and child. Others offered cases of striking emotional neglect, rather than active abuse. These are the painful and familiar narratives that we construct with patients daily, if not hourly, in the course of our professional lives. But, when I asked about examples of catastrophic stress in adulthood, there was silence. No one even asked me what I meant.

My peculiar expertise lies in the extremes of human experience, what Conrad (1902) calls “those ironic necessities that lurk in the facts of human existence” (p. 91). Although this is not where most of us locate our practices, I believe it is important for psychoanalysts and psychodynamically-trained therapists to become conversant with the chronic disorders to which massive psychic trauma can give rise, for too often they have been misunderstood. These disorders do indeed “lurk,” often well beneath the surface; they are not always easy to detect. By suggesting clinicians become conversant with them, I do not mean giving a cursory glance at or even memorizing the list of symptoms of Posttraumatic Stress Disorder (PTSD) in the Diagnostic and Statistical Manual (American Psychiatric Association 1980, 1987, 1994), but developing an understanding of how these symptoms arise and the far-reaching consequences for the survivor’s psyche. As Terrence Des Pres (1976) repeatedly makes clear in his work on the Holocaust, the phenomenology of adult onset trauma has been almost impossible to address in psychoanalytic terms. In this book, I intend to provide a way of thinking psychodynamically about that phenomenology.

By and large, psychoanalysis resides most comfortably in the quotidian. Reaching back to the past to search for and understand patterns that disrupt the steady flow of life in the present day, the small and not so small terrors of childhood, the errors of omission and commission carried out by those who should have known better and often wished they had known better, but did not. In the United States, until very recently, psychoanalysts have rarely found themselves coming up against the aftereffects of violence in adult life. Our training has not prepared us to address encounters with earth-shattering external events. The changes wrought by adult onset trauma have occupied a contested space in psychoanalytic theory, if they can be said to have occupied any space at all. All too often the psychoanalytic clinician will avert her gaze from these reactions, conflating them with childhood trauma, or attributing them to prior pathology or psychic conflict.

As I started to speak about the apparently very rare phenomenon of adult onset trauma to my class, one after another of the candidates looked quite shocked and hands tentatively were raised. At least half of the members of the class had such cases in their current practices. Most, if not all of them, recognized that they had treated such patients at one time or another. A couple of cases were shockingly violent: a man who had been held hostage and tortured for several days; a woman who had made a daring and very frightening escape from a life threatening situation, not knowing from one second to the next whether she would actually find her way to safety or die trying. Other candidates suddenly recalled that, earlier in their training, they had spent months working in rape crisis centers or in the Veterans Administration with combat veterans. How was it that these dramatic stories had not immediately come to mind when I asked about cases of adult onset trauma? The candidates offered several explanations. One talented clinician remembered feeling so badly about the way his work had gone that he had simply pushed it out of his mind. Another suggested that she didn’t know how to think about these horrors in psychoanalytic terms.

I shouldn’t have been surprised by this encounter, but I was. It was this kind of experience that led me to ask myself whether the treatment of adult onset trauma belongs in psychoanalysis, or, more accurately, whether psychoanalysts can effectively treat those who have suffered massive psychic trauma in adulthood. My answer is no … and yes. We have the tools but not the theory, a fact born out by one psychoanalyst who commented shortly after the destruction of the World Trade Center that his own psychoanalytic treatment was immensely helpful to him as he worked with survivors, but his analytic thinking was not much help at all (Meyerson, 2001). Cohen (1985), in a volume on treating Holocaust survivors, wrote, “We are dealing with a psychotic experience anchored in reality events, one therefore that psychoanalytic theory may not be equipped to address” (p. 166).

The third candidate in my class volunteered that she and her patient had spent a lot of time speaking about the patient’s terrifying experience that had initially led her to seek therapy; it was now part of the background of an ongoing treatment. It had not been dismissed, overlooked, or explained away; its aftermath continued to reverberate through the patient’s sense of self, the feeling that she was in some deep and unwelcome way permanently changed by her experience. Nonetheless, with considerable courage on the part of the patient and skill on the part of the analyst, this recognition was becoming integrated into her life and into the treatment.

The adult survivor of a catastrophe—be it an airplane crash, a life threatening assault, an act of terrorism, torture, war or genocide, natural disasters, or an illness presumed to be fatal—frequently finds nonanalytic therapists and self-help groups more open to the psychological consequences of his or her experience. Psychoanalysts, for the most part, maintain an uncomfortable silence on the topic or attempt to understand the reactions in terms of developmental arrests, childhood trauma or conflict. This book considers the uneasy relationship that has existed between psychoanalysis and catastrophic trauma. It is uneasy because psychoanalytic epistemology has traditionally provided few ways of understanding the plight of an adult who has survived a life threatening trauma; it is uneasy because this theoretical shortfall has left some clinicians feeling dissatisfied with their treatment of these patients and often led patients to dismiss their analysts as out of touch; and it is uneasy because those who have worked effectively with survivors often find their own peace of mind has been seriously disrupted by the painful realities they have to entertain.

It is as if psychoanalytic theory itself has denied or dissociated the possibility of lasting reactions to late onset trauma, just as childhood seduction was also denied for much of the last century. This stepchild to psychoanalysis is properly located in Lacan’s register of the Real. Events that constantly fail to secure a place in social discourse—slipping out of conscious awareness and defying memory’s attempts to register them, leaving instead a gap where understanding might be, or a sense of confusion where clarity might be—belong to the Real. The Real is at work in every act of destructive violence that is rapidly normalized, every instance of genocide that is overlooked, every war whose combatants find no socially acceptable avenue in which to describe their experiences and so are condemned to silence.

Despite the uneasy relationship that has existed between psychoanalysis and adult onset trauma, I hold that among mental health professionals, psychoanalysts should be uniquely situated to work with massive trauma. “A brute appeal to reality can never be the explanatory end of the line,” writes Lear and (2000, p. xiv). Indeed, there is always a relationship between the survivor’s psychodynamics, the psychological impact of the traumatic event itself, the psychological consequences and meaning that event assumes, and current symptoms. To overlook any of these variables and their interaction with one another is to fail the patient. The trauma must be contextualized; if it is given short shrift, as has been the case too often in psychoanalysis, the patient feels misunderstood and blamed, her ordeal minimized. On the other hand, if the trauma is emphasized but its psychic consequences are not considered and understood in and of themselves, which is too often the case in trauma therapy or grief counseling when the patient is given some formulaic explanation for her catastrophically altered perceptions and feeling states, the patient continues to be overwhelmed by aspects of internal experience that have not been articulated and that therefore remain inchoate and incomprehensible. Without words and concepts to capture the inner experience, the patient continues to be silent about subjective aspects of the ordeal, and silenced by the ordeal, fearful and confused. The sense of being alone and isolated—a consequence of the trauma and the legacy of her encounter with the Real—is confirmed rather than repaired by the treatment. Davoine Gaudillière (2004) emphasize the further dangers of not recognizing and treating adult onset trauma when it is first manifest. The cases they describe trace the passage of catastrophic trauma through the psyches of several generations until it emerges in treatment. Perhaps it is not surprising that these authors are French; they work in a country that has been subjected to wave after wave of hostile occupations and wars affecting civilians as well as soldiers, giving Davoine and Gaudillière all too many opportunities to analyze previously unrecognized wartime trauma as it precipitates out during the treatment of a daughter or grandson.

My purpose in the first half of this book is threefold. First, to make a distinction between childhood and adult onset trauma. Second, to consider why, as Meyerson (2001) previously quoted put it, our analytic thinking is no help at all in this area. And finally, to offer a way of conceptualizing adult onset trauma in psychoanalytic terms that facilitates questions, a way of framing the experience that helps patients feel sufficiently understood so that they are prepared to begin the often terrifying work of coming to terms with the meaning of this catastrophic event that has, in fact, taken meaning out of their lives.

Before turning to psychoanalysis itself, however, it is worth taking a brief detour into psychiatry to see how diagnostic practices have changed in relation to massive psychic trauma. In the late 1970s, an unlikely alliance of Holocaust survivors, Vietnam veterans, and women’s movement activists (see Boulanger, 1990; Archibald and Long Herman, 1992) lobbied for the inclusion of the diagnosis of Posttraumatic Stress Disorder in DSM III (APA, 1980). An earlier diagnosis of Gross Stress Reaction had been introduced in DSM I (APA, 1952), where it was noted that this reaction “differs from neuroses or psy-choses chiefly with respect to clinical history, reversibility of reactions, and its transient character. If the reaction persists,” the editors warned, “this term is to be regarded as a temporary diagnosis to be used only until a more definite diagnosis is established” (p. 40). This point of view clearly reflects Freud’s (1920) claim, made after World War I, that “most of the neurotic diseases which had been brought about by the war disappeared on the cessation of war conditions.” In 1968, with publication of DSM II, the diagnosis of Gross Stress Reaction was subsumed under the category of Transient Situational Disturbances. The editors reiterated that “if the symptoms persist after the stress is removed, the diagnosis of another mental disorder is indicated” (p. 49). Although DSM I and II note that individuals “without apparent underlying mental disorders” (1968, p. 49) could develop acute reactions to overwhelming environmental stress, the emphasis is on the fleeting quality of these disorders. It is an interesting footnote to history that in 1968, the year that DSM II was published, (1968), among others, confirmed the persistence of stress reactions among combat veterans twenty years after the conclusion of World War II. Subsequent studies with World War II veterans and surveys of combat veterans from Vietnam have found posttraumatic reactions lasting up to thirty years after their return from the war.

The question of whether predisposition plays a role in posttraumatic stress reactions has been the subject of considerable speculation, and different editions of the Diagnostic and Statistical Manuals have taken different positions. Epidemiological studies (Grinker and Spiegel, 1945; Kadushin et al., 1981; Card, 1983; Boulanger, 1986; and Bromet, Sonnega, and Kessler, 1998, among others) and clinical experience (Krystal, 1968; Kardiner, 1969) suggest that, regardless of character type and prior psychopathology, a specific set of symptoms arises in many adults in response to life-threatening trauma, that the likelihood of a psychological reaction increases in proportion to the intensity and duration of the trauma, and that the reactions can last indefinitely. These conclusions are at variance with the psychoanalytic and diagnostic mainstream.

The criteria necessary for the diagnosis of Posttraumatic Stress Disorder listed in DSM III, IIIR, and IV (APA, 1980, 1987, 1994) do not do justice to the pervasive nature of this disorder.¹ The symptoms include recurrent, unbidden thoughts; intrusive visual, and occasionally auditory, memories and dreams about the trauma. Sometimes a memory is so vivid that it temporarily blots out present reality, causing the survivor to behave as though she were reliving the trauma. Although the often catastrophic content of these memories and thoughts are experienced as uncontrollable, it is not unusual for those who experience them to remain silent about their obsession for fear of being condemned as crazy, or, by talking about them, increase their intensity. To the survivor, these memories are frequently more real than the present moment; consequently, she feels out of touch with the world, as if the daily concerns of other people have little meaning in the face of the momentous and very private experiences she is constantly reliving.

In an attempt to restore balance to the psychic economy, events that might trigger memories of the trauma, such as movies, particular locations, or groups of people who have had similar experiences, are often avoided by survivors. The survivor is not always aware of this avoidant behavior; it is locked out of consciousness, along with the significance of the trauma.

Despite the considerable media attention given to this topic in recent years, and its increased visibility since the 2001 terrorist attacks in the United States, it is not uncommon to hear survivors deny that the disaster they survived had or should have had any impact on their lives. The overall effect of these symptoms is a determined disregard for what was the most shattering event in the survivor’s life. Paradoxically, in her attempt to belong and to forget, the survivor becomes increasingly disenfranchised.

One of the most difficult aspects of detecting the symptoms of massive psychic trauma is that they are not immediately observable and they are rarely volunteered. Many patients fail to mention intrusive imagery, fearing that they are hallucinating. The avoidant symptoms and denial are passive symptoms; often the survivor does not recognize a pattern of avoidant behavior or feels too self-conscious to mention particular phobic behaviors, unless these behaviors are directly inquired into. As my early encounters with Ellen, described in Chapter 6, attest, posttraumatic responses are easy to overlook. Furthermore, the longer the symptoms go untreated, the more entrenched they become, over-laying and interacting with earlier character traits and conflicts, becoming chronic in themselves, giving rise to depression and hopelessness as the survivor finds she has become unrecognizable to her former self.

Although the introduction of the diagnosis of Posttraumatic Stress Disorder in 1981 was an important milestone in acknowledging the long reach of adult onset trauma, with overuse and misuse the diagnosis is in danger of becoming a cliché. Since its introduction, it has given rise to a veritable industry of research, an avalanche of papers based on that research, national and international organizations devoted to the study of catastrophic trauma, and the commodification of trauma therapy and training in a range of treatments from Eye Movement Desensitization and Reprocessing (EMDR) to Critical Incident Stress Debriefing (CISD) to grief counseling. At the time the diagnosis was introduced, psychoanalysts appeared relatively aloof to the phenomenon. This book is not about Posttraumatic Stress Disorder per se, but there is some overlap between the syndrome described in DSM III, IIIR and IV (APA 1980, 1987, 1994) and the far-reaching consequences of adult onset trauma.

As a graduate student in clinical psychology in search of a dissertation topic, in 1976 I joined a team of social psychologists, sociologists, political scientists, and anthropologists who had been asked by a small group of Vietnam veterans to undertake an epidemiological study of Vietnam veterans and their civilian cohort. It was an ambitious undertaking at that time, comparing the postwar adjustment of Vietnam veterans with their nonveteran peers in terms of social and marital relations, educational and occupational achievements, substance use and abuse, and psychological problems. A grant from The National Institutes of Mental Health enabled the first 300 men to be interviewed, and six months later the Veterans Administration asked us to add a further 1,000 men from several key urban, suburban, and rural sites across the country (Kadushin et al., 1981). I was particularly interested in what had caused the psychological breakdown of so many Vietnam veterans on their return home; I wanted to understand this Post Vietnam Syndrome, as it was called at the time. My plan met with considerable resistance from the chair of my program, who said that this topic was not appropriate for a clinical psychologist; it should be left to social workers and sociologists. Although I prevailed, I was left with the feeling that the topic I had picked had marked me as an outsider; it was slightly off color. I wavered between fascination with what I was discovering about the veterans whose transcripts I read and a sense of shame about this fascination. Shame is a fertile breeding ground for the Real. I now know that this sense of shame is not unusual among psychoanalytic researchers and clinicians that push beyond the accepted epistemological boundaries in their search for understanding.

At the time, I did not intend to push beyond the accepted epistemological boundaries. Consistent with my traditionally psychodynamic graduate training, I was sure that I would find predisposing factors leading to the psychological disorder I was attempting to measure. The working papers for DSM III (APA, 1980) were made available to me, listing the symptoms of the proposed diagnosis for Posttraumatic Stress Disorder. I constructed a scale with these symptoms and others listed in a study of World War II veterans, Men Under Stress (Grinker and Spiegel, 1945), those I gleaned from reading Massive Psychic Trauma (Kardiner Krystal, 1968), and from the work of (1969). When I analyzed the data, I did find a statistically robust syndrome that measured long-term stress reactions as distinct ...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Acknowledgements
• Chapter 1: Toward a Psychodynamic Understanding of Adult Onset Trauma
• Chapter 2: Catastrophic Dissociation and Childhood Trauma: Some Distinctions
• Chapter 3: The Cost of Survival: Historical Perspectives on Adult Onset Trauma
• Chapter 4: Wounded by Reality: The Relational Turn
• Chapter 5: The Core Self in Crisis: Deconstructing Catastrophic Dissociation
• Chapter 6: The Relational Self in Crisis: Further Deconstructing Catastrophic Dissociation
• Chapter 7: From Voyeur to Witness: The Crisis in Symbolic Functioning During Catastrophic Dissociation
• Chapter 8: The Ancient Mariner’s Dilemma: Constructing a Trauma Narrative
• Chapter 9: The Strength Found in Innocence: Resistance to Working Psychodynamically with Survivors of Adult Onset Trauma
• Chapter 10: The Psychological Politics of Catastrophe: Local, Personal, and Professional
• References
• Index