Nourishing the Inner Life of Clinicians and Humanitarians

The Ethical Turn in Psychoanalysis

Donna M. Orange

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317386292
• Edition: 1
• Topic: Philosophy
• Subtopic: Ethics & Moral Philosophy

Winner of the Clinical catergory of the American Board & Academy of Psychoanalysis Book Prize for best books published in 2016

Nourishing the Inner Life of Clinicians and Humanitarians: The Ethical Turn in Psychoanalysis, demonstrates the demanding, clinical and humanitarian work that psychotherapists often undertake with fragile and devastated people, those degraded by violence and discrimination. In spite of this, Donna M. Orange argues that there is more to human nature than a relentlessly negative view. Drawing on psychoanalytic and philosophical resources, as well as stories from history and literature, she explores ethical narratives that ground hope in human goodness and shows how these voices, personal to each analyst, can become sources of courage, warning and support, of prophetic challenge and humility which can inform and guide their work.Over the course of a lifetime, the sources change, with new ones emerging into importance, others receding into the background.

Donna Orange uses examples from ancient Rome (Marcus Aurelius), from twentieth century Europe (Primo Levi, Emmanuel Levinas, Dietrich Bonhoeffer), from South Africa (Nelson Mandela), and from nineteenth century Russia (Fyodor Dostoevsky).She shows how not only can their words and examples, like those of our personal mentors, inspire and warn us; but they also show us the daily discipline of spiritual self-care, although these examples rely heavily on the discipline of spiritual reading, other practitioners will find inspiration in music, visual arts, or elsewhere and replenish the resources regularly.

Nourishing the Inner Life of Clinicians and Humanitarians will help psychoanalysts to develop a language with which to converse about ethics and the responsibility of the therapist/analyst. This is an exceptional contribution highly suitable for practitioners and students of psychoanalysis and psychotherapy.

Chapter 1

Trauma and traumatism

“Burnout”—jargon but evocative—suffered its moment of fame some years ago among my psychoanalytic colleagues (Brothers, 2008; Buechler, 2000; Cooper, 1986). We wondered what we were doing wrong: working too hard, being too kind, ignoring aggression, neglecting self-care? Many of us, however, suspected much more serious reasons for our breaking down. Among the “suffering strangers” (Orange, 2011) who arrived at our doors, we had received the soul-murdered (Shengold, 1999, 2000), the all-but-drowned (Levi, 1989; Levi and Woolf, 2008), the left-for-dead, and found ourselves called “to empty oneself anew of oneself … like in a hemophiliac’s hemorrhage” (Levinas, 1981, p. 92). How were we ourselves to survive?

In the psychoanalytic world, Ferenczi was the first to acknowledge this question seriously. Many would argue that he provides a bad example, but I am not so sure. Working with those destroyed in early childhood, he found that their rage evoked his own wounds, his own capacity to hurt and even to do harm. Whether he died young from pernicious anemia (today so easily treated with vitamin B12), from exhaustion, or from both, he showed us how to give what Winnicott would later call “not less than everything” (quoted in Kahr, 1996, p. 125). These two pioneers, however, showed me both courage and human limits.¹ They did not leave the other to die alone even at the risk of their own death.

Staying with the traumatized demands all our capacity. The spectacular event mesmerizes us for the proverbial fifteen minutes. Victims, of clergy, of football coaches, of war, of genocide, and of child abuse command our attention just as long as they remain on the front pages and on television news; in other words, not for long. Somewhat better, our hospitals’ trauma centers attend to the wounds of the raped and those almost dead from gunshot wounds or war injuries. If they can get help from the Veterans’ Administration at all, soldiers receive drugs and brief cognitive therapies, while survivors of more private, familial violence are consigned to the indignities of managed care. At best, the traumatized become the “subjects” of scientific studies of their brains. This familiar story scarcely needs retelling here, except for the profound sorrow and helpless shame (see Chapter 5 on Primo Levi) that it creates in me; and, I imagine, in you. Responding to these abandoned ones, the biblical widows, orphans, and strangers, requires that we nourish ourselves from without and within—that is, taking the outer riches within.

This chapter will follow a thread: through trauma itself, through the need for testimony and witness, to the demands that work with extreme trauma places on those who witness and mourn, to the intersubjectively configured experience of shame embedded in trauma. It prepares the ground for the two chapters that follow on responsibility and its shadow, masochism.

Trauma itself

Others have extensively studied the nature and treatment of extreme traumatic experience. Thus, without detail, and with apologies to those neglected, let me mention a few of the courageous pioneers whose work has most affected me: Judith Lewis Herman, whose relentless devotion to human dignity keeps her always in the front of my internal chorus; Dori Laub and Shoshana Felman, who have reverently and persistently collected testimony from shoah survivors; George Atwood, who taught me and many others to regard psychotic people as trauma survivors; Robert Stolorow, whose indispensable work I consider in more detail below; others who work with those who suffer from complex dissociations created to survive violence (Chefetz, 2009; Chefetz and Bromberg, 2004); and many more (Brown et al., 2007). In addition, there are the researchers who have given their lives to the organized study of trauma—too many dedicated people to count, and too much research to summarize here.

The worst traumatic states result, I believe, from human cruelty, often organized by schemes that seem unquestionable: slavery (Gump, 2010), discrimination, racism, sexism, childism (Young-Bruehl, 2012). These arrangements are often invisible to the participants in the systems, especially to those who benefit from them, but are nonetheless violent and leave transmitted scars, infecting “to the third and fourth generation” (Numbers 14:18).

What I want to revisit now, from several angles, results in part from this societal maltreatment, and can be variously described in what I might call a hermeneutics of trauma and madness.² Trauma’s first phase arrives as a shocking, disorganizing event: a bomb, an earthquake, the loss of a child, parent, or other dear one, the loss of one’s own functioning, a threatening diagnosis. Still, as many have observed (Atwood, 2011; Carr, 2011; Davoine and Gaudillière, 2004; Orange, 2011; Stolorow, 2007), albeit few have truly listened, trauma becomes intractable suffering in the absence of relational holding and even more so in the presence of relational contempt and devaluation. Psychological trauma’s essence, according to Stolorow and Atwood (1992, pp. 52–53), lies in “the experience of unbearable affect,” absent the “requisite attuned responsiveness [needed] from the surround to assist in its tolerance, containment, modulation and alleviation.” Let us first listen to the voices of those who have already developed this point before I expand on it.

Robert Stolorow (2007), from some twenty years of reflection on his own traumatic experience and on his engagement with Heidegger’s philosophy, has developed a phenomenology of traumatic experience that emphasizes at least three important elements. First, trauma disrupts temporality; that is, it destroys our experience of the threefold dimensionality of past, present, and future. The traumatic event is always now, and always impending. Nothing firmly recedes into the past—whatever that may mean—where it no longer threatens. Second, trauma creates a profound sense of personal alienation, in which the traumatized person does not belong to the human world of others, but always walks around as a ghost or a stranger, with a permanent sense of weirdness. Third, trauma destroys what Stolorow calls “the absolutisms of everyday life,” the familiar sense that others will be there in the morning, and so on. The only hope for the traumatized to continue at all is that they find, in the second phase after the initial shock, what Stolorow calls a “relational home” in which the traumatic experience, with all its disorganizing consequences, can be welcomed and held, and thus find a “sibling in the same darkness” (2007, p. 47).

Military psychiatrist Russell Carr (2011) has brilliantly applied and expanded Stolorow’s work by creating a short-term therapy for soldiers who return from combat. He speaks of the necessity of the therapist’s engaging his own experience in finding an “intersubjective key” to the soldier’s traumatic experience, and of the absolute necessity that this key, like a “portkey” in Harry Potter (Rowling and Dale, 2000; Stolorow, 2011), be carefully understood together in the “relational home.”

The lifework of George Atwood illustrates the indissoluble link between trauma and madness. Like Harry Stack Sullivan, Frieda Fromm-Reichmann, and Donald Winnicott (“we are poor indeed if we are only sane” (Winnicott, 1945, p. 140)), Atwood has always seen the so-called psychotic or schizophrenic as one of us, and all of us as their brothers and sisters. Traumatized others abandoned in the second phase, siblings in the darkness whose hand no one ever took, they appear so strange that we avoid them. Atwood hears Daniel Paul Schreber,³ like his own patients, no matter how confused or deluded, as telling their own stories of soul murder in the only way they can. He reminds us that trauma cannot be cured. It has befallen us:

The traumatic events we are speaking of will affect the person down to the moment of his or her last breath. There is, however, hope for the person, for his or her life and future … The role of the analyst is to work, in concert with the patient, to establish a setting that will come to include the unbearable and unsayable. The patient will fall, sometimes devastatingly, into despair in the course of this process, feeling there is no hope for survival at all. At such times the analyst must connect to the despair and reflect his or her developing understanding of its original and contemporary emotional contexts. In this way, he or she contradicts the patient’s expectation that there is no place for the suffering that is felt, and a new context gradually comes into being wherein the unbearable can begin to be borne and the unsayable can begin to be said. This is the pathway toward wholeness, and it can be a very long one.

(Atwood, 2010, pp. 118–119)

Atwood’s open-hearted hospitality (Orange, 2011) toward unspeakable suffering, his relentless search for the meaning in every form of human psychological suffering—creating what Stolorow (2007) calls a “relational home” for traumatic experience, inspiring generations of students and colleagues like me—demands tremendous faithfulness from both therapist and patient.

Thus far, American voices with European inflections—from phenomenology, hermeneutics, and ethics: that is, from Husserl and Heidegger, from Gadamer and Levinas—have filled our account. Let us turn to French voices (Davoine and Gaudillière, 2004), themselves informed by many years of American dialogues through Austen Riggs Hospital, but profoundly rooted in the violent world of twentieth-century Europe. Every mad/traumatized patient Davoine and Gaudillière describe carries the stigma of some unspeakable, unspoken other or others gone missing, in war or genocide. In each “case” (casus, we are informed, in Latin means falling, as if into a common human befallenness), the “intersubjective key,” to borrow Carr’s felicitous phrase, consists in the analyst’s moment of recognition of a profound common fate, a “social link” between patient and analyst. Davoine and Gaudillière (2004, p. 136) generalize:

Like it or not, analytic discourse can be established when speech emanates from a locus without a subject or from someone who experiences himself as a reject … In the proximity of combat and risk, this speech can be addressed only to a therapist who is familiar with the same field … the intersection of two trajectories allows for a triangulation. Only in this way can essential facts, expelled from transmission [of trauma], sometimes be located. Their existence becomes possible once again, after having been annulled, because an other attests to them, from an independent source, on the basis of his experience.

The analyst must be listening most attentively, both to the patient and to herself, to catch these moments of intersection. My own patients taught me well.

Jeb, close to my age, who grew up in the same part of North Dakota where my own grandfather—whom I met only once—had lived, arrived for his first consultation with a specific plan for suicide by gunshot. Brought up as a more or less proper psychoanalyst, and long before I had learned to be more easily self-disclosing in my practice, I instinctively told him in that first session that like him, I was a transplant in New York and that my grandfather came from North Dakota. I then asked him if he would get rid of the gun so that we could work together. He did, and we worked together for seven years until he died from lung cancer.

Meanwhile, he told me that when he was eight, his father, a troubled but larger-than-life figure whom he had adored, threw himself in front of an approaching train. His older brothers, he remembered, wanted nothing to do with his grief, so he wandered the streets of his town alone. His mother, who did speak to him, he remembered only from her back as she worked in the house. He was her audience from behind.

Probably I was able to work with Jeb, despite his horror of my politics, which he inferred from catching me with the New York Times on my desk, because the “intersubjective key” involved not only the North Dakota link to a missing history still unknown to me, but even more to the faceless mother endlessly talking at me, but never with me. At the time I did not know this well enough to make use of it directly—no matter, perhaps—but it probably formed the “intersubjective key” or the “social link” (Davoine and Gaudillière, 2004). This link allowed me to be Jeb’s witness.

Trauma and witness⁴

Several years ago, having encountered a disturbing error message on my computer, I called technical support. The competent helper, whose accent I recognized as Indian, managed in a half-hour or so to solve my problem. During a pause, I asked where he was located, and he named an area of southern India. “Were you close to the tsunami?” I asked. “Oh yes, but we are all safe here, and all my family too, some of whom were much more exposed. Thank you for asking.” Then he began to repeat, almost singsong style, “It was so unexpected. We didn’t expect it. It was so unexpected. We didn’t expect it.” We returned to our task, but as soon as there was another pause, the refrain returned. “It was so unexpected. We didn’t expect it. Thank you for your concern. Thank you for asking,” and so on. Even when our task was successfully completed, it was difficult to end the call.

This incident illustrates several aspects of the phenomenology of traumatic experience, familiar to all clinicians and humanitarian workers: emotional freezing, the violation of expectancy, the destruction of temporality, the need for witnessing, the selective disorganization of experience, and mourning. For now, let us focus on witnessing, with its potential to release traumatic experience from freezing and partially restore human dignity. Next we will briefly explore the effect of this witnessing on those supporting the sufferers. This radical passivity, vulnerability, or receptivity we might rename the ethical formation of subjectivity or, in short, traumatism, an ethical condition of what Levinas called persecution, or useful suffering, and a concept to which we will return.

To begin, let us assume that trauma is both event and experience. Something terrible has occurred: an earthquake, a rape, the death of a child, torture, genocide, a cancer diagnosis. Nothing can be as it was before, nor trusted to be as we assumed it to be. One’s world is just deranged (Stolorow, 2007), and even when gradually reorganized around the tornado’s devastation or the dic...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Acknowledgments
• 1 Trauma and traumatism
• 2 Radical responsibility and clinical hospitality
• 3 Is ethics masochism? Infinite ethical responsibility and finite human capacity
• 4 Philosophy as a way of life: Pierre Hadot
• 5 Witness to indignity: Primo Levi
• 6 Substitution: Nelson Mandela and Dietrich Bonhoeffer
• 7 Ethics as optics: Fyodor Dostoevsky Written in collaboration with Maxim Livshetz
• 8 Clinical and humanitarian work as prophetic word
• 9 From contrite fallibilism to humility: clinical, personal, and humanitarian
• Index