Archives for : Thoughts on trauma
Aftermath
I’ve rarely devoted a post to criticizing one book. But there are aspects of Aftermath that highlight all that’s wrong with the adoption of trauma theory by literary critics, a recurring theme of this blog.
What makes Aftermath different is that it is engaged with an actual trauma. Instead of using trauma theory to explain a text, it uses the literary imitation of trauma, above all the experience of fragmentation, to explain a genuinely traumatic experience, a double murder. It doesn’t work.
A highly regarded book
Preti Taneja, a British author of Indian descent, received the Gordon Burn Prize for Aftermath. The prize honors the year’s most dazzlingly daring and avant-garde work of English-language fiction and non-fiction. Her first book, We That Are Young, a version of King Lear, set in a modern-day Indian business family, received the Desmond Elliott Prize, and was short-listed for several others. I found it hard to find critical reviews. Critical comments yes, here and there, but no critical reviews.
The most critical comments were reserved for Goodreads, a reader response website sponsored by Amazon. Many readers stated that large parts of the book were incomprehensible due to its stylistic peculiarities: absent punctuation, large gaps between words and phrases, incomplete sentences, and so forth. One reader says rip out 80 pages, presumably the ones written in an attempt to represent the traumatic experience as a textual one, and the book makes sense as a history and critique of the Muslim experience in India and England. I agree. The book gets better toward the end.
The Atrocity and its background
Though the book often reads as though Taneja was in the midst of the double murder, she wasn’t. She didn’t learn about it until the next day when her partner read the newspaper to her over breakfast, and Taneja realized she knew the name of the attacker, Usman Khan. The 28-year-old had taken the creative writing course Taneja led at a high-security prison two years earlier. The attack took place at a reunion of the program. The newspaper reported that he had been shot dead by police, after stabbing five people, two fatally. One was her colleague, Jack Merritt. Darkly amusing to some was the fact that Khan was initially subdued by a participant using a Narwhal tusk fastened to the Cambridge conference room wall.
Taneja had been invited, but stayed home, preparing for a literary festival. She says she feels both relieved and guilty to have missed the horror and has been left wondering how to make sense of her peripheral connection to the atrocity.
She tells me she has now come to call it “disenfranchised grief … for those who had known the perpetrator, it was something unspeakable”. She is now, she notes in Aftermath, writing “in the wreck”. (Guardian, November 27, 2021) *
“Astro-city”: the attempt to represent trauma in a text
The simplest way to convey the narrative style is to point out that “atrocity” is spelled “astro-city” every single time, I estimate well over one-hundred times throughout the book. It took me 88 pages to figure out what she was trying to say with this affectation. The state did it, creating the conditions that led to the atrocity. One problem with this use is that it denies Khan his autonomy. Furthermore, at other points she presents a nuanced account of the question of where the responsibility began and ended. The narrative portion of the book is capable of subtleties the stylistic portion can’t capture.
Taneja uses fractured form to reproduce in the text the experience of trauma. Trouble is, actual trauma becomes confused with textual trauma, as when she refers to “the atro-city, this prison of narrative and counternarrative.” (p 60) Elsewhere she states that “prison is a palace made of narrative . . . nothing in there but narrative.” No, prison is a place made of concrete and steel. It’s hard and its real. “Concrete Mama” it’s called by some prisoners (McCoy and Hoffman). It’s hard and its cold but it’s always there, always waiting to take you back. To be sure, prison is alive with stories. I listened to prisoners’ stories for more than a year (Alford,1997). But no one tells stories in solitary confinement (“administrative segregation”), and confined lives lead to confined stories, lacking in imagination. Dreams, a realm of freedom, are the exception, and prisoners generally keep dreams to themselves.
“Tell Me Why It Hurts: How Bessel van der Kolk’s Once-Controversial Theory of Trauma Became the Dominant Way We Make Sense of Our Lives,” is a strikingly good article on the appeal of The Body Keeps the Score (New York Magazine, July 31, 2023). It’s not long, and you can read it for yourself (the web address is given in the references). The article, and my comments, are not about whether van der Kolk (vdK) is right or wrong, but why his book has become so extraordinarily popular, spending 248 weeks on the New York Times paperback-nonfiction best-seller list and still counting. It’s sold 3 million copies and has been translated into 37 languages. It’s made vdK the world’s best-known psychiatrist.
The book’s thesis is that post-traumatic stress disorder (PTSD) is not just something that happens on the battlefield. It happens in childhood, and for many of us throughout our lives. PTSD is the intrusion of experiences that cannot be emotionally or cognitively assimilated, in many cases because we are too young or overwhelmed to make sense of them. Instead, these experiences are stored in a special type of memory he calls somatic memory that is based in the body, not the mind. Because these memories are stored in the body, they can’t be reached by talk therapy or reflection. Body work is necessary, by which vdK means virtually any therapy that involves the body and its movements. Yoga and massage are exemplary, but dance, play therapy, and psychodrama, in which people replay traumatic experiences with others, also count. Indeed, almost any therapy counts that isn’t just talk, but involves the body (I’m not quite sure why vdK includes psychodrama; it’s almost all talk).
But why did the book become so popular?
The book has been so influential because it says that you are emotionally ill not because of something in you, or about you. You are in a state of anxiety, depression, and despair because of what was done to you by others, frequently parents who paid insufficient attention to your needs, or responded inappropriately.
Stephanie Foo went through hell, finally coming to terms with C-PTSD.
Stephanie Foo is not a trauma theorist. She is a radio journalist and author of an account of her journey through C-PTSD, What My Bones Know. Not always well-written, it is a horrifying story of her childhood, her encounter with at least a dozen unavailing therapies, and finally finding one that worked. It includes her account of intergenerational trauma in general and her family in particular. Her use of intergenerational trauma theory is deeply touching and theoretically unsophisticated.
In another post I’ve discussed the definition of C-PTSD. Complex PTSD refers to long-term exposure to trauma, usually beginning in childhood and continuing for years. Often it involves sexual abuse, but not always. Almost always there is no escape. Dissociation is a predominant coping mechanism. The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM 5tr) does not recognize C-PTSD. The International Classification of Diseases (ICD 11) does but limits it to those already suffering from PTSD, a compromise that has never made sense to me. The psychiatric community generally seems less interested in the diagnosis than do those who suffer from it. Foo, like so many, was relieved to find a diagnosis that helped make sense of her experience.
A childhood in hell
It’s worth spending a little time with her story in her own words. Her abuse was spectacularly awful, becoming worse as she entered puberty.
A few times a year, my mother would get so tired of me that she decided God should take me back forever. She grabbed my ponytail at the top of a flight of stairs and used it to hurl me down. She raised a cleaver above my wrist, or she pulled my head back and pushed the blade into my neck, its cold edge pressing into the softness of my skin. I’d apologize frantically, but she’d scream at me that I didn’t mean it, to shut up before she sliced my jugular open. I’d fall silent, but then she said I was never repentant. So I’d start to apologize again, and she said my apologies were worth nothing, plus now my tears made me so ugly she was certain I had to die. So I stayed quiet until she screamed at me to speak again. We’d sit there, trapped in a senseless loop for hours. (p 13)
How did I feel about the fact that my mother blamed her suicide attempts on me? I couldn’t tell you. Those would be some very big feelings for a very little girl. But I do know this — that every night before bed, I kneeled and said the same prayer over and over like a mantra. “Please, God — let me not be such a bad girl. Please let me be able to make Mommy and Daddy happy. Please make me into a good girl.” (p 15)
Her father was no help.
“It’s not her [mommy’s] fault. It’s just that I’m bad, I’m awful, I’m evil,” I told him, and he believed me. “Why do you have to be like this,” he’d ask. “Why can’t you just be better?”
Worse was what she calls her father’s car terrorism.
My father didn’t hit me once after my mother left, but he was a fan of car terrorism.
“It’s time for both of us to die,” he’d sing, smiling. “I’m going to kill myself because I’m tired of this life, and you’re a fucking bitch so you’re coming, too.” He almost killed us a dozen times; each time, I’d beg and plead and placate him, feeding him reasons why we needed to live. (p 34}
How did she survive?
Though she doesn’t linger on it, Foo seems to attribute her survival to her hatred. (p 30) Hatred that she put into practice after her mother left, and her father took over her abuse.
Then I heaved the ax up above us in a graceful arc that would end on his balding skull. And I started to scream . . . . “ How do you like it? ” I said quietly, in that same chilling, deadpan, serial-killer tone I knew so well, and it felt delicious in my own mouth. “How does it feel to be on the other side of things? To be inches from death? How does it feel when someone wants to kill you?” (p 35)
“Okay, then let’s get one thing straight. You are never going to threaten my life again. NEVER. Do you understand me? ” “Yes.” “I SAID. DO. YOU. UNDERSTAND. ME. “Yes!” “You will never grab me. You will never touch me. You will never go over the fucking speed limit. You will drive right. You will never use your car to punish me. Do you have any idea what growing up with a constant fear of death has done to me? It has turned me into the fucking monster you see right now. This is happening because you did this to me.” (p 35)
Her anger, I believe, saved her from psychosis. She cossetted her nascent self in rage. “My anger was my power.” But her rage only bought her time. It didn’t heal; it only protected her fragile, broken self from obliteration. That was no small thing.
A remarkable recent book, Caste: The Origins of our Discontents, by Isabel
Wilkerson, suggests a new way of thinking about the trauma experienced by
large groups in stratified societies. Wilkerson calls these groups “castes,” and her examples are Blacks in the United States, Jews in Germany, and Dalits (“untouchables,” but literally “broken people”) in India. I’ll focus on the United States, as she does.
While the subtitle of Caste suggests that Freud’s Civilization and its Discontents might have been an inspiration, there is little that is psychoanalytic about Wilkerson’s book. Nevertheless, her psychological insight is often keen, and she helps makes sense of the difficult question of how very large groups of people could experience trauma. Through their shared experience of belonging to a particular caste is her answer. Hers is not the whole answer, but it’s a neglected part.
Caste
Caste, writes Wilkerson, sets the supremacy of one group against the inferiority of other groups based on ancestry and other immutable traits, such as skin color (p 40). Caste is the bones, race is the skin. Caste is the institutional structure that keeps people in their place. Race is the marker, and is fluid and superficial. Above all, race is a social structure, not a biological one. We are all descended from the same group of tribes that migrated out of Africa in the last 100,000 years.*
Though she never quite says it out loud, Wilkerson seems to hold that the division of humans into a higher and lower status is a natural human tendency, shared with other primates and pack animals such as wolves. What’s optional is whether race is the identifier. In India it’s jati, or kinship group, generally rendered as caste.
Also optional is whether this hierarchy is built upon the humiliation, devaluation, and exploitation of those at the bottom, as it generally is, at least among humans. That’s not the rule among primates and wolves.
So where’s the trauma?
Consider the most horrendous humiliation and devaluation of those at the bottom, the lynching festival, the last of which was carried out by the KKK in 1981 in Mobile, Alabama. Unless that is, you consider the spate of police murders of Black men a type of socially sanctioned lynching. Wilkerson seems to believe it is (pp 400-403).
Lynchings were part carnival, part torture chamber, and attracted thousands of onlookers who collectively became accomplices to public sadism. Photographers were tipped off in advance and installed portable printing presses at the lynching sites to sell to lynchers and onlookers like photographers at a prom. They made postcards out of the gelatin prints for people to send to their loved ones. People mailed postcards of the severed, half-burned head of Will James atop a pole in Cairo, Illinois, in 1907. They sent postcards of burned torsos that looked like the petrified victims of Vesuvius, only these horrors had come at the hands of human beings in modern times. Some people framed the lynching photographs with locks of the victim’s hair under glass if they had been able to secure any. . . .
This was singularly American. “Even the Nazis did not stoop to selling souvenirs of Auschwitz,” wrote Time magazine many years later. Lynching postcards were so common a form of communication in turn-of-the-twentieth-century America that lynching scenes “became a burgeoning subdepartment of the postcard industry.” (p 123)
The euphoria of hate
Wilkerson titles her description of lynching “the euphoria of hate.” (p 304). Lower-caste whites, who suffer their own relative devaluation in the caste system, need a Black sacrifice to reassert their superior status. For Wilkerson, even rumored violations of caste are so profoundly threatening as to fuel evil and hate.
Author’s note: I could not write this post until after Trump was defeated; I’m not sure why. But he will be with us in one form or another for some time.
There is no cult of Trump. He is a skilled politician who allows others to share in his narcissism and his rage. To suggest that Trump has a cult-like following suggests that his appeal is extraordinary in some way. It’s not. Trump is an extremely clever politician, adept at manipulating nativism, racism, and rage. He gives voice to what is already out there. To treat Trump as a cult leader risks mystifying the appeal of authoritarian leaders.
What’s this have to do with PTSD?
Submerged deep inside the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is a category that designates the victims of cults, labeled Other Specified Dissociative Disorders, 300.15.
Identity disturbance due to prolonged and intense coercive persuasion: Individuals who have been subjected to intense coercive persuasion . . . by sects/cults . . . may present with prolonged changes in, or conscious questions of, their identity.
In The Dangerous Case of Donald Trump: 35 Psychiatrists and Mental Health Experts Assess a President, Jennifer Panning describes what she calls “Trump Anxiety Disorder,” a “unique postelection anxiety syndrome that has emerged as a result of the Trump presidency.” It is characterized by “increased worry, obsessive thought patterns, muscle tension and obsessive preoccupation with the news.” (p 229) In the same volume, Betty Tang (p 215) writes of the “parallels between the anxiety reactions suffered by increasing numbers of concerned Americans and the symptoms of PTSD.”
Certainly, there is/was much to worry about with Trump as President; indeed, as long as he remains on the national stage. However, to refer to “PTSD-like symptoms” that afflict not only soldiers and other victims of terrible trauma, “but many of the rest of us as well” (Tang, p 215), risks trivializing PTSD and misunderstanding Trump.
Nevertheless, it makes sense to look at Trump from a psychological and psychoanalytic perspective. On the other hand, looking at Trump from only this perspective risks ignoring the power of ordinary politics to exploit our anger and fear.
Using Psychoanalysis to Understand #MeToo Memories
This is not an original post. It is from The New York Review, but it seems so important and relevant I decided to reprint it here because it helps explain how events that were not experienced as traumatic in the past can become traumatic many years later. This is the reason some women have waited decades to report their experiences. Elapsed time does not invalidate trauma; it helps make it. Subheads and emphases are my own.
Using Psychoanalysis to Understand #MeToo Memories, Avgi Saketopoulou
New York Review of Books, New York Review Daily, Oct 11, 2018
As the #MeToo movement has gathered momentum, we’ve seen a proliferation of allegations of sexual harassment and sexual assault. In some instances, one or two accusations are followed by a series of others, as happened during the course of Brett Kavanaugh’s Supreme Court confirmation hearings. Although Kavanaugh’s supporters, including Republican senators on the Judiciary Committee, professed respect for the demeanor of his main accuser, Christine Blasey Ford, even as they dismissed the allegations of others, they also called into question the integrity of her testimony. One of the main objections was the length of time, thirty-six years, that had passed before Ford had gone public with her report of his alleged sexual assault. Why would someone who has been hurt, they wanted to know, not speak at the time the injury was inflicted? Isn’t this very delay, as President Trump recently said, itself evidence that the claims are suspect? These questions are not new or specific to Kavanaugh, but they became especially urgent when a Supreme Court nomination is at stake.
Much trauma doesn’t fit PTSD
Part of the disconnect in appreciating how and why allegations arise as and when they do has to do with our culture’s understanding of trauma. We are accustomed to thinking about only one of the ways that trauma works. Here is the clinical definition most generally familiar: something is traumatic when it overcomes the subject’s capacity to cope, and it interrupts the self’s ability to absorb and process distressing or painful events. Such trauma can bring about feelings of helplessness and produce long-lasting disturbances in the subject’s life. This type of trauma is understood to happen in real time; the harm itself occurs at the time of the scarring event. This is the most widely held understanding of how trauma works, but psychoanalysis offers an alternate conception of trauma: specifically about how a traumatic experience can mean quite different things for the same individual over time.
Can psychoanalysis explain why people can be so cruel? Klein and Mitchell
This post a little different. Not the experience and treatment of psychic trauma, but psychoanalytic accounts of why people seem so eager to hurt each other is its focus. If most studies of psychic trauma are concerned with the experience of being traumatized, this account is about why people traumatize others. Aimed at people with a little knowledge of psychoanalytic theory, its main point is available to anyone. That’s why I post it here. You can read my view on Mitchell’s contribution to trauma theory in another post on this blog.
When I look around the modern world, I see progress, such as the toppling of the Berlin Wall in 1989, and the peaceful end of apartheid in South Africa in 1994. But for me, at least, it is the genocides that stand out: The Holocaust, the Cambodian genocide, genocide in Bosnia and Herzegovina, the Rwandan genocide, and the genocide in Darfur. The list is incomplete, and not up to date, but the point is simple: people seem to be driven to hurt and kill each other. Is there any hope that psychoanalysis could help us understand why people do such horrible things to each other? (https://genocideeducation.org/resources/modern-era-genocides/)
Melanie Klein
The only psychoanalytic theory that might possibly make sense of all this is the psychoanalytic theory of Melanie Klein. But here’s the problem: while Klein helps us understand the terrible things people do to each other, hers is not really a very good way to help people in psychological pain. I would hate to be treated by a traditional Kleinian analyst, of whom few remain. Nonetheless, traditional Kleinian theory makes the best sense of the larger world. Do we need two theories, one to explain the world, another to help people who suffer psychic pain? Maybe.
Epigenetics: of mice and men and women.
This is the second of two posts on epigenetics. In the first I was critical of using epigenetics to explain the transgenerational transmission of trauma. In this post I am less critical, but the epigenetics of trauma remains a research project in its early stages. The ACE test (adverse childhood experience), available now, is a better use of epigenetics.
The epigenetic scaffold
It used to be thought that the chemical scaffold that surrounded the DNA double-helix was unimportant. Today scientists recognize its importance. This scaffold is called the epigenome (epi from the Greek for above), and is composed of proteins and other chemicals. The scaffold chemically tells a gene whether to turn on or off. A gene that is turned off is like no gene at all. Experience in the world effects the epigenome, which means that the experience of trauma, or more accurately susceptibility to trauma, can be genetically transmitted in the same way other traits, such as hair color, are genetically transmitted.
Two mechanisms are particularly important for gene silencing. DNA methylation and histone modification. DNA methylation is the best-known example of a mitotically (referring to cell division) heritable epigenetic modification. (Ennis, loc 354). Unlike DNA methylation, most scientists thought that histone modification patterns weren’t copied directly to the new chromosomes produced during mitosis (cell division). However, a study by Susan Strome showed that some of the original strand’s modified histones are passed to the newly forming strand during DNA replication (Ennis, loc 354, 422). Other studies have confirmed this result.
It seems clear that epigenetic changes brought about by experiences such as trauma may be transmitted to subsequent generation during the process of reproduction. Whatever else is discovered about the epigenome, it is no longer makes sense to distinguish sharply between nature and nurture. Still, we should not become overenthusiastic. Strome’s study was done with worms; most are done with mice or rats.
The most obvious thing to say about the relationship between torture and severe psychic trauma is that psychic trauma is often the result of being tortured. That’s true, but the relationship is closer than that. Severe psychic trauma is torture. PTSD has many of the same features as the pain intentionally inflicted by torture. (PTSD is a narrower category than severe trauma. I use PTSD only for convenience, not as a diagnostic category.) In other words, the relationship between torture and PTSD is not simply sequential. In many respects, PTSD is torture.
My authority for the pain of torture is the well known work by Elaine Scarry, The Body in Pain: The Making and Unmaking of a World. All page references are to this work unless otherwise noted. Others have written thoughtful works on torture, including Jean Améry, who was himself tortured. I have written about Améry elsewhere (Trauma and Forgiveness), but Scarry’s description of the experience of torture seems more relevant.
Trauma is the disruption of the ability to maintain relationships. Psychoanalysis can help. Stephen Mitchell tells how. Unfortunately, the cure takes time and money. A lot of time and money. Here I’m going to lay out what I think it would take, and roughly how it would work. Those uninterested in psychoanalysis may be tempted to skip this post, but I think laying out an ideal, a utopian treatment plan, shows us how far we are from an ideal, as well as directing our next steps, even if the pathway is currently blocked for most people.
Trauma is the loss of relationality
Trauma is the loss of relationality to self and to others. By relationality I mean the ability to participate in relationships. Trauma is the loss of access to sources of vitality deep within oneself, sources that are brought to life in spontaneous and authentic relations with others, from families to strangers.
Is it time to drop the diagnosis of PTSD?
CAUTION! The material in this post was rejected by the “Proceedings of the Listening to Trauma Conference: Insights & Actions.” The reason: “Its tone is too contentious for a collection with positive studies of the physiological underpinnings for trauma and meaningful emerging clinical treatments.” Proceed at your own risk.
In many respects post traumatic stress disorder (PTSD) has been an extraordinarily fruitful diagnosis. It connected the politics of the Vietnam War with the suffering of hundreds of thousands of veterans (Alford, pp 9-13). As the authors of The Empire of Trauma, Didier Fassin and Richard Rechtman, put it, trauma today is not a clinical but a moral judgment. Its advantage is that it has given us “this unprecedented ability to talk about—and hence experience—the violence of the world.” (p 276) In addition, trauma has given us a new perspective on contemporary history, up close and from the ground up. History written from the perspective of trauma is history written from the perspective of the victims.
Reliability versus validity
And yet I think PTSD has come to an intellectual dead-end for all the reasons discussed in this blog over the last two years.
Dori Laub has a bad trauma theory, but he has still made a contribution.
Laub concludes an autobiographical essay, “On leaving home and the flight from trauma,” with the following lines.
Perhaps it is only through resisting the temptation and the pressures of becoming the same that he [the therapist] can listen to the patients as they really are, without succumbing to the generalizing effects of theory and the homogenizing produced by fashion and by political correctness. (2013a, pp 579-580)
Laub has adopted some of the most fashionable theories of trauma. At the same time, it is hard to imagine that he is not a good therapist to the traumatized. I conclude this from the way he writes about his patients, as well as having seen him interview survivors for the Fortunoff Video Archive for Holocaust Testimony at Yale University.
Are PTSD and C-PTSD dissociative disorders? Yes, but it’s more important to remember that they are first of all about terror.
It appears that PTSD and C-PTSD may be grouped under the dissociative disorders in the next edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders). As Matthew Friedman points out, the new DSM-5 category of trauma and stress related disorders was intentionally placed next to the dissociative disorders in order to suggest their similarity (p. 549). Whether this is a good direction to be heading is another question.
A quick definition: dissociation is the division of parts of the self. Dissociation occurs when the parts of the self that know and feel traumatic experience no longer communicate with the rest of the self. Dissociation is generally seen on a continuum, more or less.
What’s dissociative about PTSD and C-PTSD?
I’ll get to C-PTSD (complex PTSD) in a minute.
It’s easy enough to interpret the leading symptoms of PTSD in terms of dissociation. The flashback is a dissociative symptom, a failure to prevent intrusion of unwanted and painful experience.
PTSD criteria read like a short laundry list of dissociative isolative and exclusionary processes (intrusion, numbing, and avoidance). (Chefetz, p. 28)
The dissociation associated with PTSD is characterized by an alteration between hyperarousal and numbing or constriction. The dialectic of trauma moves between intrusion and numbing.
Judith Herman (pp. 47-49) and others have argued that the experience of trauma generally moves from early hyperarousal to later numbing and constriction. Others, such as Richard Chefetz see no progression, just the dominance of one position or another.
Some people with PTSD present with flooding, and others are so emotionally shutdown that they present as emotionally flat, detached, with active dissociative process. (p. 80)
It’s time to stop letting the stressor define PTSD. Not doing so makes the new categories of C-PTSD and DESNOS largely irrelevant.
I’ve been posting on this blog for about eighteen months now, a total of fifty-two posts. Though I’ve written a couple of books on trauma (my latest is Trauma, Culture, and PTSD), I still feel like a newcomer to the field. In this post I want to talk about what still puzzles me about trauma theory. The experience of writing this blog has led to more questions than answers.
I’ve been able to reconstruct to my own satisfaction the origins of PTSD in the Vietnam War. The new diagnostic category served political ends, pointing out what war does to the people who fight it. The introduction of the disorder called PTSD was progressive politics. It was also a humane diagnosis, helping to explain to those who suffered from it what was happening to them, giving both soldiers and their families a vocabulary for their pain.
PTSD in DSM-5
At almost the same time as DSM-5 was being released, the National Institutes of Mental Health was refusing to fund any more research based on the DSM.
National Institute of Mental Health (NIMH) announcement
By Thomas Insel on April 29, 2013Patients with mental disorders deserve better. . . . That is why NIMH will be re-orienting its research away from DSM categories . . . . The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.
If the DSM were the model for physical medicine, then a heart attack would be defined as “chest pain disorder,” a symptom without a cause.
Henceforth, the NIMH research goal is to fill in the “Draft Research Domain Criteria Matrix,” which links 5 basic natural formations, such as “systems for social processes,” including attachment and fear, with eight columns of units of analysis, such as genes, molecules, and cells.
The goal is to move from mind to brain, so that there will no longer be any need to talk about mind at all. It’s all about electricity and meat, as Gary Greenberg puts it. And electricity and meat can be measured. Not, however, in the language of human suffering.
American psychiatry and psychology have been cut off from the official world of science, but not from VA funding (over 100 million dollars since 2012 for PTSD). This has consequences. One, I believe, is the failure of more trauma specialists to object to the VA’s endorsement of cognitive behavioral therapy (CBT), including exposure therapy, as the treatment of choice, the only “evidence based treatments.”
These treatments are short-term, can be learned from a manual, and administered by lesser trained persons. CBT is quick and cheap compared to long term therapy by well trained persons. But consider CBT’s difference not only from traditional talk therapy, but also from the rap groups that sprang up in the Vietnam War era, in which veterans could exchange experiences. CBT discourages “cross talk,” as people talking with each other is called (Tasman et al., p. 1928). The potential of PTSD to help sufferers explain to each other the varieties of torment and relief has been lost.
This does not mean we should abandon the diagnosis of PTSD. Indeed, when this is proposed it is often sufferers who object most strenuously, for the diagnosis has helped many people make sense of their disrupted lives. It does mean that we should rethink the category.
The best trauma narrative I know is Aftermath: Violence and the Remaking of the Self, by Susan Brison. It’s an account of her rape and attempted murder. I call it the best trauma narrative because it combines philosophy, trauma theory, and narrative. Alice Sebold’s Lucky, probably the most well known rape narrative (reviewed in this blog), is better written, and makes a more compelling story. But Susan Brison is a distinguished philosopher, and she approaches her trauma, and trauma theory in general, from a perspective that combines philosophy and experience.
Actually, Brison doesn’t think being a philosopher did her much good. Rape and trauma challenge philosophy because they reveal how embodied we all are. Before we are minds, even before we are body-minds, we are body. Philosophy is generally not comfortable with bodies. Philosophy is practiced by questioning the obvious, asking questions such as “what is time?” But when confronted with an experience that is overwhelmingly obvious, her rape and near murder, Brison found no comfort in philosophy.
But now, when I was confronted with the utterly strange and paradoxical, philosophy was of no use. (p. x)
Testimony can create the trauma it discovers.
Trauma theory and testimony grew up together, beginning in about 1980. By this I mean that trauma theory and Holocaust testimony emerged as socially and historically significant at about the same time. It’s worthwhile thinking about their relationship. If we take the limits of testimony seriously, then much of current trauma theory, especially Cathy Caruth’s account of the “missing moment,” is mistaken.
It is, of course, not literally true that trauma theory emerged in 1980. Freud built much of psychoanalysis on his reinterpretation of his patients’ trauma almost a hundred years earlier. Shell shock, as PTSD was then known, emerged with the First World War. What happened beginning in the early 1980’s was the inclusion of PTSD in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) for the first time. The introduction of PTSD coincided with the “narrative turn” in the humanities and social sciences. At about the same time, the Fortunoff Archive for Holocaust Testimony was established at Yale University.
I have come to believe that Holocaust testimony leads to a misunderstanding of trauma, especially if one does not understand testimony’s limits. I have published three books on trauma that draw on Holocaust testimonies in the Fortunoff Archive. I think I understand the limits of testimony better now. My instructor, so to speak, is Henry Greenspan, author of On Listening to Holocaust Survivors. I also draw on some more recent papers of his. In place of testimony, Greenspan has engaged in extended conversations with survivors. Some of these conversations have lasted decades. Out of these conversations comes a different way of thinking about testimony and trauma.
Trauma escapes language, but so does life.
Trauma theory has a problem with language. Leading trauma theorists such as Cathy Caruth hold that the mark of a traumatic experience is that it escapes language. This is the primary reason that Caruth and others have been attracted to the work of Bessel van der Kolk, and neuroscience generally. Van der Kolk holds that traumatic experience is so sudden and overwhelming that it cannot be put into words. Ruth Leys addressed the problem in a 2010 interview. I don’t believe the intellectual situation has changed much since then, other than the increasing influence of affect theory: the claim that there is an autonomous neurological system that experiences not just trauma, but life, in such a way that language is always playing catch-up.
It is my claim that a major reason for the popularity among postmodern theorists of non-cognitive theories of trauma and affects is that there is a deep coherence between the views of cultural critics and those of the scientists to whose work they are attracted. . . . Van der Kolk [a psychiatrist and neuroscientist] believes that the literal nature of the traumatic flashback or memory means that it belongs to a system of traumatic memory different from that of ordinary memory and as such is cut off or dissociated from ordinary recollection, symbolization, and meaning. In the case of Caruth the same argument takes the deconstructive form of claiming that the aporia or gap in consciousness and representation that van der Kolk and others believe characterizes the victim’s traumatic experience stands for the materiality of the signifier in de Man’s sense, that ‘moment’ of materiality that simultaneously belongs to language but is aporetically cut off from the speech act of signification or meaning. (p. 666)
An aspect of this argument that does not get a lot of attention is how language normally develops. The answer seems to be that language is always cut off from experience, not just among the traumatized, but among us all. If so, then traumatic experience is continuous with ordinary experience. Trauma does not operate in a parallel neurological or linguistic universe. The difficulties the traumatized experience putting words to their experiences are exaggerated versions of everybody’s experience with language. Trauma is uniquely painful, but the way traumatization happens is not unique, but is shared by all who speak.
Affect theory is coming to trauma theory. In fact it’s already here. The best account I’ve read is Ruth Leys “Trauma and the Turn to Affect.” A historian of science, Leys is the author of the highly regarded Trauma: A Genealogy. This post is indebted to her work.
The main thing to understand about affect theory is that it has nothing to do with affect–that is, feeling and emotion. According to affect theorists, affect is a
pre-subjective force that operates independently of consciousness or the phenomenological concept of subjectivity. (Leys, 2012)
Affect is a mental state, separate from belief and desire, the affect program system as it is called. Affect is the body acting on itself, free of cognition and emotion on the one hand, the quality of the stimulus, or stressor, on the other. If this sounds weird, stick with me.
As Patricia Clough puts it,
Trauma is the engulfment of the ego in memory. But memory might be better understood not as unconscious memory so much as memory without consciousness and therefore, incorporated, body memory, or cellular memory. (p. 6)
The transference is always active between the scholar and what he or she studies. This is especially so when the subject is trauma. So Dominick LaCapra argues, and I think he’s right. What does the transference mean in the case of trauma? For LaCapra it means that “at some level you always have a tendency to repeat the problems you are studying.” (p. 142)
More generally,
by transference I mean primarily . . . the tendency to repeat in one’s own discourse or practice tendencies active in, or projected into, the other or object [of study]. (P. xv)
In the case of trauma, those writing about it often write as though they have been traumatized. The writing of Cathy Caruth and Shoshana Felman is frequently in “unmodulated, orphic, cryptic, indirect allusive form” that is designed to transmit the disorientation of trauma. (LaCapra, p. 106) This may be suitable for trauma fiction, as it is sometimes called (though I have questioned that in another post), but it is unnecessary and counterproductive when trying to explain trauma.
There’s lots of talk these days about the transgenerational transmission of trauma (TTT). Some of it focuses on epigenetic changes in the chemical environment of the genes that make people more or less susceptible to trauma. I find this topic incredibly complicated and difficult to understand. I’ll try to explain it the best I can, but the reader should be clear that as far as PTSD is concerned, the epigenetic transmission of trauma is still up in the air, a hypothesis with no established empirical (scientific) basis. As two of the leading researchers put it in the Journal of Traumatic Stress,
There have been no empirical demonstrations of epigenetic modifications per se in association with PTSD or PTSD risk. (Yehuda and Bierer, p. 430)
This reality has done little to dampen speculation, including that of Yehuda and Bierer, as we shall see. I’m not sure if this is bad or good. Mostly I think it’s irrelevant.
Dori Laub puzzles me. A child survivor of the Holocaust, and co-founder of the Fortunoff Archive for Holocaust Testimony at Yale University, both he and his achievements are admirable. I’ve spent over 300 hours viewing testimony in an Archive that would not have existed, at least not in its present form, without Laub’s effort. More than any other person, Laub created the format in which the testimonies were given, one in which the interviewer asks few questions, allowing the witness to speak for long periods without interruption. Laub is a psychoanalyst, and the format psychoanalytically inspired.
But if the man and his creation are admirable, his claims about trauma and the Holocaust are troubling. The Holocaust, he says was an
event that produced no witnesses. . . . One might say that there was, thus, historically no witness to the Holocaust either from outside or from inside the event. (Laub, An event, pp. 80-81, his emphasis)
Elsewhere Laub says
The Holocaust created in this way a world in which one could not bear witness to oneself. (Laub, Truth, p. 66, his emphasis)
What Laub means is that in order to experience an event, one must communicate it to an “inner Thou,” the addressee with whom inner dialogue takes place. Without the “internal Thou,” an event cannot be symbolized, and hence cannot be known, even as it exerts a continuous pressure which expresses itself in trauma.
Most who study severe trauma agree that it stops time. Trauma time is frozen time, in which the experiences of the past never become past, but remain as alive and intrusive as the day on which they happened, maybe more so. Flashbacks, nightmares, hypervigilance, constriction: all are expressions of a past that continues to intrude upon the present.
Less frequently written about is the way in which trauma can reach back behind the traumatic event itself and devalue past good experiences, experiences of attachments met and love acknowledged, experiences that preceded, often by decades the traumatic event.
These observations about trauma are best suited to explaining adult-onset trauma. It need not be the trauma of a single incident, it could be an experience as extending over years, but I assume that before the trauma there were good experiences, and good memories. These good memories are not forgotten, but too often they become unavailable as an emotional resource to be drawn upon when times are tough.
Many who study trauma from a psychoanalytic perspective turn to Freud’s Beyond the Pleasure Principle (1920) in order to make sense of the apparent desire of people to repeat unpleasant experiences. Why, the sensible person wonders, would a traumatized person keep repeating a horrible experience, whether it be war-time trauma, or the trauma of an abusive childhood? In this context, the term “repeating” covers multiple forms of repetition, from flashbacks and nightmares, to acting-out an original trauma, in which, for example, a woman who was abused as a young girl continues to choose abusive partners.
Freud begins Beyond the Pleasure Principle with what he calls the traumatic neuroses, brought about by accidents and wartime trauma. However, he quickly turns from “the dark and dismal topic of traumatic neurosis,” to children’s play (pp. 50-52). The reader is at first disappointed. Should not Freud have paid more than passing attention to the psychological suffering of so many who had just returned from a war that inflicted immense psychic suffering on its combatants? He does, but one has to search for it. Or create it.
Trauma is a popular topic these days because it meets a widespread longing for intensity. So argues Michael Roth (p. 90) and I think he’s right. Much of what is wrong with trauma theory today is the attempt to participate in this intensity through writing about it. The result is a mistaken view of how one should write about trauma. Either the author tries to imitate the experience through literary effect, such as multiple voices and sudden changes in time and place (see my post on trauma literature). Or the author approaches trauma as though it were a sacred experience, almost too awesome for words. But only “almost,” for academics write a lot about trauma. That includes me.
The problem of writing about trauma is a real problem. The experience of trauma is too extreme for words. Indeed, trauma is often described as the inscription of intense emotions on the psyche (or brain) in a way that cannot be put into narrative speech. If trauma is speechless, then how to write about it?
This problem is compounded when one is writing about massive historical traumas, such as The Holocaust. It has become almost a commonplace that the event cannot be understood, indeed that we show our respect by not even trying to understand it. “The obscenity of understanding” is how Claude Lanzmann, producer and director of the movie Shoah, puts it.
Words always disappoint, but sometimes they are all we have
I think we should write about trauma, including large scale historical trauma, just like we write about any other event. Words are a wonderful and terrible thing. Putting any intense experience into words never does it justice, if justice means reproducing the experience in the mind of the reader.
The Urban Dictionary says that the “University of Google” refers to a major ignoramus who pretends to be an intellectual. Well, I decided to attend the University of Google for a few days to see what I could learn about PTSD. It’s pretty depressing. So-called reputable sites were the worst. There are a couple of interesting exceptions.
I looked at every site listed on the first three pages of my Google search “PTSD.” This was over the days February 18-22, 2016. The top sites changed every day (sometimes every hour), but not by much, and I included sites that paid to be listed first. Since I’ve done a lot of trauma searches with Google on my computer, my rankings were not quite the same as on my wife’s computer, my i-pad, and my school computer, which I rarely use. Google customizes (that is, markets) its information. Nevertheless, the overlap was considerable.
After a while, the sites started to sound the same. There were a couple of exceptions.
Wiki disappoints
Wikipedia’s entry on PTSD was disappointing. “Psychotherapy is the ‘gold standard’ of treatment for PTSD.” A promising start, but under psychotherapy Wiki includes prolonged exposure therapy (PE), cognitive behavioral therapy (CBT), and eye movement desensitization and reprocessing (EMDR). I expected more from Wiki; I’m not sure why.
Rats, mice, ecstasy, and dogs
A surprising number of sites reported on research with mice and rats, and several report the results of delivering electric shocks to people. In one, people with PTSD show heightened brain activity in areas thought to be associated with stress when shown pictures of frightened face when shocked and not shocked (that is, no difference), while people without PTSD show more anxiety when shocked. The significance of this is left unclear.
The same site, The Brain and Behavior Research Foundation, summarizes a study which shows that MDMA — also known as the rave drug Ecstasy — can treat symptoms of post-traumatic stress disorder in mice. At: https://bbrfoundation.org/ptsd?gclid=CIrI-YnshssCFclkhgodKkIKew. Don’t try this at home.
Bessel van der Kolk (vdK) is probably the world’s most well known trauma theorist. I reviewed his recent book, The Body Keeps the Score, in an earlier post. Since then I’ve read more of his work and listened to him speak for hours (he is all over youtube). The best way I’ve figured out to think seriously about his work is to ask what difference it would make if he were right.
What he says
Asked about how he treats the victims of acute trauma, vdK says
Holding them, rocking them, giving them massages, calming their bodies down is a critical issue. I am probably the minority among my colleagues in that I am much more focused on bodily state than on articulating what’s going on. I think that words are not really the core issue here. It is the state of being, of tenseness, of arousal, and of numbing, and that people need to learn again to be safely in their bodies. (http://www.medscape.com/viewarticle/408691)
Think about this for a minute. One might expect a trauma therapist to say something like “I try to create a safe environment in which my patients can put words to unspeakable experiences. I try to help them remember an experience so they don’t have to constantly relive it.” This makes sense, for trauma is a disorder of time, in which the past is never past but is constantly intruding upon the present.
VdK would have no difficulty with the last sentence, and yet his treatment program (or rather programs) has little to do with the past, and everything to do with the present. Trauma is when the past colonizes the present. Its treatment depends on reappropriating the present, and one does that not through understanding the past, but coming to live in the present, and the best way to do this is to bring the body into the present.
Behind vdK’s approach is his view that PTSD and related traumatic disorders, particularly developmental trauma (childhood abuse and neglect), are disorders of the limbic system, one of the oldest parts of the brain, the one we share with all mammals. In the limbic system, threat is experienced as sensation, and the impulse to fight or flee. Threat turns into trauma when we can neither fight nor flee, when we are trapped, and the stress is turned against the self. Trauma is embedded in the body-mind, a single entity.