Nelleke J. Nicolai, psychiater, psychoanalytica

Respons op de presentatie van Prof. Renos Papadopoulos tijdens het NAAP symposium "Trauma and Tricksters, Post-Jungians Innovations" dat op 19 januari 2008 gehouden werd in Woerden

What can a psychoanalyst, educated in a Freudian tradition and relationist and intresubjectivist by choice and working with survivors of very different kinds of trauma as rape, sexual abuse, early losses, child maltreatment, say when confronted with such an insightful and concise narrative as we had from Renos Papadopoulos? 

Slide 2 Thank god, was my first reaction. Here is somebody who confronts the inflation of the trauma concept and emphasizes the possibility of not only recovery, but also reorganisation on a higher level. Secondly, he gives us food of thought about the dire consequences of medicalisation and secondary victimisation. That is what people keep helpless. And so true, was my third thought. Because refugees have done something. They took flight. They took a turn. They fled instead of being immobilized, helpless and powerless. For flight or fight is better than freezing and collapse. Doing,taking action and thinking -imaginary action and symbolisation- that is what works. And so the are in a very different position than is the core of the present concept of trauma. What I want to do is to take a different angle on trauma and what I means to be traumatised. I propose to pare down the definition, that is grossly inflated in everyday usage and in the media. 

Slide 3 The concept of psychic trauma 

In the first place,” trauma” is a metaphor. It is like most psychological concepts transferred from the realm from the body to the realm of the mind. There is nothing wrong with metaphors. As we know from Lakoff and Johnson (1993): we live in metaphors. Our conceptual apparatus is metaphorically structured: we think for example, about time as a stream. We see our mind as containers, see our future before us, and see our lives as a journey and so on. Our thinking is not possible without metaphors. Metaphors give an immediate insight on an emotional level. They structure our thinking. And in structuring our thinking they bring with them different other metaphors. But they also can be deceptive and tricky. For example, our concept of a self as container is a recent introduction, that can lead to ideas of a special kind of psychic autonomy. But for the sake of argument, I will use the metaphor of self as container. 

For example the skin. As we have heard is trauma the piercing or as Papadopoulos told us, the rubbing of the skin. The original meaning of trauma means wound, inflicted by a piercing element. We see this piercing element back in Freud´s1920 definition of trauma when he speaks about the elementary relation between a living organism and its environment. The living organism is protected by a protective shield. This shield allows only tolerable quantities of excitation thorough. When these excitations are too strong and break through this shield we talk about trauma. The shield in a psychological sense consists of our intact brain, our emotional mind, psychological defence mechanism. Should this barrier suffer any breach, we have a trauma. The task of the mind is to muster all available forces to permit the restoration of the organism. 

You see in this definition, also a metaphor, three elements. The element of a violent external event, the element of a wound that pierced or broke the skin and third the consequences, that affect the whole organisation of the mind. 

Back to Papadopoulos metaphor of the rubbing on or off. As we all know rubbing does not pierce the skin. It leads metaphorically speaking to abrasions. But abrasions heal quickly. Look at your own hands and skin. How many times you had a small cuts and grazes? Probably they did not leave even a scar. Small wounds do seldom lead to scars. Even bigger wounds that led to scars can heal. Think of your own body and all the healed scars it harbours. It is only the not- healed or not properly healed scars that we must call traumatic. So I agree with Papadopoulos that we must not call any event traumatic, but I do not agree with his concept of rubbing on or off. The core of trauma is the breaching or piercing of a metaphorical skin. The metaphorical skin that protects us, by regulating arousal, by giving vent and expressing feelings, by seeking support with attachment figures .By reflecting, talking, symbolization and mentalisation. 

Papadopoulos disagrees with the common notion that refugees are traumatised. I agree. I think this is a consequence from the history of the DSM. In 1980 psycho- traumatic stress disorder became recognized as a psychiatric illness. The only illness that connected a cause: external events to psychological sequelae. As we all know, this was the result of the Vietnam-war, when so many veterans came back with complaints as intrusive images, nightmares, numbing, hyperarousal and secondary drugs and alcohol abuse and depression. 

The definition of PTSD became embedded in a heroic psychiatric effort to objectify and rationalise symptoms and disorders. So trauma became defined in terms of an event or series of events instead of a response. The definition of PTSD however has been changing. It brings back a subjective element . Let us look at the present PTSD-definition of the DSM-IV-TR (2001). 

Slide 4
The person has been exposed to a traumatic event in which both of the following are present. 1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serous injury, or a threat to physical integrity of self and others AND 2. The person’s response involved intense fear, helplessness and horror. (APA, 1994). 

The prevalence of trauma: epidemiology
In a recent state of the art review on posttraumatic stress disorder from Nemeroff, Bremner, Foa and others (2006), the authors stress that most people do not develop PTSD, following a disaster or an event considered traumatic. Following the bombing in Oklahoma for example, about 36 % of the survivors, who had in most cases extensive physical injuries, developed PTSD. More than half of the survivors, 55 % had no psychiatric diagnosis. 

The strongest predictors on PTSD are female gender, ethnic minorities, youthfulness, prior psychiatric problems, inadequate psychosocial resources, developing rather than developed countries, severity of exposure and mass violence. But the strongest predictor of having a d full-blown PTSD after six months. was avoidance, psychogenic amnesia, detachment and estrangement. 

Peritraumatic dissociation
Researchers call this peritraumatic dissociation and population surveys show that this is an important marker for the likelihood of PTSD. Far more than the more known intrusive symptoms, like intrusive memories, dreams and nightmares and being physiologically upset. These symptoms abate with time if they are not accompanied by the aforementioned peritraumatic dissociation. 

The peritraumatic dissociation is an equivalent of the freezing response in animals. In freezing there is immobility, but heightened awareness of the environment. Freeze is followed by surrender, if the stressor is chronic repetitive and inescapable. Freezing becomes then tonic immobility and somatic collapse. Tonic immobility is associated with a decrease in heart rate, decrease in temperature and a shutting down of the environment. In terms of survival it is an ultimate remedy: the “Todstellreflex”. It is an old parasympathetic reflex and is elicited by physical restraint, entrapment or confinement. It is what we know from the extermination camps: the so called muzelmansyndrome. 

With the concept of peritraumatic dissociation, the individual response has come back as central given in trauma theory. From events to response, from objectivity to subjective risk factors. The original Freudian definition of an organic whole, overwhelmed by physiological arousal that can not be put in the action of fight and flight, has become full circle. That can also be reversed: any action that an individual can undertake, even if this action is imaginary, can help to break this cycle of immobility and powerlessness. 

The traumaspectrum
A robust finding on the relationship between event en response is the dose-response effect. The more exposed an individual is to traumatic events, the bigger the chance of PTSD. The symptoms are more severe and risk of psychiatric problems as depression is bigger. The more repetitive or cumulative the events, also the bigger the chance of a PTSD. In trauma theory we make a distinction between trauma I en II type. Type I is one-time, impersonal, like a car accident, a gunfight, a robbery and type II trauma: repetitive, cumulative, and interpersonal. We also recently distinguish a type III trauma. Type II traumas are characterized by long time exposure to isolation, pain, sensory deprivation, torturing, mind control procedures, especially with children.

There is also a developmental perspective. When children are beaten, abused by parents, their attachment system becomes disorganised. The people they tend to turn to as safe haven are also perpetrators. This leads to an approach-avoidance conflict that interferes with the development of safe and balanced representations of self and other. 

Slide 5 The American psychoanalyst Jon Allen went a step further and proposed a trauma spectrum. Attachment traumas like separation, loss of parent’s maltreatment, childhood sexual abuse by parents on the left extreme, when the attachment system as a system for affect regulation is destroyed to intimate interpersonal and repetitive violence in the middle: for example rape, chronic abuse, torture. More to the right: manmade disasters, terrorism, political violence and one time events in adulthood on the right hand. Loss of parents or of your fatherland or mother tongue is not traumatic in itself, when you are an adult with a history of reasonable normal development. It belongs to the realm of what Papadopoulos calls: “Ordinary human suffering”. It is a loss. It is a loss of your culture. Loss of the container of your own culture can lead to homesickness, yearning, sadness and a sense of alienation. 

That brings me to the question of what we can know. When we meet a refugee, what do we know of his or her history? What went before the flight? What kind of traumatic events have taken place? For example and from my own experience. How often we hear about rape as a form of intimidation in all kind of civil wars. In Bosnia many Muslim women were raped by and became pregnant from Serbian soldiers. These women did not dare to talk about these events, because when this was known, they would become ostracized by their own family. It was considered wiser to keep silent about what you had to endure. Rape is one of the events with a conspiracy of silence that binds victim and perpetrator. 

Structural damage
Let us refer to one element that did not get attention sofar. The concept of the skin and the structural damage. That what means that a traumatic history not is resolved. The unresolved trauma we have to talk about if we do not want to lose ourselves in an inflated concept of “eventology”. Like I said before, not every event leads to a traumatic reaction. Sometimes traumas do heal. But when they do not heal, we speak of an unresolved trauma. The skin is our container of our subjective self. The definition of trauma emphasises the breaking of the skin. When a psychological skin is pierced, and the wound does not heal, several well known structural consequences ensue. 

Slide 6 - loss of sense of time and future - loss of the capability to symbolize or mentalize: - Concrete and equivalent mode thinking - Splitting of different modalities. For example Sensory awareness from emotional awareness. Emotions from cognitions. - loss of autobiographical sense of self - change in representation of self and other 

One of the core elements of being overwhelmed by trauma is what we call the invasion by the otherness of the other. So not only is the metaphoric skin pierced, it leads also to an invasion. This is more than rubbing on or off. We can also call it disorganisation, in which elements of feeling bodily sensations interfere with normal thinking or mentalisation. We can call it the introjected or internalised perpetrator, or the internal persecutor or like Fonagy does. “Alien self”. Bion would call it a loss of alpha elements and a return to beta-elements. All these metaphors refer to a loss of distinction between self and other, al loss of potential space, a loss of symbolisation. In their seminal article (Knowing an not-knowing massive psychic trauma, 1993) Laub and Auerhahn describe a continuum of psychological distance. You can also consider it as a pathway to psychological processing of traumatic event. If everything goes alright and the process is not interfered with by negation, disavowal, violence of the environment. 

Slide 7 1. Not knowing 2. Fugue states 3. Fragments 4. Transference phenomena 5. Overpowering narratives 6. Life themes 7. Witnessed narratives 8. Metaphors. 

On one hand is the not-knowing about trauma, the amnesia, or disavowal and the loss of I or subjectivity. An observing ego is lost. The second are fuguestates or dissociative states. The third are fragments: bits of memory, intrusive imagery,dreams. The fourth: Transference phenomena. That implies behavioural re-enactments in relation to others. For example, the well known re-enactment: “Perpetrator-victim”. The last three terms are more descriptive of integration and the process of traumaresolution. 

The shattering of illusions 
Traumatic events, has been said, are so traumatic, because they shatter our assumptions about a safe and just world (Janoff-Bullmann). The strange paradox is that adults with a safe attachment, those who grew up with an idea about a safe and just world and dependable and trustworthy others, are for that very reason those who are more able to cope, to recover, to reorganise. They are more resilient and are more able to use others, to information and others to heal. We know, that people can tolerate the most awful circumstances, even extermination camps, if they are protected by others, as is so beautifully shown in the movie ”La vita e bella”. Resilience is considered by Papadopoulos as a relational process. I quite agree. In the core resilience is not only interpersonal, but also social. Resilience can be enhanced when a wider community does not turn his head, when public speaking of what happened is allowed. 

The second skin 
If you have blisters you can use a new kind of bandage: it is called second skin. You put it on and your skin heals without traces underneath. It protects and at the same time contains substances that benefit healing. Speaking in this metaphor, how can we enhance healing? What works? What evidently works with PTSD is exposure. Exposure is studied with guided imagery and EMDR, telling and retelling the story or writing it time and again. No second skin, but the wound exposed to the air so that it cannot fester silently. Social support is important but the problem is that it must be perceived support and not intended. The same applies for all other social interventions except for work. Meaningful work two tend to enhance feelings of self directedness and autonomy. It is so sad that refugees are forbidden to seek work or education. 

We also have a communal second ,hat envelops us all: culture. To illustrate the power of culture and more specifically art I took a citation from an impressive lecture from the British writer, Jeanette Winterson (2007).

Slide 8 and 9
She uses the metaphors of the cup, the knife and the cloak.The cup, to keep our culture intact. You can not give meaning when you use a sieve. The knife, to cut away all unnecessary information, the information overload from email, internet, cheap TV programs. The cloak, that wraps us and protects us, when we are able to tell stories, have a storage in our own head of myths, songs, poems and thoughts that nobody can take away. A good example of the last is the story of the Crow Indians. All indogenous Americans, have been subjected to brutalised behaviour. They lost their land and livelihood, were massacred in contact with government and army, became addicted to alcohol and gambling. Their children where sent tot schools, where their own language and own cultural expressions were forbidden or considered backwards or primitive. As a result, most indigenous cultures were lost and although there is the beginning of a new revival, most American Indians lead a life of cultural and financial poverty. But the Crow Indians are an exception. They kept their songs and stories and were consequently able to transmit their way of life and culture to their offspring. 

Conclusion
My conclusion is that trauma as a concept is grossly inflated. It is very important to realise that not every human suffering is psychiatric pathology. We cannot speak about trauma, if we do not define what kind of trauma and what structural damage it has done and how to measure this structural damage. The core of traumatic stress is that it leads to unresolvedness. That is the reason why narratives do not become integrated, symptoms will not abate, emotional upheaval can not be regulated. Unresolved trauma has strong connections with dissociation, and the disorganisation of the attachment system. Ways to measure unresolvedness do exist. We also can not tell if refugees are traumatised, if we do not know their full histories. Not all events are traumatic – in the sense that they break a metaphorical skin. Some events do break a metaphorical skin, but they heal. Probably after being healed, they make a person stronger. Sadder and wiser. Even traumatic events do not always have PTSD as consequence. But you can recover from PTSD and even a wounded angel still stays an angel. 

Literature Allen, J. (2001) Traumatic relationships and serious mental disorders. New York, Wiley.
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Lakoff, G. & Johnson, M. 81980) Metaphors we live by. Chicago. University of Chicago Press.
Laub, D. & Auerhahn, N. (1993). Knowing and not-knowing massive psychic trauma: forms of traumatic memory. International Journal of Psychoanalysis, 74,287-302.
Nemeroff, C.B., Bremner, D. et al (2006).Posttraumatic Stress Disorder: a state of the science review. Journal of Psychiatric Research, 40.1-21.
Winterson, J.(2007). The cup, the knife and the cloak. Belle van Zuylenlezing Utrecht. www.vredevanutrecht.nl  
Jung, C.