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VARVIN, S.:
Trauma and the Posttraumatic Process:
Reliving or Rememmbering?
Varvin, Sverre, Norwegian Psychoanalytic Society, Oslo, Norway
(Presented at the Conference «FREUD'S SCREEN MEMORIES in the Light of the Contemporary Psychoanalysis and Neurosciences» in Prague, May 4-6, 2006)
Abstract
The posttraumatic process after extreme traumatisation is characterised by experiences of intrusion and avoidance. The traumatised person tends to feel the world as unsafe and dangerous. Mental schemata or relational scenarios with roots in the traumatic experience are easily evoked which both may increase the fright but also may function as a template for giving meaning to the present and also give direction for behaviour be it increased defence or physical action.
Such relational scenarios are evoked in the transference during treatment and give repercussion in the analyst's countertransference. The transference-countertransference situation thus becomes an arena for remembrance at different levels: at the procedural level through ways of being with the analyst, through images and sensations in the body and through episodes from autobiographical memory which often is fragmented. Embodied cognitive science supports the psychoanalytic view that reliving in the transference is a special way of remembering. What is usually called re-experiencing is then put in a new light. Moreover, the remembering in a transference setting has the potential for healing the traumatic wounds.
This paper will discuss how these insights can be utilised in the treatment of the extreme traumatised patient (survivors of torture, war, concentration camps etc). I will argue that work in the transference is a viable avenue for treating these patients in that this work addresses not only the derivates of the traumatic experience but also the disturbances in the underlying mental processes (especially failure in symbolisation and emotional regulation). Analyses of therapeutic processes will be used to support this argument.
Introduction
This paper is about the effects of extreme traumatisation and the possibilities of therapeutic help in the posttraumatic process 1. The traumatised individual relives, endlessly it is often felt, fragments from their traumatic experience. The traumatised person tries to remember and organise a memory that can be a part of autobiographical memory while at the same time desperately attempting to avoid the painful sensations and memories of the atrocities. The traumatised person is literally a hunted person, a person who is persecuted by fragments of representations from different memory systems, represented in all possible modalities; visual, auditory, sensual, vegetative, procedural and verbal autobiographical memory fragments. For the more fortunate the parts of the personality that harbour reminiscences of trauma may be split off or "abgespaltet" only to show in occasional nightmares, bodily symptoms, (pain is one of the more constant findings in posttraumatic patients), in inexplicable sensations, in altered states of mind appearing at moments of undiscovered crisis (the crisis is triggered by signs of danger outside awareness) and so forth. For many, the mental space is constantly occupied by frightening images and very unpleasant sensations of danger causing emotional upheaval and often disorientation. Krystal describes the effect of giving up in face of an overwhelming unavoidable danger as a transition from fright to a catatonic reaction (Krystal 1978), a reaction that can last long into the posttraumatic process.
Elena has lived through long periods of extreme hardship. Married into a political active family in a country in the Middle East she experienced that her husband and many of his family were arrested and gravely tortured and many of them killed. Soon after she was arrested with her two small children, aged 4 months and two years respectively. With her children she had to endure hard prison ship for more than two years which included malicious maltreatment of both her and her children. Blindfolded for longer period she learned to watch the children by hearing. Apart from the maltreatment inflicted on her she had to watch inmates be tortured and killed. After released followed a long period of persecution and periodically imprisonments before she managed to flee. When she in exile she began treatment she was stiff and almost totally immobilised in her emotions and plagued with constant serious bodily pains. After partial recovery after a long treatment period she could describe this initial state as a paralysis of all her emotions, a constant watchfulness for signs of danger, an overwhelming fright that she was not able to experience consciously and a desolate view on the future, clinging to the hope that it was "only" something wrong in her muscles.
Anna, apparently functioning well in her daily life had experienced the beginning of the war in Bosnia and had managed to escape before being caught in the atrocities done against the civilians in this war. She experienced at a distance the sufferings and death of her relatives. A Rorschach test showed a most extraordinary picture dominated by perceptions of fragments that could signify danger or threats. Behind her social façade, in her mind, the world was structured as a dangerous place where the principal strategy for survival was based on the distinction between what was safe and what was dangerous 2.
Both Elena and Anna suffered from what lays at the basis of every posttraumatic condition as it is seen in persons who have undergone atrocities; the world is no longer safe, you have to watch out and prepare for the catastrophe. But there are also other important aspects of the posttraumatic process. It is not only a situation of constant strife for basic survival. Preservation of the self, of self worth, seeking of meaning, accomplishing tasks not achieved, regaining of infantile omnipotence and fulfilling of wishes and desires are important motivational factors active in the posttraumatic process. When we say the traumatised relive or re-experience the traumatic situation, it is only partial correct. In fact it misses the important points having to do with mental survival in a broader sense than just physical survival. It would more correct to say that the traumatised person are prone to see dangers not only to physical survival but to mental survival and that, moreover, that the traumatised person is highly involved in the most human tasks, not only for keeping oneself alive mentally but also of fulfilling tasks having to do with attachments needs both for the self and for the offspring. When experiencing potential dangers the traumatised then use available mental schemata, based on earlier traumatic experience to organise perception, cognition and memory. Re-experiencing trauma represents, according to this line of thinking, a different way of remembering rather than reliving or re-experiencing and it moreover represents ways of dealing with basic human needs. Memories are moreover in the therapeutic process condensed expressions referring to many aspects of the experience and can, when therapy is successful, successively function as metaphors. That is; they become screen memories (Freud 1899; Krystal 2001).
I will in this paper argue that this conception has important consequences for how to conduct therapy with trauma survivors.
Trauma, traumatisation and the posttraumatic process
The type of traumatisation in question here happen in violent and aggressive milieus such as concentration camps and inhuman prisons where torture is the rule and involves harm done with malignant intention aiming at destroying the personality of the individuals, the coherence of the group or family, and that it moreover often is carried out in a malignant political context of persecution, power struggle and ethnic cleansing. We know that living under these conditions may produce long lasting adverse effects in the personality (Eitinger 1964; Niederland 1981). The effects are complex, involving both psychic and somatic aspects as well as the family/relatives and the groups to which the person belongs (Allodi 1980; Miller 1996; Hjern and Angel 2000; Herman 1992; Hjern, Angel et al. 1998). These types of catastrophic or extreme traumatisation cause major destabilisation in the mind: emotionally and cognitively including the capacity for making meaning of the post-traumatic situation (Tutté 2004).
What makes an experience a trauma? Freud stressed in his later works the importance of the attack on the egos capacity to organise experience (Freud 1926). The person becomes totally helpless overwhelmed by automatic anxiety that cannot be bound and represented and must therefore be dealt with on other ways: very often the body becomes affected in a profound way.
What kind of danger is involved? The danger of loosing the love of the object loosing the object and castration is at the basis. The real danger comes from the destruction of inner structure and the mechanism of the mind that makes daily survival possible. Laub and Podell has described this as the damage or destruction of the bond to the inner empathic object that functions as security and as source for giving meaning to experience (Laub and Podell 1995). Traumatisation creates thus a situation of utter loneliness where the inner resources for maintaining psychic balance and health is constantly threatened.
Based on Freud's work traumatisation one can delineate two interrelated aspects of traumatisation; a psychobiological economic aspect characterised by dysfunction of the psyche's and the body's binding functions and an object relational aspect characterised by internal breakdown in relation to an empathic other (see also Bohleber (2000)). The first aspect concerns the mind and the brains capacity to bind and symbolise emotional experience, the last concerns the capacity for emotional regulation using the other as mediator for ameliorating difficult emotions (rage, hatred, fright etc.) (Varvin 2003). The result is expressed different aspects of the posttraumatic pathology as we know it in PTSD (intrusion, emotional avoidance, hyperarousal), somatisations (lack of symbolisation of emotional experience which then are processed at a bodily level), dissociative conditions as a direct expression the psyche's lack of binding capacity and the defence against being overwhelmed by reminiscences of traumatic experiences. At the core of the posttraumatic experience are disturbances in the capacity for symbolisation and emotional self-regulation, which then causes the known disturbances in the memory function.
Symbolisation and emotional self-regulation are basic mental processes that are necessary for emotional growth. Alan Schore claims that these also are basic for all psychopathology. He writes:
A body of clinical and experimental evidence now indicates that all forms of psychopathology have concomitant symptoms of emotional dysregulation, and that defence mechanisms are, in essence, forms of emotional regulation strategies for avoiding, minimizing, or converting affects that are too difficult to tolerate (Schore 1997) p. 44).
The capacity to regulate negative emotions seems to be essential and the possibility to have access to complex symbolic representations, for example of good internal object relations, gives the possibility for self comfort during period of stress and therefore counteracts the tendency to be overwhelmed by negative emotions. The systems of symbolic representations build up during development and become anchored in mental schemata or object relations schemas. These are functional units in the mind in constant dynamic interaction with each other and with the environment. They function to contain somatic stress and organise emotions and are thus ate basis of the process of giving meaning to emotional experience.
Posttraumatic pathology arises as the result of two interrelated but apparently opposing processes:
- The situation where the transition between different levels of symbolisation of experience is blocked in a way that hinders validation of the experience. This is a situation of excessive defence. We often see patients who are emotionally blocked and do no have any understanding of what they are feeling. Elena, described earlier, realised after several years of therapy that she had been frightened all the time for almost everything. She only came to know this when ordinary feelings like joy and jealousy, too her surprise, began to appear in the later part of her therapy.
- When defences do not protect the ego or consciousness from being overwhelmed in a way that makes it difficult or impossible for the subject to integrate emotional experience. This is a situation marked by a failure of defence. This is typical for situations where patients are overwhelmed by affects in connections with for example talking about painful and shameful traumatic experiences.
Both processes are operative in the posttraumatic process and accounts for the fluctuations we see in these patients during therapy. They seem to live between the Scylla of emotional flatness and poverty and the Charybdis of emotional storms, often with painful somatic sensations. In the worse cases, the traumatised person may prefer to withdraw into loneliness and isolation.
The traumatised person lives, as it seems, both in a present that may be unbearable and a past that is dominated by unspeakable frights (Varvin 2000). This is expression of grave disturbances in the mind's way of dealing with emotional experience. Space does not allow discussing the neurobiological underpinnings of these processes 3.
New conceptions on how memory works can give us additional perspectives on the difficulties the traumatised person meets when trying to orient him/herself, organise experience and relate present to past. It is well established now that memory is not stored and memories are not drawn from a storehouse that contains traces of all our experiences (Schacter 1997). Onforebrain results in failure of semantisation of affect the contrary, the act of remembering is an active process highly dependent on the context. Leuzinger-Bohleber, Pfeifer & Röckerath hold, following Edelman (Edelman 1992), that memory is a function of the whole organism, and sees it as:
"…komplexen dynamischen, regkategorisierenden und interaktiven Prozeß, der immer auf aktuellen sensormotorisch-affektiven Erfahrungen basiert und sich im Verhalten des Organismus manifestiert". (Leuzinger-Bohleber & Röckerath1998) p. 519).
This view supports the psychoanalytic notion that therapeutic change is not the consequence of the cognitive "discovery" of early traumas, but is the result of the continuous recatgorisation in a present relationship, the transference, to the psychoanalyst. One may claim that traumatic memories in this sense are not principally different from other memories. They are actualised in the transference and the work of "recategorisation" done here may change the structure and impact of memories. The difference between traumatic and ordinary memories lays in the quality of the memory traces in that the former consist to a larger extent of senso-motoric and iconic elements (procedural memory). Memories from traumatic experiences are furthermore actualised in relational scenarios, that is, a traumatic memory becomes present in relation to the analyst because this relation inevitably evokes the dangers and hopes involved in any relationship to another. Motivation and agency are involved in these actualisations. Remembering trauma in a healing context may become integrated into the present relationship in ways that are activated by motivation and desire not only to survive but also to accomplish tasks and secure mental survival 4.
The following case may illustrate this process:
Fatima, a woman in her late thirties, came to Norway as a refugee from a country in the Middle East 9 years before she started therapy. She had not had any psychiatric illness or problems prior to her traumas. She reported a relatively happy childhood, being loved both by father and mother and her siblings, and she had managed to get an education. She was married and was working as clerk when she was arrested because of participating in a political organization that pursued their political aims by peaceful means. At the time of her arrest, she was pregnant in the last trimester. She was maltreated physically (including beatings on her pregnant womb) and psychically (threats, seclusion etc.) and suffered from malnutrition and lack of proper medical care when she became ill. Her husband was arrested at the same time and was tortured to death some months later. She was allowed to go to a public hospital to give birth, and an escape was arranged for her shortly thereafter. While she was living clandestinely, her child died of an unknown disease, probably caused by the torture, maltreatment, and lack of adequate medical care during her prison experience (she had had fever and bleeding).
After the death of her child and husband, she lived clandestinely for about one year before she fled from her country under difficult circumstances. During this time, she experienced additional serious traumas. When she arrived in Norway the authorities did not believe her. She was put in prison and sent back to a third country where she had to live under very poor conditions for some time before she again was allowed entrance to Norway. She was then severely depressed and suicidal and had serious eating problems in addition to post-traumatic symptoms and psychosomatic symptoms.
In the first years of her stay, she had a short period of psychotherapy. She continuously had symptoms including nightmares, re-experiencing, avoidance behaviour, somatisation, and psychosomatic illness (duodenal ulcer), and recurrent depression. In spite of this, she managed to settle and achieve a considerable degree of integration in the community. She was educated in a health profession. She lived alone and had friends but no intimate contact with men.
The stress of losing a child and a husband was complicated by Fatima having to flee and settle in exile. She had additional losses, of family, friends, language, culture, and so forth. The forced loss is for many the most burdensome part of being exiled (Varvin & Hauff 1998), and even after 9 years in Norway the exile-conflict 5 was still very much alive in her.
Fatima had to a large extent mourned her husband, for example, performing grief-rituals on his birthday. Not so with her child. The loss of the child remained difficult to talk about and she reacted strongly whenever confronted with situations that reminded her of her child's death. Her choice of a profession working in the health care system, which also involved work with children brought her, however, into situations where she was reminded of her lost child and probably had additional psychological meaning. However, facing the loss was so painful that she did not tell the analyst the circumstances of the loss until the facts emerged haltingly after some time in therapy.
Her grief work was hindered both by her external circumstances and by her internal situation. Culture-specific modes and schemes for grief had been interfered with. For example, her culturally based inclination to give time and space to mourning was opposed initially by the regime's suppression and by her comrades' rather cynical attitude towards loss and bereavement. Similarly, her life in exile was characterised by high levels of activity, lots of helping others, and little time for herself, seemingly reflecting a need to act rather than feel.
Themes of loss were present during the first part of the treatment without, however, Fatima talking about her own loss. In what I will cal a key session, the loss of her child appeared seemingly abruptly on the scene. This was the first session after a weeks break in therapy. She came running to the session believing she was late; "I lost the bus", she exclaimed with short breath. The therapist had a feeling of urgency and a strong desire to calm her down. She spoke of being alone and her need to have someone to be dependent on, someone who can take care of her. On the other hand she maintained that all in all she had to be independent, manage on her own. She described her problems in being apart from her family. Her mother wanted her to come home but realized it would have been dangerous. Fatima wanted to feel close to her family, but on the other hand they did not know how she lived, and so their advice and attempts to influence her often seemed misdirected. She acknowledged an analogy between her leaving home earlier to establish her own family against her father's wishes and her present wish to settle in Norway. Her positive, albeit ambivalent, picture of her own family, together with the safety she felt in therapy, seemed to underline her wish to belong somewhere.
The holiday had been hard for her and she had felt alone and vulnerable. As she struggled with her desire to have close contacts, Fatima expressed, maybe more implicitly than explicitly, a wish to have a family. The analyst's confirmation of this wish brought up the unfinished grief, starting with rather strong psychic and somatic reactions, which continued after the session.
A while into the session she became silent, crying, "I have been thinking", she said, "if I had my daughter, he would have been 13 years old and .. (crying). Reluctantly she narrated in fragments what happened when she gave birth to her child.
"It is like a film that goes", she said, "I have thought about it ...", and she cried heavily, but also smiling. "It was so terrible. I don't know what to say". "I had forgotten all that happened. In a way I think it was like a fight that I won. (incomprehensible) and then I heard that she cried, the child. then I thought that it is a living child, healthy. .. later. "It was like a dream everything (laughs and cries)". " It was a short time; ... the happiness was only (incomprehensible). Short time that the child was alive. and then I was very frightened of (police) and I lived in a secret place, but I; ... was, had really a hope that it would go well, And then a person who had been in prison together with the father; he told me much about (how her husband had reacted); he had been thinking so much (about us)".
In the evening after this session, Fatima reacted physically and psychically, being very upset and getting pains, and she had to seek a medical doctor. Such somatic symptoms had previously been usual for her but had abated during therapy.
This session represented a breakthrough of memory fragments that belonged to her traumatic past and her reactions indicated that she was on the verge of being re-traumatised. It proved, however, to represent a starting point for working through of her traumatic loss.
What was then the context for this emergence within the transference of this re-experiencing or remembering?
In the next session she revealed that she some days before had a terrible dream:
I did not tell you, I dreamt for three nights ago that I cried.. I was very narrow in my throat and, and had like saliva around my mouth. It's like a; then I thought like, what is it that makes me feel. I don't get enough oxygen and, like heavy breathing. When I, eh, was in the middle of crying, when I woke up.
She revealed also that she the same night had dreamt about father who had died while she was in exile.
She was then able to tell how her baby died. The baby was in her arms, gasping for air, slowly being suffocated while the helpless mother could nothing but trying to comfort her. She was, needless to say, desperate and felt an urgent need for help.
The sequence before the session could then be understood in terms of the actual transference situation. The analyst had been away for a week and she had felt desperately lonely and had longed for her family and for the analyst, for someone to take care of her. The separation had evoked her losses and unconsciously she had identified with her suffocating child (she was almost out of breath when she arrived at the session, having "lost" the bus, and her short breath lasted for quite a long time in the session). The analyst felt an urgent need to help her in the session.
A scenario had then been staged in the session where she was the suffocated child and the analyst was assigned the role as the helpless mother. It is maybe not insignificant that the analyst had the following countertransference dream in this period of the treatment: "I was travelling and happened to pass a sick person. I felt desperately that I had forgotten my medical skills and made plans to re-educate myself".
In the sessions following the key session, she tried to gain coherence and meaning about the child's death; what happened? How did it happen? What was the cause? She spoke of the pain of not having any pictures or things from her child (these were all confiscated by the authorities, together with her other belongings). She described not knowing what to do when the milk did not stop. She talked about the name of the child-the one that she wanted to give him and also a name her parents wanted to give. Moreover, she recalled the impossibility of a proper burial. Telling these stories gave voice to the experience. This process was emotionally laborious. She experienced a spectrum of feelings from sorrow and sadness to anger. She tried, however, to fight the tears during the sessions; she cried but felt that she would have liked to be alone when crying. In this connection she remembered the hard style in her political group towards what was described as woman-feelings. After a while other losses emerged in the session and she was gradually able to mourn her father and other close ones she had lost.
Memory: past, present and future
It has been claimed that the traumatised lives in the past; that there may be two parts of the personality, one occupied with the present and daily living and the other deeply occupied with past traumatic experiences, unfinished or not worked through traumas and losses. This seems to be only one part of the truth. Posttraumatic disorders represents a special reorganisation of the personality that implies a potential mental state concerned with anticipation of danger. These mental states are recurrent and can be actualised in many situations and we must understand that there are many such situations in a traumatised person's life. For many, any situation may be possibly dangerous, others develop phobic conditions so as to avoid the posttraumatic mental state.
In these mental states consciousness is not only drawn towards the past but more basically towards the future. The most important issue for the traumatised is to anticipate dangers and this can only happen when certain emotions/affects are evoked that give significance or relevance to present experiencing, most often fright, anxiety and anger. There is in this situation an aberration of the normal functioning of memory. Under ordinary circumstances, when old memories emerge in a new context, the normal process implies a recontextualisation in light of the present affective context. Central in this process is, according to Modell, the function of the metaphor (Modell 2005). Metaphors mediate between past and present and can function as mental tools, so to speak, in the cognitive process where memories are retranscribed, that is, gain new significance by being actualised in a new context. The "storehouse" model of memory (to which Freud adhered in many texts (se for example "The magical writing pad" (Freud 1925))) is, as mentioned, insufficient to understand this process. Memories are not extracted from a "memory bank" and reproduced in its original form. According to the dynamic view on memory and remembering memories are not only re-transcribed and re-contextualised when they are remembered. The next time you remember past occasions of remembering will have set their marks on memory traces from the same experience. This is a central feature of the insights from "embodied cognitive science" developed by Leuzinger-Bohleber, Pfeifer and Röckerath mentioned earlier. Memories are evoked in an emotional-bodily context that gives significance to what is remembered and how it is remembered. Memory is thus under normal conditions reconstructive, re-categorisational and context-dependent. Traumatic memories are also in this sense context dependent; that is, based on actualised senso-motoric and affective experience. The reason for their apparent repetitive character is that recategorisation on a symbolic level fails and this has as background the failure or insufficient symbolisation of the traumatic event or events. Experiences are inscribed in the implicit, nonverbal procedural memory systems and the result is a failure of the function of the metaphor as mediating between past and present experience. The metaphor looses its transformative power.
For the metaphor to function a protected inner space is necessary; a space where it is possible to play with meaning and where meta-perspectives may put experiences in a new light where new affective contexts may support different interpretations of past and present. Fatima achieved this, at least partly, in her treatment. The fact of her child's death was unavoidable, but her desperate guilt for not having been able to protect and save the child diminished and she was, in the affective context of the transference, able to re-contextualise important aspects of this painful experience. Moreover, she could start a delayed process of mourning.
The functioning metaphors in this context were connected with the affective tie with the analyst where different aspects and positions in her dramatic inner scenario could come to life in the transference. She could in this context be the young girl seeking protection and belonging from her family through the affective tie with her analyst. She could expose herself as the helpless mother not being able to save her child and she could identify with the child leaving the role as the helpless helper to the analyst and express her anger and disappointment in relation to him. Before this was verbalised in the transference these experiences where represented on a unconscious and non-conscious level in her body (pains, depressions etc) and only gradually they approached the verbal level through dreams (being suffocated) and lastly through the laborious working through where also other losses joined in.
The following case vignette may illustrate an almost complete failure of the metaphoric function of the mind.
M, a woman from an African country lived through a period of civil war in her youth. She experienced violent combats close by, air attacks and several arrests where she was tortured and raped. She managed almost ten years in exile without seeking help, raising three children alone and combating her posttraumatic problems quietly and apparently efficiently. Two years before she was referred for treatment her son was abducted by a paedophilic. He managed to flee, but from that moment the nightmarish experiences from her home country came for full, day and night. She had nightmares, constant fright, hallucinations of persecutors and became sleepless. She was barely able to continue taking care of her children. She constantly feared that the perpetrator would return and the fact that the police did nothing to help her signified for her she again was totally alone faced with grave dangers.
This situation is not uncommon for traumatised persons: a new incident, here a serious one, set in motion all the horrors from the past. The world again becomes unsafe, unpredictable and very dangerous. What is experienced here is a repetition of the utter helplessness of the traumatic situation, the experiences "that nobody helps and the devastating feeling that nobody cares". In this situation M's mental functioning was characterised by concrete thinking: a sign of danger was a signal of danger. The metaphors failed her; she could not use a metaperspective to orient herself in any social situation. She functioned in an equivalence mode as described by Fonagy, Gergely et al (2002); what is in her mind is also out there. Modell suggest that this type of cognitive functioning is characterised by "metonymy". Metonymy takes the part for the whole. This way of organising perception was obvious in the Rorschach protocol mentioned earlier. Percept are not organised according to ordinary wholes where foreground and background have a reasonable relationship. Details and odd, idiosyncratic organisation of precepts take the foreground and on closer observation, these percept are more or less directly derived from the trauma related mental schemata. The intention or aim, however, is future oriented; to avoid danger.
The protective barrier (Freud 1920) or membrane surrounding the inner psychic space has in these situations become perforated. Impressions from within or without are no longer contained in viable psychic representations that can mediate between past and present. In a way, the past becomes the present. The traumatised person finds herself in a situation where ordinary experiences become intolerable and she is cut off from an otherness that can provide life saving metaphors in a meaningful affective context where symbolisation again can be set in motion.
This points to the two aspects of trauma mentioned earlier: the intrapsychic, economic; there is a too much and the intersubjective relational. Traumas, and re-traumatisation such as experienced by M, are situations of utter loneliness where others, both internal and external are experienced as out of reach. There is damage in the relation to the empathic internal other and other people are experienced as unreliable. Therapy aims to remedy these failed processes. The strength of psychoanalytic therapy lays in the fact that it addresses the processes that lies at the ground of the posttraumatic process. It does not rely on only a retranscription of the cognitive picture of the traumatic situation as in many exposure therapies (for example EMDR).
Conclusion
The disturbed structure of the internal subject-object relationships in traumatised patients manifests themselves in discourse and symbol-formation, and their ways of relating to others socially, emotionally and in fantasy. Dimensions of hope and mistrust mark the initial meeting with a potential helper. Hope of emerging from the inner emotional chaos and haunting nightmarish perceptions and a profound suspicion that this encounter may be felt as a repetition of past helplessness and ignorance. In my experience therapies with extremely traumatised persons may, stronger than with other patients, be characterised by an initial hopefulness often leading to an euphoric feeling of at last be heard and understood. The inevitable disappointment when painful symptoms do not disappear and when the analyst proves "insufficient and incompetent", may lead to strong negative transference reactions. This may take up the larger part of therapy. The emergence of a new hopefulness is as a rule characterised by a beginning dominance of binding forces of the mind. The un-binding (Entbindung) of the emotional chaos subsides and connections are made where metaphors that emerge in transferential affective context, may mediate between past and present experiences just as we saw with Fatima.
The posttraumatic condition is thus not only defined by the trauma but represents an amalgam of the defence and coping during trauma and the personal elaboration of the traumatising influence afterwards. The first, the subjective experience during traumatisation, will depend on the traumatic context (type of trauma, interpersonal context, etc). The last will be dependent on many factors; previous traumas, ego-strength (dependent also on disposition), the environment's reactions afterwards 6 and the highly individual way of coping with the traumatic influence; ability to repress or dissociate, creative elaborations of the past (see for example Primo Levi's work (Levi 1987; Levi 1987)). In short the posttraumatic condition is an experience coloured by unconscious conflict, fantasies and wishes. What we meet in the transference is thus a highly personalised version of the original trauma. The fact that traumas seem to appear as "foreign bodies" in the mind may be the background for treating them as fixed entities that could be removed or modified by suggestive or manipulative techniques (exposure therapies) etc. Psychoanalytic work with and in the dynamics of the transference stands in sharp contrast to the mechanic approaches where considerations on unconscious intention and desire are excluded and the therapist acts more as coach that helps the patient change cognitive schemas related to trauma 7.
Underlying these differences are different concept of the meaning and the function of the symptom. In the mechanistic approach, first represented by Janet, there is no intention involved in the disorganisation of the mind after trauma. He coined the term "feebleness of mind" as a quasi explanation to distinguish those who became affected and those who were not. The psychoanalytic approach gives priority to the meaning the traumatic memory achieves in a given situation in therapy and to the intentions and wishes that is behind its appearance. In Fatima's case it was clear that the emergence of her traumatic loss gained significance within the transference and the wish behind was to change the traumatic chain of events, putting the analyst in the role of the saviour. At the same time there was an acknowledgement that the battle was lost. She could then start a complicated process of mourning.
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FOOTNOTES
1 I use the term "Posttraumatic process" to underline that what happens after trauma is a process of change and adaptation depending on the interplay between trauma, personality factors and context (especially the responses from others). back
2 Marianne Opaas has generously offered me access to this Rorschach protocol back
3 A dominance of conditioned responses and priming are connected with diminished functioning of the hippocampus and the forebrain result in failure of transformation of bodily experiences and affects into symbolic representations on different levels. This process may be called semantisation of affects, a process whereby bodily excitation is connected with mental representation, verbal meaning and eventually narratives (that is, increasing elaboration of emotional meaning). Chiozza calls this "secondary affect", which reflects a tempering of the affects through the thought process. Full discharge is called "primary affect", a situation where affects is expressed directly and forceful without any modulation Chiozza, L. (1999).. The gap between primary and secondary affect may then be viewed as reflecting the discrepancy often seen when the traumatised person in a disaffected mood can tell parts of a trauma story while in the next moment be severely affected by raw unmediated re-experiencing. It may also be seen as the inability of the implicit memory or representational system to bind and symbolise or mentalise affect. The process whereby primary affect leads to secondary affect is in fact what characterises regulation of emotional experience. At a basic level experience is organised in the body. Here information from the body and the sense organs are integrated ate level of the brains into complex patterns, which creates more or less coherent patterns. Information from these different sense modalities is organised in parallel-distributed processes and assembles information in for example a picture of a tree, a table a human being, different forms of actions etc. Hippocampus in the brain plays a decisive role for categorisation and integrations of information from these different sense modalities in a coherent symbolic picture Bucci, W. (1997; Saporta, J. (2003)... There is, according to Mesulam, several "transmodal nodes" in different parts of the brain whose task is to bind and integrate information from different areas of the brain to "multimodal" models and to conceptual (verbal-symbolic) knowledge Mesulam, M. M. (1998). Hippocampus and the entorhinal cortex are decisive in this process that binds and integrates information into coherent episodic memory (which is part of the explicit memory system). Wernicke's and Broca's areas in the brain integrates for example information from the sense into verbal symbols and the prefrontal "transmodal nodes" distributes these information to working memory (the memory we have active at any time, in which we work to gain some coherence of the impressions of the actual moment). It should be noted that the "transmodal nodes" are not store-houses for information but functions rather as directories that bind together information from different areas back
4 This contrast the view by many trauma researchers that remembering trauma basically is a passive process van der Kolk, B. A. (1994). "The body keeps the score: memory and the evolving psychobiology of posttraumatic stress." back
5 This a common conflict in exiles where adaptation and integration can imply a feeling of betrayal of one's roots Varvin, S. and W. B. Stiles (1999). back
6 Keilson and Sarpathie's research on young Jewish survivors after World-War II showed that what happened when survivors came back predicted to higher degree than the traumas of persecution and concentrations camps health and sickness 25 years later Keilson, H. and R. Sarpathie (1979). back
7 The differences presented here have its roots in the differences between Freud's and Janet's views respectively. back
© Sverre Varvin, MD, PhD, 2006
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Norwegian Centre for Violence and Traumatic Stress Studies
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