Approaches to Psychic Trauma: Theory and Practice 9781442258150, 9781442258143, 9781442258167

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Approaches to Psychic Trauma

Approaches to Psychic Trauma Theory and Practice

Edited by Bernd Huppertz

ROWMAN & LITTLEFIELD

Lanham • Boulder • New York • London

Published by Rowman & Littlefield An imprint of The Rowman & Littlefield Publishing Group, Inc. 4501 Forbes Boulevard, Suite 200, Lanham, Maryland 20706 www.rowman.com 6 Tinworth Street, London SE11 5AL Copyright © 2019 by The Rowman & Littlefield Publishing Group, Inc. All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without written permission from the publisher, except by a reviewer who may quote passages in a review. British Library Cataloguing in Publication Information Available Library of Congress Cataloging-in-Publication Data Names: Huppertz, Bernd, author. Title: Approaches to psychic trauma : theory and practice / Bernd Huppertz. Description: Lanham, MD : Rowman & Littlefield Publishing Group, Inc., [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018026470 (print) | LCCN 2018037502 (ebook) | ISBN 9781442258150 (electronic) | ISBN 9781442258143 (cloth : alk. paper) | ISBN 9781442258167 (pbk. : alk. paper) Subjects: LCSH: Post-traumatic stress disorder—Treatment. | Psychic trauma—Treatment. Classification: LCC RC552.P67 (ebook) | LCC RC552.P67 H87 2019 (print) | DDC 616.85/21—dc23 LC record available at https://lccn.loc.gov/2018026470

™ The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI/NISO Z39.48-1992. Printed in the United States of America

Dedicated to my parents with gratitude

Traumatized people suffer damage to the basic structures of the self. They lose their trust in themselves, in other people, and in God. Their selfesteem is assaulted by experiences of humiliation, guilt, and helplessness. Their capacity for intimacy is compromised by intense and contradictory feelings of need and fear. The identity they have formed prior to the trauma is irrevocably destroyed. —Judith Herman, Trauma and Recovery, 1992, 56

Contents

Preface xi Acknowledgments xvii Introduction xix

Part I: A General Introduction to the Nature of Trauma

1

 1  On the Development of the Concept of Trauma: Definition, Elements, and Relevant Terms

3

Bernd Huppertz

 2  The Psychiatric Approach, the Subgroups of Posttraumatic Syndromes, and the Neurobiology of Stress and Trauma Bernd Huppertz

Part II: Dimensions of Trauma

 3  Development and Trauma: Recapitulation of Traumatic Themes in Early Interaction Louise Newman

17

37 39

 4  Historical and Intergenerational Trauma: Radioactive

Transmission of the Burdens of History—Destructive versus Creative Transmission Yolanda Gampel

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 5  The Reality of Horror: Psychic Survival in the Face of Massive Trauma Louise Newman

 6  The Role of Cumulative Micro-trauma in Psychic Life:

An Abridged Description of Injurious Relational Functioning Margaret Crastnopol

 7  Building Resilience: The Example of Ambiguous Loss Pauline Boss

Part III: Social Psychological Aspects of the Totalitarian Communist System

 8  Political Psychology, Effects of Historical Processes, and Cultural Trauma Bernd Huppertz

63

73 91

107 109

 9  Sociohistorical Overview of Germany: The Development

of the Federal Republic of Germany (GFR) and the German Democratic Republic (GDR) Bernd Huppertz

10  The False Self Adrian Sutton

11  Totalitarian and Post-totalitarian Matrices: Reflective Citizens Facing Social-Psychic Retreats Marina Mojović

12  A Post-totalitarian Group: A Collective False Self or Posttraumatic Growth? Helena Klímová

115 143

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177

Part IV: Clinical Material

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13  Case History Summaries 14  The Case of Mr. Q 15  The Case of Mrs. U 16  The Case of Mr. R 17  The Case of Mrs. O

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205 211 217 223

Contents



18  The Case of Mrs. P 19  The Case of Mrs. M 20  The Case of Mrs. N 21  The Case of Mrs. B Part V: Trauma Treatment Grounded in Psychodynamic-Psychoanalytic Approaches

22  Challenges of Treatment with Traumatized Individuals from a Modern Freudian Perspective Anna Balas

23  Trauma and Inner Reality: A Kleinian and PostKleinian Perspective Mariângela Mendes de Almeida

24  Trauma Treatment from the Winnicottian Perspective Adrian Sutton

25  Theoretical and Clinical Implications of the Concept of the Zero Process: An Ego-Psychology Perspective Joseph Fernando

26  Extreme Traumatization: Conceptualization and Treatment

from the Perspective of Object Relations and Modern Research Sverre Varvin

27  Contemporary Self Psychology and Its Treatment of Traumatized Patients Koichi Togashi and Amanda Kottler

28  Relational Psychoanalysis and Trauma: The Significance of Witnessing and Containing Adrienne Harris

29  Trauma Work via the Lens of Attachment Theory:

Gaslight—Reality Distortion by Familiar Attachment Figures Orit Badouk Epstein

Part VI: Arts Therapies

30  Embodied Mentalizing or “Meaning-Making” in Music Therapy with Traumatized Children Jacqueline Z. Robarts

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229 233 239 245

251 253

265 281

295

307

323

333

347

365 367

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31  Trauma Work in Play and Drama Therapy: The Importance of the Theatre of Resilience Sue Jennings

389

Part VII: Other Trauma Treatment Approaches

401

32  Mentalization and Its Role in Processing Trauma

403

Nicolas Lorenzini, Chloe Campbell, and Peter Fonagy

33  The Treatment of Trauma: The Neurosequential Model

and “Take Two” Annette Jackson, Margarita Frederico, Allison Cox, and Carlina Black

423

Part VIII: Summary and Outlook

457

34  Conclusion

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Bernd Huppertz

Index 471 About the Editor and Contributors

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Preface

This volume is written for people who are interested in a book covering the

many developments in the relatively new field of trauma therapy. Its main task will be to examine the nature of the wide variety of treatments available for traumatized people. This will involve describing elements they have in common, as well as those that are specific to each treatment. It should be of interest to therapists, social workers, psychologists, and psychiatrists who are concerned with the effectiveness of treatments. It will also be of interest to historians, social historians, sociologists, social anthropologists, systems analysts, and politicians because a further task undertaken was to illuminate the historical context in trauma therapy. When I started in my psychiatric work in the former GDR, I focused strictly on the internal psychic structure of my patients. Then, as I began to understand the effects of history and political processes on so many of my patients, it became clear that I had to take external factors more into account. Considering these political processes in terms of “history as trauma” and the “inter-generational transmission of trauma” (Lifton 2001), I saw that “we cannot take the case history out of history, and also that we cannot take history out of the individual case” (Lifton 2001). In particular, Dr. Wallerstein, a psychoanalytic commentator on the psychiatric patients in my first book (Huppertz 2013), asked the important and interesting question of whether there might be a link between the passive inhibited character constellation of these patients and their exposure to authoritarian regimes. My patients had lived under two totalitarian systems, the Nazis and the Communists, experiencing war, migration, and flight, living finally in a system that attempted to penetrate every aspect of individual life. They did not focus on the specific

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traumas of political oppression such as prison, torture, or persecution, but only on the “normal” results of repressive systems. This book presents a diversity of theories and tools centering on trauma and history, and through the microcosm of individual personalities, one may have a close-up view of how historical events, as well as personal narratives and reactions to them, consciously as well as unconsciously, affect the individual. THE STRUCTURE OF THE BOOK An introduction to the field of trauma therapy is followed by part I, “A General Introduction to the Nature of Trauma.” Chapter 1 gives a short overview “On the Development of the Concept of Trauma: Definition, Elements, and Relevant Terms.” Chapter 2, “The Psychiatric Approach, the Subgroups of Posttraumatic Syndromes, and the Neurobiology of Stress and Trauma,” also by the editor, integrates findings from neurobiology with those from trauma theory and treatment. Part II addresses “Dimensions of Trauma.” Chapter 3, “Development and Trauma: Recapitulation of Traumatic Themes in Early Interaction,” by Louise Newman, illustrates the implications of trauma for development. Chapter 4, “Historical and Intergenerational Trauma: Radioactive Transmission of the Burdens of History—Destructive versus Creative Transmission,” by Yolanda Gampel, illustrates how social upheaval may affect the individual psyche. Chapter 5, again by Louise Newman, discusses a further element, “The Reality of Horror: Psychic Survival in the Face of Massive Trauma.” Chapter 6, by Margaret Crastnopol, describes “The Role of Cumulative Micro-trauma in Psychic Life: An Abridged Description of Injurious Relational Functioning,” and chapter 7, by Pauline Boss, “Building Resilience: The Example of Ambiguous Loss.” In part III, titled “Social Psychological Aspects of the Totalitarian Communist System,” chapter 8, by the editor, gives an overview: “Political Psychology, Effects of Historical Processes, and Cultural Trauma.” Chapter 9 then moves on to setting the particular scene, “Sociohistorical Overview of Germany: The Development of the Federal Republic of Germany (GFR) and the German Democratic Republic (GDR),” again by the editor, and focuses on the common effects of repressive totalitarian systems on individuals and groups. To further understand the general and lasting effects of larger factors, such as social upheavals and the development of totalitarianism on the personal history and psyches of individuals and groups over time, I have included chapters on “The False Self” by Adrian Sutton (chapter 10), “To-



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talitarian and Post-totalitarian Matrices: Reflective Citizens Facing SocialPsychic Retreats” by Marina Mojović (chapter 11), and “A Post-totalitarian Group: A Collective False Self or Posttraumatic Growth?” by Helena Klímová (chapter 12). In part IV, “Clinical Material,” I illustrate several of these contextual issues by describing eight cases from my private psychiatric/psychotherapeutic practice in the former GDR. My patients experienced war, migration, and flight under the Nazi dictatorship. Then, from 1945 until 1989, they lived under the Communist dictatorship, a system that attempted to penetrate every aspect of individual life. During these forty years of the GDR, as I have said, everything was under the direction of the one party, the SED; its police state was organized by the Stasi (state security service of the former GDR) secret police unit and under strict control—so-called Lenkung (guidance), which controlled and organized the population “from the cradle to the grave.” The repressive consequences of the German Communist totalitarian system on individuals and groups will be discussed and illustrated. The two world wars, together with the effects of the Nazi and the Communist totalitarian system (chapter 9), seem inevitably to have affected all my patients, some more than others. Here I focus not on the extreme traumas of political oppressive systems such as imprisonment, torture, or persecution, as, for example, in the history of the Lithuanian people (Gailienė and Kazlauskas 2005; Gailienė 2015). Rather, I focus only on the “everyday” effects of repressive systems. At first, I give summaries of these case histories in chapter 13 and will then describe their symptoms and history of trauma. I also describe the trajectory of their development in treatment in chapters 14–21. With the level of conflict and violence still so evident throughout the world, it is vital for clinicians, of whatever theoretical persuasion, to be able to consider how to help those so damaged by conflicts, both past—often long past—and present. APPROACHES TO TRAUMA TREATMENT In parts V to VII, I invited various colleagues with different approaches to the treatment to demonstrate their theoretical frame in a short overview, and then to review its technical consequences and possible implications for interventions. I asked them to give their own rationale for their therapeutic thinking. I have included a group of psychodynamic and psychoanalytic treatments, a group of arts therapies, and some newer treatments. I have not been able to include many other forms of trauma treatment approaches. However, in so

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doing I may have missed out on some excellent treatments, and my selection does not claim to be comprehensive. Part V is called “Trauma Treatment Grounded in PsychodynamicPsychoanalytic Approaches.” Anna Balas describes in chapter 22 “Challenges of Treatment with Traumatized Individuals from a Modern Freudian Perspective.” In chapter 23, Mariângela Mendes de Almeida writes about “Trauma and Inner Reality: A Kleinian and Post-Kleinian Perspective.” Adrian Sutton discusses in chapter 24 “Trauma Treatment from the Winnicottian Perspective,” while in chapter 25, Joseph Fernando writes about “Theoretical and Clinical Implications of the Concept of the Zero Process: An Ego-Psychology Perspective.” Chapter 26, by Sverre Varvin, describes “Extreme Traumatization: Conceptualization and Treatment from the Perspective of Object Relations and Modern Research,” while in chapter 27, Koichi Togashi and Amanda Kottler discuss “Contemporary Self Psychology and Its Treatment of Traumatized Patients.” Chapter 28, written by Adrienne Harris, looks at “Relational Psychoanalysis and Trauma: The Significance of Witnessing and Containing” and in chapter 29, Orit Badouk Epstein describes “Trauma Work via the Lens of Attachment Theory—Gaslight: Reality Distortion by Familiar Attachment Figures.” Part VI, “Arts Therapies” will be described by two workers in the field. Jacqueline Robarts in chapter 30 discusses “Mentalizing or ‘MeaningMaking’ in Music Therapy with Traumatized Children,” while Sue Jennings writes about “Trauma Work in Play and Drama Therapy: The Importance of the Theatre of Resilience” in chapter 31. In part VII, “Other Trauma Treatment Approaches,” chapter 32 presents a more recent trauma treatment approach, through the work of Nicolas Lorenzini, Chloe Campbell, and Peter Fonagy, titled “Mentalization and Its Role in Processing Trauma.” Finally, chapter 33, by Annette Jackson, Margarita Frederico, Allison Cox, and Carlina Black, discusses “The Treatment of Trauma: The Neurosequential Model and ‘Take Two.’” Part VIII, “Summary and Outlook,” addresses in chapter 34, the book’s conclusions, which offers a distillation of common elements of trauma treatment. All eight parts of the book open with an introductory note by the editor. REFERENCES Gailienė, Danutė, and Evaldas Kazlauskas. 2005. “Fifty Years On: The Long-Term Psychological Effects of Soviet Repression in Lithuania.” In The Psychology of Extreme Traumatization: The Aftermath of Political Repression, Genocide and Resistance, edited by Danutė Gailienė. Vilnius: Akreta Research Center of Lithuania.



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Gailienė, Danutė, ed. 2015. Lithuanian Faces after Transition: Psychological Consequences of Cultural Trauma. Vilnius, Lithuania: Eugrimas. Huppertz, Bernd, ed. 2013. Psychotherapy in the Wake of War. Lanham, MD: Jason Aronson. Lifton, Robert. 2001. “History as Trauma.” In Beyond Invisible Walls, edited by Jacob Lindy and Robert Lifton. New York: Brunner-Routledge.

Acknowledgments

First, I would like to remember Robert S. Wallerstein with gratitude, whose

comments provided the motivation for this book. I would also like to thank Anne Alvarez for her enthusiastic support, her discussions, and her help with editing issues. I am also very grateful to Judith Edwards for her help with the English translations of the chapters and to Anne-Marie Sandler and Mario Jacoby with discussion of the cases. I thank Zoe Sutherland and Taylor Frecker for their assistance with the grammar, proofreading, and formatting. My special thanks go to Molly White, Nancy Roberts, and Kathleen E. O’Brien from Rowman & Littlefield Publishing Group. In addition, I would like to thank the following people for helpful advice: Jon Allen, David Armstrong, Carl Bagnini, Paula Barkay, Ghislaine Boulanger, Peter Buirski, Theodore B. Cohen, Shelley R. Doctors, Pamela Donleavy, Wendy D’Andrea, M. Gerard Fromm, Danutė Gailienė, Penelope Garvey, Viviane Green, Nick Grey, Grazina Gudaite, Bruno Hildenbrand, Catherine Henderson, Evan Imber-Black, Theodor Jacobs, Angela Joyce, Donald E. Kalsched, Bessel van der Kolk, Marie Monica Lanyado, Christine Laznik, Marinella Lia, Donald Meichenbaum, Jean Jacques Moscovitz, Eva Münker-Kramer, Morris Nitsun, Kerry Novick, Anton Obholzer, Pat Ogden, Jaak Panksepp, Bruce D. Perry, Daniel Pick, Joan Raphael-Leff, Sheila Ritchie, Sibylle Schacke, David Scharff, Edward Shapiro, Neil Skolnick, Mark Solms, Frances Thomson-Salo, Vamik D. Volkan, Janine Wanlass, Ruth Wraith, Yoram Yovell, Richard Zeitner and Maggie Zellner. Finally, I remember with much gratitude the inspiration I had from my teacher in medical history, Hans Schadewaldt, MD. He taught me to see things and terms in their contexts. Thankfully I remember Jeanne Lampl-de xvii

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Groot, MD, and Annemarie P. Weil, MD, for their empathic support. Last but not least, I have to thank Gottfried Appy, MD, who taught me my first steps in trauma treatment, Jacob Arlow, MD, and Angel Garma, MD. Special thanks remembering Eberhard Bay, MD, professor of neurology for his support of my work and Joseph Beuys for his suggestions for difficult times. The case histories and treatments presented in this book have all been made anonymous, with significant details changed, in order to protect the confidentiality of my patients. I would like to thank them all very much for allowing me to use their material, published here in the hope of advancing understanding and progress in the field.

Introduction

DIFFERENT PERSPECTIVES ON THE TREATMENT OF TRAUMA

My previous book illustrated the ways in which analysts from different psy-

choanalytical positions viewed my work in the former East Germany with a group of patients who were suffering from depression and anxiety. In the course of that project, it emerged that behind their psychiatric symptomatology lay elements of trauma and transgenerational trauma that needed more attention. I came to learn that there is a wide variety of compelling accounts of the treatment of such trauma. In this current book, I wish to give the reader a sense of the depth and breadth of the work that is going on. The first object is to identify the nature of trauma itself. THE COMMON EFFECTS OF REPRESSIVE TOTALITARIAN SYSTEMS ON INDIVIDUALS When I arrived in the GDR in the early 1990s, the whole country had a gray and overcast feel to it. The wall had fallen only recently in 1989. The houses were rough, looking as though they were held together by pieces of old metal. The whole country had a monotonous feel, relieved only by these sporadic rust spots. The color and vibrancy of life in the years before the war had largely disappeared under the Communist dictatorship of the GDR that had ruled from 1949 until 1989. Yet, in certain ways, everything during those forty years had been extremely well organized, from day nurseries, kindergartens, and primary schools through to secondary schools (POS), youth movements, apprenticeships, vocational schools (for practical professional xix

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learning), colleges, councils, other institutions of higher education that grant degrees, and university education. University education was also established after the rules of a socialistic “workers’ and peasants’ state.” However, this overall “organization” and control by the Socialist Unity Party of Germany— the SED, or so-called “Lenkung”—was so strict that it permitted no deviation from the prescribed norm and no room for creative growth. There was only one ordained route and set of rules. This, of course, produced lives that were also gray and monotonous. Life was the same wherever you lived: the geographical area might have particular differences, but the totalitarian oversight of a life without choice had a deadening effect on the individual. From the cradle to the grave, you were in the hands of the party, the SED, and the police state or Stasi, so that even something as simple as selecting the furniture for your house was prescribed: at most there would be the “choice” of up to three different versions of any single product. My patients had lived under two totalitarian systems, one following the other: the Nazi and the Communist systems. In addition, they had seen war and its inevitable traumas, and many of them had suffered migration as well as the resultant uncertain life of the refugee (Binion 2011; Gautier and Sabatini Scalmati 2010; Garland 2007; Lifton 2001; Lindy and Lifton 2001; Papadopoulos 2002). Living under such conditions is a difficult enterprise. While the Nazi regime lasted only just over twelve years, the Stasi system presided over my patients for around forty years. Both systems had their secrets. During the Nazi period, many people “seemed” not to have known what happened to the Jews, the gypsies, or the Slavic people; however, the Nazi system had only a few years of successful functioning, and the people could soon see the coming end. During the Stasi period, nobody “seemed” to have known what the Stasi was doing in and out of its jails: how it observed, controlled, harassed, or wrecked people who did not believe in the system. And the system seemed permanent. The Stasi system was able to control, manipulate, and penetrate the minds of people over several decades. It could control people from birth through social institutions for babies and children (day nursery, week nursery, kindergarten), schools, youth organizations, the Publicly Owned Enterprieses (German: Volkseigener Betrieb; abbreviated VEB), SED party, and other mass organizations. Also, by isolating people from the free world, this system managed to develop considerable sustainability over time. To understand the way in which this state of affairs ruled the lives of the whole population and influenced psychic development, Šebek’s term “the totalitarian object” (Šebek 1996b) is helpful. The totalitarian society seems to be, as Šebek says: an emotionally immature society, consisting mostly of emotionally immature individuals whose inner world is ruled by internal totalitarian objects: mighty authorities which are internalized by every individual in the course of his/her



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socialization. It seems that early outer parental objects have a totalitarian character for the child, because the child perceives them as mighty from its dependent position. The totalitarian objects, inner and outer, are intrusive, they have a tendency to own the other and to manipulate him, and they have no respect for individuality and for social and individual differences. Instead of individual values they strive for the establishment of an ideology, obligatory for all. (Šebek 1996a)

These totalitarian objects, as he avers, have the aim of controlling the thoughts, feelings, and acts of others. They are dogmatic, static, rigid, and intolerant. These undifferentiated, mainly narcissistic, and destructive entities can be represented by schoolteachers, party members in the firm, leaders, or others with political power, often with traumatizing effect. In this way, as Šebek states, an individual’s sense of self and potency can be destroyed and replaced by a powerful and dictatorial internal, as well as external, control (Šebek 1996a). Totalitarian states in twentieth-century Europe, especially Communist states, embodied what Šebek has described. Totalitarian power penetrated all aspects of individual life and, as he says, these internal objects “do not disappear at the end of any sort of social revolution (or adolescent protest). They continue to be a part of psychic structure” (Šebek 1998). In traumatic cases they may create “enduring personality traits” (Lindy 2001). As Temple (2006) has also stated: In both the totalitarian state and the totalitarian state of mind in patients, the paranoid defence is successful because power and strength are derived from projecting weakness, vulnerability and guilt into others while identifying the state or the self with all that is good, righteous and strong. There is an avoidance of guilt about the ruthlessness, cruelty and destructiveness because the victims or the opposition are identified as fully deserving this treatment precisely because they are identified as bad. There is the gratification of sadism when they are attacked. By creating this state of affairs omnipotent power is released, based on sadistic excitement, freedom from guilt, depression and self-doubt. (Temple 2006)

Šebek described a variety of different ways of responding to these totalitarian systems and objects. First, people may merge with the totalitarian object, the aggressor, by an unconscious process of identification and thus become “depersonalized,” as their original self is fused with the aggressive object (Šebek 1996b). Another solution for survival may involve the development of a false self (Lindy 2001). This was the most common way to handle the pressure of the system (Šebek 1996a). On the surface, those who adopted this strategy were well adapted and wanted “to be ‘good pupils of all teachers’” (Šebek

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1996a). These people, the “yes-sayers,” were over-adapted to all manner of authority without exception. They sacrificed any notion of, or aspiration to, an individual and authentic identity. If an internal conflict existed that might be said to be typical of the life of individuals living in this oppressive social system, it was the conflict between the split parts of the self: the true self and the false self. There was a continual dilemma: “Shall I say (express, feel, be conscious of) the truth (real genuine feelings, opinions)? Or shall I, with rigid and currently used defences (regression, repression, denial, etc.), survive?” (Šebek 1996a). It was a question of choosing between freedom, which resulted in persecution, or adaptation, silence, lying, and pretense, which resulted in the loss of individuality. A further method is the conscious disidentification with the totalitarian objects and the resultant necessity to live in a paranoid state of mind, while acknowledging the hard truth that reality is indeed persecutory and that to live in a paranoid state is sometimes appropriate (Mandelstam 1970). Some people of this type developed permanent problems in relating to others. For some also, the chronicity of victimization and of the helplessness it engendered led to a giving up, and to an existence permeated with a sense of inner deadness. Šebek also describes what he terms “war personality,” where perverse or xenophobic solutions are employed in order to survive. Many of the above features were to be found in my patients. There was also, of course, the option of finding creative solutions: these internal conflicts with the totalitarian object could be resolved at least in part (Šebek 1996b) by, for instance, involvement in art projects or the making of new and helpful relations through personal analysis and other creative endeavors. As a result, on the one hand we may have enduring, though also highly individual, personality character constellations, formed in order to adapt in different ways to specific traumas. These formations can be partially constructed by common, nonspecific personality traits, often found among people in general who are living under such political conditions. These formations are connected with the oppressive authoritarian political, social, and economic climate created in East Germany at that time by the overall control of all social systems as I have outlined above. As a result, these repressive circumstances tended to be expressed in the form of a general adaptation of the personality to the inescapable social systems that obtained at that time. This of course then can result in stultified and arrested development. These personality traits created by totalitarianism were marked especially by passivity, compliance, obedience, conformity, plasticity, subjugation, resignation, lying, and pretending (Šebek 1996a, 1996b, 1998). Yet in the new post-Communist society, things were changing, both in terms of the state’s relationship to the individual and in terms of the individual’s experience of interpersonal relationships. This could conceivably over



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time change the personality traits of people who had lived under such political power. Often, however, there was no ostensible change in post-totalitarian personality traits. In the minds of those who have lived under totalitarian conditions, totalitarian objects and the experiences connected to them tend to survive intact within the internal world for a long time. Younger people, born after the fall of the old system, may not, however, show the same personality traits. They may possess their own post-totalitarian internal objects and introjects, embodied in the shape of their parents and other caregivers. Beyond the intimate sphere of their experiences, new modern objects may be formed in an era of more freedom and the lack of total social control. These are new, largely nonintrusive objects, generated in particular by new media, as well as by new political problems, such as the social tensions caused by unemployment. While they too, of course, influence the individual personality, it is in very different ways. The effects may well be wider when the educational system is influenced or dominated by the ideology. A research project, “Psychological Effects and Coping with Extreme Trauma and Social Transformations,” showed that following the restoration of Lithuanian independence, the returning emigrants found that the residents showed more “distrust, intolerance, hypocrisy reticence, and failure to keep one’s word” (Gailienė 2015). It was found that normal individuals, living under the restricting regime but not specifically persecuted, nevertheless felt “in some ways similar to victims” (Gailienė and Kazlauskas 2005). Psychological strategies were to be found in the context of the totalitarian system, such as “deception of authorities and the system, secrecy, duplicity, passivity, and change of identity” (Gailienė and Kazlauskas 2005). These served as survival strategies, which often were identified only after longterm psychotherapy. REFERENCES Binion, Rudolph. 2011. Traumatic Reliving in History, Literature and Film. London: Karnac. Gailienė, Danutė, ed. 2015. Lithuanian Faces after Transition: Psychological Consequences of Cultural Trauma. Vilnius, Lithuania: Eugrimas. Gailienė, Danutė, and Evaldas Kazlauskas. 2005. “Fifty Years On: The Long-Term Psychological Effects of Soviet Repression in Lithuania.” In The Psychology of Extreme Traumatization: The Aftermath of Political Repression, Genocide and Resistance, edited by Danutė Gailienė. Vilnius: Akreta Research Center of Lithuania. Garland, Caroline, ed. 2007. Understanding Trauma: A Psychoanalytic Approach. Second edition. London: Karnac.

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Gautier, Andres, and Anna Sabatini Scalmati, eds. 2010. Bearing Witness. London: Karnac. Lifton, Robert. 2001. “History as Trauma.” In Beyond Invisible Walls, edited by Jacob Lindy and Robert Lifton. New York: Brunner-Routledge. Lindy, Jacob. 2001. “Invisible Walls.” In Beyond Invisible Walls, edited by Jacob Lindy and Robert Lifton. New York: Brunner-Routledge. Lindy, Jacob, and Robert Lifton, eds. 2001. Beyond Invisible Walls. New York: Brunner-Routledge. Mandelstam, Nadezhda. 1970. Hope against Hope. New York: Atheneum Publishers. Papadopoulos, Renos, ed. 2002. Therapeutic Care for Refugees. London: Karnac. Šebek, Michael. 1996a. “Aggression in Society and on the Couch.” Free Associations 6: 477–92. ———. 1996b. “The Fate of the Totalitarian Object.” International Forum of Psychoanalysis 5: 289–94. ———. 1998. “Post-totalitarian Personality: Old Internal Objects in a New Situation.” Journal of the American Academy of Psychoanalysis 26: 295–309. Temple, Nick. 2006. “Totalitarianism: The Internal World and the Political Mind.” Psychoanalytical Psychotherapy 20: 105–14.

I A GENERAL INTRODUCTION TO THE NATURE OF TRAUMA

The basics of trauma treatment will be given in this general introduction by the editor. Relevant terms, the psychiatric approach, and the particular subgroups of posttraumatic syndromes will be described. Transgenerational and intergenerational trauma, trauma-related symptoms, and the neurobiology of stress and trauma will all be discussed.

1

1 On the Development of the Concept of Trauma Definition, Elements, and Relevant Terms Bernd Huppertz

Since the Vietnam War and its aftermath, the concept of trauma, in particular of psychological trauma and combat(ant) trauma, has become widespread. This has led to a duality in the understanding of trauma as either physical or mental. The notion of trauma originated in ancient Greece and was referred to as “wound.” Etymological studies of the word “trauma” show that the root of the verb can have two meanings: the first is to rub in, and the second to rub off or away; the first is associated with injuries, scars, and a deficit; the second, a now clean surface that is without markings. With a new perspective, it is ready for a fresh start in terms of posttraumatic growth (Papadopoulos 2007). The concept of trauma eventually found its place within the fields of medicine and surgery. Here trauma means impairment or injury of body tissues inflicted by external influences. This concept is well established in trauma surgery, and the scientific study of physical injuries is referred to as “traumatology.” MENTAL TRAUMA Toward the end of the 1970s, when an ever-widening segment of the public became aware of mental damage as a result of war, natural disaster, or great personal loss, the concept of psychological trauma for mental injuries, and in particular the concept of posttraumatic stress disorder (PTSD) in psychology, began to be disseminated. The process leading to mental injury was called “traumatization,” and thus the concept of “traumatology” was developed, analogous to trauma surgery. This gave rise to the identification of related mental disorders and diseases within the realm of trauma response and 3

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trauma-related disorders. Victims of, for example, accidents, rape, violence, life-threatening diseases, childhood calamity, war, and political persecution, as well as witnesses of such incidents, could be considered the victims of trauma. Psychological trauma is not a rare event, and those affected by it can be damaged in various ways. It is estimated that more than one out of every two people has already suffered a potentially traumatic situation with possible posttraumatic effects. Estimating the extent to which it is possible for traumatic situations to produce posttraumatic reactions can only be done on an individual basis and by careful assessment. Only a portion of those afflicted display posttraumatic reactions. People can experience trauma at any stage of life. There is no protection against it. Many people do not like to talk about such situations in order to prevent a reactivation of traumatic memories. Only when specifically questioned do they reveal such events. The most typical effects are the stress disorders, such as acute stress disorder (ASD), posttraumatic stress disorder (PTSD), or brief psychotic disorder with marked stressor(s) (BPDMS, also known as brief reactive psychosis). Many distinct effects may follow: dissociative symptoms and disorders, depressive disorders such as traumatic grief, anxiety disorders, somatic symptoms and related diseases such as psychotic symptoms or BPDMS, borderline personality disorder, substance use disorder, and physical health complications such as chronic pain or complex traumatic stress (Briere and Scott 2014). It is not only the nature of the traumatic event that is critical to the effects that may follow but also the individual’s evaluation, experience, and processing of the event. Psychological damage is identified where the usual management capabilities of the person concerned are overwhelmed. Intensity/massiveness of the trauma, as well as individual resources in the processing of the event will play an important role. Traumatic events can have a wide range of negative, neutral, or positive effects and do not automatically end with, for example, a PTSD diagnosis. Only a minority of sufferers who have experienced a difficult situation develop PTSD (Brenner 2004). Depending on the specific situation, it can also lead to a new beginning (Papadopoulos 2007). HISTORY OF THE CONCEPT OF TRAUMA People have always searched for ways to cope with trauma. Hence mourning rituals are known to exist within nearly every group and population. Rituals to process psychological trauma were already in place among primitive populations. Today, attempts to process a traumatic event can be seen particularly in the arts, such as painting or literature. Jean-Martin Charcot (1825–1893)



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was one of the first psychiatrists who looked at the relationship between trauma and mental illness. He was the first to view hysterical symptoms as psychologically motivated and possibly caused by trauma. Since then, there has been a continuous production of new conceptualizations and models of trauma (Ringel and Brandell 2012). Charcot’s student Pierre M. F. Janet (1859–1947) studied the effects of psychological trauma on mental development. He clarified the concept of dissociation, which he saw as a result of an overload of awareness during the attempt to process traumatic, overwhelming experiences. Memories that could not be processed would be split off, resulting in dissociation, and could be lived through again at a later date (Howell and Itzkowitz 2016). Traumatic experiences, which cannot be verbally described, may manifest themselves in images, bodily reactions, or behavior and lead to memory problems. Janet recognized that the inability to integrate traumatic memories was the cause of the posttraumatic syndrome. Sigmund Freud (1856–1939) was impressed by Charcot’s ideas, such that Freud and Breuer in Studies on Hysteria ([1895] 2000) would conclude that hysteria was caused by previous trauma and that this would generate dissociative processes. Later, Freud, who went through various phases (seduction and conflict theory phases) in defining his concept of trauma, came to believe that these symptoms were not caused by memories of real trauma but by the inner world of the patient with his or her own wishes and desires, which were often intolerable for the patient. The latter could lead to inner infantile conflicts. For Freud, it was still possible, however, for external trauma to affect the mind and mental developments. As far as so-called traumatic neurosis and even more primitive defenses were concerned, Freud upheld external traumatic events as one proven cause for these (Freud [1917] 1989, [1923] 1990, [1926] 1990). Sándor Ferenczi (1873–1933) saw external trauma, especially as it related to childhood sexual seduction, as of primary importance for the development of neurosis. Significantly, alongside the traumatic situation is the denial of this situation by an important attachment figure, mostly the mother. The latter was of the utmost importance for the development of neurotic disturbances (Ferenczi [1932] 1988). In connection with sexual trauma and sexual abuse, Ferenczi saw a confusion of levels: the child’s desire for tenderness and the adult’s desire for passion and sexuality. Thus, the child would feel powerless and helplessly exposed to massive fears. While such trauma will always be denied, nevertheless, a memory of it will remain. Trauma could lead to personality fragmentation through respective “splits” (Ferenczi [1933] 1955). The ego psychology developed by Anna Freud introduced the concepts of adaptation, coping, and defenses of the ego, which she considered to be relevant to the study of trauma. For Anna Freud, trauma could be caused

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by either external or internal factors and was related to the helplessness of the ego. According to her, trauma breaks through the protective barrier, the stimulus barrier, and the defense structure of the ego, resulting in a disruption of ego equilibrium. Every external event accompanied by insufficient defense mechanisms should be seen as potentially traumatic. External traumata that happened to coincide with great internal anxieties or powerful wishful fantasies could transform themselves into internal ones. She differentiated the terms “trauma” and “traumatic” from “pathogenic.” The former concerns internal shock through trauma with inner disruption and abrogation of ego defenses and ego mediation; the latter concerns the release of an internal conflict or the influence of psychic development. Signs of trauma will be a sudden psychological reaction, for example, not being able to act, or symptoms on the bodily level. The incapacitation of the ego functions allegedly leads to functioning on an archaic pre-ego level, as with a regression. Anna Freud differentiated between overwhelming threats that came from the outside and those dependent upon certain inner constellations. Of supposed importance here is the length of the impact of the traumatic event, the complete or partial collapse of the ego functions, the point in time and the extent of recovery of the ego functions, and the influence of all of these factors on personality development. The influence of trauma on the whole of psychic development could be observed (A. Freud 1967). Neither classical Freudian nor Kleinian models saw children’s development as being strongly influenced by the type of parenting to which they were exposed, but many members of the British Independent Group considered this to have major influence. William R. D. Fairbairn (1889–1964), who saw the child as object seeking, that is seeking connections to others, suggested that if such a search for relationship was frustrated, the child might turn away from reality and create a fantasy world with internal objects that would resemble aspects of the child’s relationship to the real objects who had been rejecting. Fairbairn assumed that the child fends off traumatic experiences through a process of ego splitting, using real objects in the external world and illusory objects as internal objects, followed by a further second splitting between the exciting and rejecting object (Fairbairn [1952] 1994; Mitchell and Black 1995). Donald W. Winnicott (1896–1971) assumed that early child development could only go undisturbed if the child was optimally complemented in its development and thereby maintained the illusion of infantile omnipotence, which would later gradually diminish. Trauma, resulting, for example, from failure of the environment or assault, could destroy the childlike fantasy of omnipotence and lead to a premature disillusionment. An insufficient adjustment of the environment to the needs of the infant could lead to an adjustment of the infant to his environment, which would overtax the infant. This would



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then lead the infant to build a false self-system and subject itself to environmental demands (Winnicott 1960). Michael Balint (1896–1970), another independent, saw the beginning of every psychopathology as associated with the caregiver’s failure to react to the needs of the child appropriately. He saw this as a “basic fault,” and the foundation for the development of personality disorders (Balint 1968). Masud Khan in 1963 defined a cumulative trauma as one in which sub-traumatic events and loads could develop into a major traumatic disorder (Khan [1963] 1974). The self-psychologist Heinz Kohut (1913–1981) also saw trauma as being bound up with psychological development and the relationship between child and caregiver. He assumed that errors in the development of the structures of the self and a wide variety of mental disorders and diseases are the result of constantly occurring fractures in parental empathy, either due to the parents’ own pathology or to external circumstances, leading to insensitivity or lack of attunement with the child’s needs (Kohut 1977, 1984). Other important findings or conceptualizations regarding trauma from the perspective of relational theory, intersubjectivity theory, and self psychology were made in the next few decades by Davies and Frawley (1994), Shane, Shane, and Gales (1997), Stern (1997), Bromberg (1998), and Stolorow (2007) (Ringel and Brandell 2012). John M. Bowlby (1907–1990) developed what he called attachment theory. This was based on his observations of the child’s need for secure attachment and children’s reactions to separation and loss. He explored the nature of deprivation trauma in his book trilogy, whose titles reflect the most important terms in this context: volume 1, Attachment: Attachment and Loss; volume 2, Separation: Anxiety and Anger; and volume 3, Loss: Sadness and Depression. This need for the security of caregivers implies a severe problem if the security fails. Bowlby found three different response levels: first, protest and crying; then despair followed by general disinterest and disengagement; and thirdly, detachment and aloofness toward the caregiver upon their reemergence after appropriate adjustment and adaptation to the new circumstances and attachment figures (Bowlby [1969] 1999, 1973, and 1980). The attachment researcher Mary Ainsworth (1913–1999) was experimentally using the so-called strange situation with children and outlined three attachment styles: “secure,” “avoidant,” and “anxious-ambivalent attached” (Ainsworth and Bell 1970; Ainsworth et al. 1978). Mary Main and Judith Solomon discovered a further attachment style, the “disorganized” behavior connected to contradictory and alternating behavior. Children who showed this behavior tended to have had caregivers who showed conspicuous apprehension. This apprehension seems to stem from unresolved trauma from the caregiver’s childhood (Main and Solomon 1993). Other conditions may predispose the child to developing a disorganized attachment. Attachment ruptures and threatened abandonment through death

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or loss of the caregivers can lead to attachment-based trauma and the loss of physical and emotional safety in the child. In her more recent studies of children afflicted with these conditions, Lyons-Ruth has found a high incidence of abuse, neglect, unresolved trauma, or loss. Furthermore, unresolved childhood traumas of caregivers could in turn create characteristics of disorganized attachments for their children. Attachment traumas seemed to be transmitted from caregiver to child. Disorganized children have been found subsequently to show much aggressive behavior (Lyons-Ruth and Jacobvitz 2008). Modern infant research has shown that early childhood trauma such as attachment ruptures in the early mother-child interaction can strongly influence mental development (Ringel and Brandell 2012). The stages of the caregiver-child interaction require dyadic collaboration. This begins with appropriate behavioral responses and interchange, affect regulation; and internal regulation, finally ending with the exchange of more complex and dyads and inner experiences. If the mutual regulation of the caregiver-child dyads and the nonverbal and verbal behaviors were inappropriate or disturbed, affect regulation, and self-soothing capacities in the infant could be disturbed or impaired. A disturbed interpersonal dyadic interaction in infancy could be caused by an inappropriate approach on the part of the caregiver, often due to severe early disturbances in the caregiver’s childhood development (Beebe and Lachmann 2013). In addition, should such mutual interactions between the caregiver and child be disturbed, this may have the added consequences of distortion or delay in the ability for mentalization. This involves the ability to have a view of other minds and to respond to states of minds of others at varying levels of development, such as “psychic equivalence,” “pretend play,” and the mature stage of mentalizing (Fonagy et al. 2005; Fonagy and Bateman 2008). Modern neuroscience research has also shown that early child development disturbances and attachment ruptures can have an influence on the development of the brain and the nervous system. These should not be ignored. Thus the development of cognition, emotion, behavior, and interpersonal relationships can significantly be affected (Tronick 2007; van der Kolk 2015). RESEARCH ON STRESS AND TRAUMA The work of Hans Selye (1907–1982) is important for the understanding of traumatic stress. During the course of his research on stress, Selye developed a model of the stress reaction as being due to pathogenic environmental stimuli—that is, so-called stressors (for example performance pressure, mental stress, or physical stimuli). His model outlines three phases: alarm,



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resistance, and exhaustion. His “general adaptation syndrome” was regarded as the general pattern of reaction of the human body to prolonged stressors. If a stressor lasts too long, then massive, partly irreversible consequences may occur. Selye called negative, unpleasant stressors “distress,” and positive, stimulating experience “eustress” (Selye 1956, 1974). STRESS RESPONSE SYNDROME Mardi Horowitz, a stress researcher in the 1970s, studied stress resulting from traumatic events—that is, mental stress—and coined the term, “stress response syndrome.” He found that stress situations of considerable proportions could be followed by periodic flashbacks or intrusions. Intrusive states were found to alternate with avoidance and denial or hyperarousal. Symptoms manifested in many areas of mental processes, such as perception, attention, information processing, emotion, and behavior. It became generally recognized that a further consequence was impaired social skills. Horowitz developed a phase model with variations of trauma responses after a stressor episode: the event, the peritraumatic and posttraumatic emotions, denial or avoidance, intrusive or flooding states, working through and adaptation, psychosomatic responses, or character distortions. Typical emotions after a trauma would include fear of the repetition of the traumatic event or of losing control of aggressive impulses. Rage or shame due to one’s own vulnerability can arise and be directed either toward those not affected or toward the agent or source. Shame and guilt about one’s own emerging aggressive impulses or simply due to the fact of surviving may emerge. There may also be sadness due to separation or loss (Horowitz 2011). It was found that chronic, continuous, and uncontrollable stress could lead to a change in the stress response system. It could lead to down-regulation and long-term effects, such as chronic dissociation. The question of differentiation of stress responses became important—that is, what could still be regarded as normal, what could not be seen as normal, what was of temporary duration, and what would last longer, or be complicated. The path from traumatic stress to posttraumatic stress syndrome was not always a long one. WAR AND CIVIL TRAUMA War-Related Trauma

War-related complaints have been known about in essence for a long time (Figley 1993; Wilson and Raphael 1993). Achilles in the Iliad was perhaps

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the first portrayal of war-related trauma, but there are more examples in literature. In the American Civil War mental grievances were observed and early symptoms described that could be compared with symptoms of the later so-called posttraumatic stress disorder. During World War I, soldiers manifested symptoms as a result of a socalled war neurosis called “shell shock.” During World War II, terms such as “combat fatigue,” or “battle fatigue” surfaced. These war-related complaints were also called “war neurosis” and “traumatic neurosis” (Kardiner and Spiegel 1947). After the end of World War II, and with awareness of the condition of Holocaust survivors and veterans, the discussion of severe stress phenomena entered an intense phase. Examination of World War II soldiers and the victims of nuclear war and of catastrophes caused by the human hand showed that these experiences could lead to extreme mental traumas, with resultant behavioral, emotional, and cognitive symptoms and difficulties. Further investigation revealed that the symptoms of traumatized concentration camp survivors and of accident victims overlapped those of war combatants displaying combat stress. During, and especially after, the Vietnam War, more and more of those returning from the experience of battle developed mental problems, which made their integration into daily normal civil life difficult. In this context, substance abuse, violence directed against partners, loss of employment, and high suicide rates were not uncommon (Krystal 1968; Lifton 1973). Civilian Trauma

Civilian trauma had already been described in 1666 after the great fire in London (Volpe 1977). A more detailed investigation began during the development of the fast-developing rail transport. Complaints related to train accidents were described that were comparable to those of the later PTSD (Erichsen 1882). These complaints were called “nervous shock” (Page 1885). Suicide hotlines, which were set up in 1902, began to gather a significant amount of data about experiences of the effects of trauma (Ringel and Brandell 2012). Further investigations into civilian trauma took place in the 1940s after a great fire in Boston in which many people died (Caplan 1961). With the increasing importance of the women’s movement in the United States in the 1970s, topics such as violence against women in the household, for example, as a result of domestic violence, or rape and incest were addressed and investigated. Other topics, like childhood sexual abuse respectively betrayal trauma (Freyd 1998; Freyd and Birrell 2013), followed.



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POSTTRAUMATIC STRESS DISORDER (PTSD) Eventually more and more war-traumatized veterans of Vietnam required and demanded treatment, and groups of severely abused women and children, alongside the groups of the war veterans, did the same. This led to the creation of a stand-alone diagnosis for complaints following such mental traumas, so-called Posttraumatic Stress Disorder (PTSD) (US Department of Veterans Affairs 2016a, 2016b). This diagnosis encompassed what had in previous decades been called “railroad spine,” “shell shock,” “concentration camp syndrome,” “traumatic neurosis,” “combat fatigue,” and “operational exhaustion” (Ringel and Brandell 2012). Other forms of psychic trauma, such as those caused by psychosocial stressors or childhood neglect, were not taken into consideration. However, later mental trauma or the diagnosis of a posttraumatic stress disorder (PTSD) was recognized by the American Psychiatric Association (APA) as a disease in itself and recorded in the Diagnostic and Statistical Manual of Mental Disorders (DSM) III and also in the International Classification of Diseases (ICD). THE PHASES OF TRAUMA AND THEIR TREATMENT In spite of many differences, the various therapists treating victims of trauma agree on the existence of stages in the reactive process. First, there is a stage of “shock,” which occurs directly during and after traumatization, an acute trauma response continuing over hours or days; this is marked by acute symptoms of intrusion, avoidance, hyperarousal, strong emotions, a feeling of helplessness and the lack of ability to believe what had happened. This phase is followed by an impact phase or a phase of “crisis,” a phase of dialectic psychic states that alternate between the reexperiencing of, and amnesia for, the trauma. This phase involves an attempt to work through what has happened, with a duration of weeks or months. The result can be an adaptation or a pseudo-adaptation, marked by the symptoms of posttraumatic process. Finally, there is the phase of integration or pseudo-adaption with posttraumatic symptoms or diseases (Herman 1992; Williams 1993; Wilson and Raphael 1993). Most of the treatments also take place in phases. First, there is the phase of stabilization, with, for example, provision of external security, resource orientation, emotion regulation, psychoeducation, and the developing of coping strategies. Second is the phase of processing the traumatic memories and reactions to these memories by developing a coherent narrative of the traumatic event. Last, the phase of reintegration, or recovery phase, involves the

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recognitation and management of the remaining dysfunctions and the ability to develop a livable life. If the treatment in phases two or three fail, the patient remains at a stage of pseudo-adaptation and retains posttraumatic diseases and symptoms (Courtois, Ford, and Cloitre 2009; Jackson, Nissenson, and Cloitre 2009). The treatment itself, as the authors have noted, needs to be phase-sensitive. It can be seen that it has been a long journey from the early observations of symptoms to the detailed conceptualization of the diagnosis of PTSD and the other forms of posttraumatic syndromes and on to the appropriate treatments. REFERENCES Ainsworth, Mary D., and Silvia M. Bell. 1970. “Attachment, Exploration, and Separation: Illustrated by the Behavior of One-Year-Olds in a Strange Situation.” Child Development 41: 49–67. Ainsworth, Mary, Mary Blehar, Everett Waters, and Sally Wall. 1978. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum. Balint, Michael. 1968. The Basic Fault: Therapeutic Aspects of Regression. London: Tavistock. Beebe, Beatrice, and Frank Lachmann. 2013. The Origins of Attachment: Infant Research and Adult Treatment. Relational Perspectives Book Series. New York: Routledge. Bowlby, John. 1973. Attachment and Loss, Volume 2: Separation, Anxiety and Anger. The International Psycho-Analytical Library 95: 1–429. London: The Hogarth Press and the Institute of Psycho-Analysis. ———. 1980. Attachment and Loss, Volume 3: Loss, Sadness and Depression. The International Psycho-Analytical Library 109: 1–462. London: The Hogarth Press and the Institute of Psycho-Analysis. ———. [1969] 1999. Attachment and Loss, Volume 1: Attachment. The International Psycho-Analytical Library 79: 1–401. London: The Hogarth Press and the Institute of Psycho-Analysis. Brenner, Ira. 2004. Psychic Trauma: Dynamics, Symptoms, and Treatment. Lanham, MD: Jason Aronson. Briere, John N., and Catherine Scott. 2014. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment, DSM-5 Update. Second edition. Thousand Oaks, CA: Sage. Bromberg, Phillip. 1998. Standing in the Spaces: Essays on Clinical Process, Trauma and Dissociation. Hillsdale, NJ: Analytic Press. Caplan, Gerald. 1961. An Approach to Community Mental Health. New York: Grune & Stratton. Courtois, Christine, Julian Ford, and Marylene Cloitre. 2009. “Best Practices in Psychotherapy for Adults.” In Treating Complex Traumatic Stress Disorders: Scien-



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tific Foundations and Therapeutic Models, edited by Christine Courtois and Julian Ford. New York: Guilford Press. Davies, Jody, and Mary Frawley. 1994. Treating the Adult Survivor of Childhood Sexual Abuse: a Psychoanalytic Perspective. New York: Basic Books. Erichsen, John Eric. 1882. On Concussion of the Spine, Nervous Shock and Other Obscure Injuries of the Nervous System in Their Clinical and Medico-Legal Aspects. London: Longmans, Green. Fairbairn, William. (1952) 1994. Psychoanalytic Studies of the Personality. London: Tavistock Publications in association with Routledge. Ferenczi, Sándor. (1933) 1955. “Confusion of Tongues between Adults and the Child.” In The Selected Papers of Sándor Ferenczi, Vol. 3: Final Contributions to the Problem and Methods of Psychoanalysis. New York: Basic Books. ———. (1932) 1988. The Clinical Diary of Sándor Ferenczi. Edited by Judith DuPont, translated by Michael Balint and Nicola Zarday Jackson. Cambridge, MA: Harvard University Press. Figley, Charles R. 1993. “Foreword.” In International Handbook of Traumatic Stress Syndromes, edited by John Wilson and Beverley Raphael. New York: Plenum Press. Fonagy, Peter, and A. Bateman. 2008. “Mentalization-Based Treatment of Borderline Personality Disorder.” In Mind to Mind: Infant Research, Neuroscience and Psychoanalysis, edited by Elliot Jurist, Arietta Slade, and Sharone Bergner. New York: Other Press. Fonagy, Peter, Gyorgy Gergely, Elliot Jurist, and Mary Target. 2005. Affect Regulation, Mentalization and the Development of Self. New York: Other Press. Freud, Anna. 1967. “Comments on Trauma.” In Psychic Trauma, edited by Sidney S. Furst. New York: Basic Books. Freud, Sigmund. (1917) 1989. “Introductory Lectures on Psychoanalysis.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, edited by James Strachey. New York: W.W Norton & Company. ———. (1923) 1990. “The Ego and the Id.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, edited by James Strachey. New York: W. W. Norton & Company. ———. (1926) 1990. “Inhibitions, Symptoms, and Anxiety.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, edited by James Strachey. New York: W. W. Norton & Company. Freud, Sigmund, and Joseph Breuer. (1895) 2000. Studies on Hysteria. Edited by James Strachey. New York: Basic Books. Freyd, Jennifer J. 1998. Betrayal Trauma: The Logic of Forgetting Childhood Abuse. Cambridge, MA: Harvard University Press. Freyd, Jennifer J., and Pamela Birrell. 2013. Blind to Betrayal: Why We Fool Ourselves We Aren’t Being Fooled. Hoboken, NJ: Wiley. Herman, Judith. 1992. Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. New York: Basic Books. Horowitz, Mardi. 2011. Stress Response Syndromes: PTSD, Grief, Adjustment, and Dissociative Disorders. Fifth edition. New York: Jason Aronson.

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Howell, Elizabeth, and Sheldon Itzkowitz. 2016. The Dissociative Mind in Psychoanalysis. Understanding and Working with Trauma. Oxon: Routledge. Jackson, Christie, Kore Nissenson, and Marylene Cloitre. 2009. “CognitiveBehavioral Therapy.” In Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide, edited by Christine Courtois and Julian Ford. New York: Guilford Press. Kardiner, Abram, and Herbert Spiegel. 1947. War, Stress and Neurotic Illness: The Traumatic Neurosis of War. New York: Hoeber. Khan, Masud. (1963) 1974. “The Concept of Cumulative Trauma.” In The Privacy of the Self, edited by Masud Khan. London: Hogarth. Kohut, Heinz. 1977. The Restoration of the Self. New York: International Universities Press. ———. 1984. How Does Analysis Cure? Chicago: University of Chicago Press. Krystal, Henry. 1968. Massive Psychic Trauma. New York: International Universities. Lifton, Robert J. 1973. Home from the War: Vietnam Veterans Neither Victims nor Executioners. New York: Simon & Schuster. Lyons-Ruth, Karlen, and Deborah Jacobvitz. 2008. “Attachment Disorganization: Genetic Factors, Parenting Contexts and Developmental Transformation from Infancy to Adulthood.” In Handbook of Attachment: Theory, Research, and Clinical Applications, edited by Jude Cassidy and Phillip Shaver. New York: Guilford Press. Main, Mary, and Judith Solomon. 1993. “Procedures for Identifying Infants as Disorganized/Disoriented during the Ainsworth Strange Situation.” In Attachment in the Preschool Years: Theory, Research and Intervention, edited by Mark Greenberg, Dante Cicchetti, and E. Mark Cummings. Chicago: University of Chicago Press. Mitchell, Stephen, and Margaret J. Black. 1995. Freud and Beyond: A History of Modem Psychoanalytic Thought. New York: Basic Books. Page, Herbert. 1885. Injuries of the Spine and Spinal Cord without Apparent Mechanical Lesion. London: J. and A. Churchill. Papadopoulos, Renos. 2007. “Refugees, Trauma and Adversity Activated Development.” European Journal of Psychotherapy and Counseling 9 (3): 301–12. Ringel, Shoshana, and Jerrold Brandell, eds. 2012. Trauma: Contemporary Directions in Theory, Practice and Research. Thousand Oaks, CA: Sage Publications. Selye, Hans. 1956. The Stress of Life. New York: McGraw-Hill. ———. 1974. Stress without Distress. Philadelphia: J.B. Lippincott Co. Shane, Morton, Estelle Shane, and Mary Gales. 1997. Intimate Attachments: Toward a New Self-Psychology. New York: Guilford Press. Stern, Donnel. 1997. Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ: Analytic Press. Stolorow, Robert. 2007. Trauma and Human Existence: Autobiographical, Psychoanalytic and Philosophical Reflections. New York: Analytic Press. Tronick, Ed. 2007. The Neurobehavioral and Social-Emotional Development of Infants and Children. New York: W. W. Norton & Company.



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US Department of Veterans Affairs. 2016a. Accessed February 23, 2018. http://www .PTSD.Va.gov/professional/PTSD-Overview/index.asp. ———. 2016b. “Complex PTSD.” Accessed February 23, 2018. http://www.PTSD .Va.gov/professional/PTSD-overview/complex-PTSD.asp. van der Kolk, Bessel. 2015. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Penguin Books. Volpe, Joseph S. 1977. “Traumatic Stress: An Overview.” Trauma Response 3: 8–9. Williams, Tom. 1993. “Trauma in the Workplace.” In International Handbook of Traumatic Stress Syndromes, edited by John Wilson and Beverly Raphael. New York: Plenum Press. Wilson, John, and Beverly Raphael, eds. 1993. The International Handbook of Traumatic Stress Syndromes. New York: Plenum Press. Winnicott, Donald W. 1960. “The Theory of the Parent-Child Relationship.” International Journal of Psychoanalysis 41: 585–95.

2 The Psychiatric Approach, the Subgroups of Posttraumatic Syndromes, and the Neurobiology of Stress and Trauma Bernd Huppertz

THE PSYCHIATRIC APPROACH

The

psychiatric approach to posttraumatic stress disorder (PTSD) (US Department of Veterans Affairs 2016a, 2016b) and the other posttraumatic syndromes and disorders is documented in the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA). In DSM-I and II, there had been no corresponding diagnostic category for trauma-related symptoms alongside what was called “traumatic neurosis” at that time. The development went from “major stress increase” in DSM-I to “Transient Situational Disturbances” in DSM-II to establishing the diagnosis of a “posttraumatic stress disorder” in the DSM-III (Horowitz 2011). For the diagnosis of PTSD following combat, rape, violence, and abuse, it was deemed necessary that the complaints had to have occurred immediately after the event. An affected person might have been either a victim or a witness of a traumatic event, or affected either through the threat of death or severe injury to the self, or the actual death or severe injury of other persons. In response to such an event, intense fear, displacement, and helplessness were possible. The stand-alone diagnosis of PTSD in DSM-III facilitated the treatment of those affected. In addition to diagnosis and criteria, which were considered in the DSM, repeated changes over the subsequent decades came about as a result of further studies and research. It was found that there were other causes, conditions, symptoms, and problems that were not yet represented in the DSM, or else fell victim to new definitions and classifications. It is important to note that at this early stage the significance of trauma for personality development and its disorders and diseases, and especially 17

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for early childhood developmental disorders, was not considered (Foa et al. 2010; Schupp 2015). Today PTSD is in the DSM-5 (American Psychiatric Association 2013a, 2013b) in a section on Stress Response Syndromes, the “Trauma- and Stressor-Related Disorders,” and is no longer assigned to “Anxiety Disorders.” The generic term/frame “stress response syndromes” diagnoses now also encompass “posttraumatic stress disorder,” “acute stress disorder” (ASD), “adjustment disorders” (AD), “other specified trauma- and stressorrelated disorder,” and “unspecified trauma- and stressor-related disorder,” as well as the trauma-related disorders of childhood “reactive attachment disorder” and “disinhibited social engagement disorder.” It is also understood that, if an affected person has to undergo several repeated different acute traumas, this can also have complex effects, leading to a wide range of symptoms resulting in maladaptive behavior. Other related diagnoses related to these conditions of acute or complex posttraumatic stress disorder are the brief psychotic disorder with marked stressor(s) (BPDMS), “dissociative disorders,” “depressive disorders,” “anxiety disorders,” “somatic symptom and related disorders,” “substance-related and addictive disorders,” “personality disorders,” or “other conditions that may be a focus of clinical attention” (Briere and Scott 2014). The theme will be elaborated later in the final chapter. The Complex Posttraumatic Stress Disorder (CPTSD)

In the early 1990s, a new diagnosis was proposed for conditions created by chronic, ongoing, or repetitive trauma, a so-called complex PTSD, first postulated by Herman and developed in the work of Leon Shengold (1989). This concerned people who had, for example, experienced lasting domestic abuse or political terror for months or years, leading to changes in affect regulation, states of consciousness, and self-awareness (Herman 1992). In spite of this proposal, and further research by van der Kolk and others, neither the diagnosis for trauma of multiple origins of “complex posttraumatic stress disorder (CPTSD)” nor “disorders of extreme stress not otherwise specified” (DESNOS) with the DESNOS criteria of alterations—for example in affect and impulse regulation, in consciousness, in self-perception, in relationships with others, or symptoms of somatization—have been included in the DSM-IV or V (Blaz-Kapusta 2008; Luxenberg et al. 2001; Luxenberg, Spinazzola, and van der Kolk 2001; van der Kolk et al. 1996 2005). However, in the ICD-10 there was a diagnosis of “personality change from catastrophic experience.” Further unsuccessful proposals for the recognition of complex trauma were subsequently made. Courtois attempted a definition for disturbances with



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multiple traumatic stressors associated with severe disorders in early interpersonal relationships, but this also was unsuccessful (Courtois 2004). Further attempts to establish a definition for CPTSD failed. However, researchers have continued to study the way in which the occurrence of stressors at vulnerable points in psychological development could lead to severe developmental disorders. Chaotic, difficult interpersonal relations and inappropriate attachments have been found to result after serious problems in the caregiverchild relationship (Courtois and Ford 2009a, 2009b). Further symptoms in complex PTSD, additional to those in classic PTSD, are disturbances in neurodevelopment; in self-regulation; and the adaptation of arousal, attention, and cognition (van der Kolk et al. 2005). Developmental Trauma Disorder

Bessel van der Kolk also proclaimed a new diagnostic category, the diagnosis of a so-called developmental trauma disorder (van der Kolk 2005). He discussed the issue of which diagnoses in childhood should contain the details of complex trauma, conduct disorders, and reactive attachment disorder. The focus in this diagnosis should lie on the underlying trauma in childhood and adolescence and concentrate on chronic or repeated traumatic events. Complex developmental traumas—for example, early trauma in conjunction with inappropriate child-caregiver relationships, such as neglect, maltreatment, abuse, illness, death of a caregiver, or a generally chaotic environment—may lead to early childhood developmental disorders (National Child Traumatic Stress Network 2017a, 2017b, 2017c). The abuse of children by their caregivers, as well as by other adults, is not so rare, according to relevant statistics. Neurological structures may be affected by overall delays in development. This may in turn have a disruptive influence on the development and functioning of information processing, affect regulation or modulation, and the ability of categorical thinking. Other consequences may include impaired impulse control, aggressive behavior, or difficulties in interpersonal relations (Schore 2001; Tronick 2007). Developmental or childhood trauma can occur at the most sensitive periods in human development and severely impair the psychophysical development of a child or adolescent. This may lead to disorders in relation to identity, learning, and behavior. A result of impaired concentration can include a worsening of educational results. Clearly, disturbed interpersonal relations, with difficulties in the development of lasting relationships, may show up later in adolescence or adulthood. It is also possible that trauma will lead to suicide attempts. Selfharming behavior, such as cutting or drug abuse, may be used to cope with unprocessable emotions. Generally, a deep suspicion of the environment in its

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broader sense can be detected among this group of people. Many long-lasting stresses in childhood can lead to typical adult, trauma-specific disorders, related to earlier childhood trauma and impaired caregiver-child attachments. Such interferences in the child-caregiver relationship can lead to vulnerability to future trauma and to further disturbances in adolescence and adulthood. Adults with borderline personality disorders frequently have been found to have experienced abuse or neglect in childhood. Childhood and adult trauma can also function interdependently, causing interactions of the two forms of trauma and calling forth diverse reactions. Overall, childhood abuse seems to have a great influence on the emergence of complex posttraumatic syndromes (Ford and Kidd 1998; Lanius, Vermetten, and Pain 2010). It has been found that in many cases of childhood trauma, overly permissive social structures are often present. Early traumatized individuals seem more likely to be subjected to re-victimization, and seem to have even higher risk factors in relation to their physical health. In particular, child abuse and neglect often lead to breaks in the child’s development, which can cause various disturbances: the early attachment development, as well as the entire psycho-physical development may be disturbed. Only primitive, early coping strategies can develop, and this may mean that the person develops little concept of self and others. It can also lead to disturbances in the sexual development of the child with, for example exhibitionism or self-stimulation (Lanius, Vermetten, and Pain 2010; Perry et al. 1995). TRANSGENERATIONAL AND INTERGENERATIONAL TRAUMA In the 1960s, the children of Holocaust survivors, as well as the grandchildren of survivors, complained of symptoms that seemed to be directly or indirectly related with the posttraumatic disorders of the survivors (Fraiberg, Adelson, and Shapiro 1975; Rakoff, Sigal, and Epstein 1966). The term “intergenerational transmission of trauma” was then coined. The transmission was regarded as the result of the efforts of the caregivers to achieve self-regulation in the context of PTSD (Bretherton 1990). Both excessive anxiety and the dissociative defenses against it can be easily transmitted in families. Intergenerational Communication of Maternal Violent Trauma

The findings concerning the psychological consequences for descendants of Holocaust survivors have been extended to other groups: Native American genocide victims, victims of African enslavement or the African Holocaust, victims of slavery among African Americans, victims of the internment of Japanese Americans, veterans of the Vietnam War, and other victims of some



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form of persecution, terrorism, violence, or clergy abuse. All these forms of trauma seem to be able to be transferred to future generations (Brave Heart 2007; Brave Heart et al. 2011; Dass-Brailsford 2007; Fromm 2011; Gudaite and Stein 2014; Volkan et al. 2002; Volkan 2012, 2014). Different terms have been used to describe the conditions: historical trauma refers to mental trauma that can impact on the life of the person affected and on his or her subsequent generations, who have experienced no personal trauma themselves (Gudaite and Stein 2014). The term “collective trauma” refers to trauma affecting a majority of people identifying with a specific group of afflicted parties, such as with the consequences of slavery, colonial wars, the Holocaust, or September 11. Intergenerational or multigenerational trauma is associated with historical events that can impact on the life of an afflicted person and his or her subsequent generations through residual grief and, in many cases, with lingering trauma. TRAUMA-RELATED SYMPTOMS AND DISTURBANCES IN CHILDREN This book, unlike that of Ford and Courtois (2016), is not specifically about trauma treatment in childhood. However, I include this data in view of the important findings of the Kaiser Family study that most of the patients with adult psychiatric disorders have had disturbances in early childhood. The symptoms listed below are often not as specific as it might seem. It is therefore always to be borne in mind that these may be symptoms of a trauma but may also occur from other causes. There are several schemas that list agespecific symptoms and diseases, such as that of Florida State University’s Center for Prevention and Early Intervention Policy or the Center for Early Childhood Mental Health Consultation at Georgetown University Center for Child and Human Development (Center for Early Childhood Mental Health Consultation 2017a, 2017b, 2017c; Florida State University 2017a, 2017b). The following list of symptoms is taken from the last and can be seen in children up to three years of age as process signs of trauma responses that may affect all domains of a child’s development: disturbances in eating and sleeping, somatic complaints, clingy behavior, separation anxiety, feelings of helplessness, passivity, irritability, being difficult to soothe, constricted or repetitive play, signs of posttraumatic play, developmental regression, general fearfulness, being easily startled, delays in language, aggressive behavior, sexualized behavior, and talking about the traumatic event and reacting to reminders or trauma triggers. Children between the ages of three to six years are prone to suffer from the following symptoms: avoidance, anxiety, clingy

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behavior, fearfulness, helplessness, passivity, frustration, restlessness, impulsivity, hyperactivity, physical symptoms (headache, etc.), difficulty identifying what is bothering them and problem solving, inattentiveness, daydreaming or dissociation, irritability, aggressive behavior, sexualized behavior, loss of recent developmental achievements, repetitive/posttraumatic play, talking about the traumatic event and reacting to reminders/trauma triggers, sadness and depression, and poor peer relationships and social problems such as being controlling or overly permissive. Complex trauma symptoms in child and adolescent development may affect all domains of a child’s development. The following list, again taken from the Center for Early Childhood Mental Health Consultation, describes common complex trauma symptoms. With regards to attachment, children may have trust issues, feeling uncertain about the reliability or predictability of others, they may experience interpersonal difficulties and social isolation, have difficulty seeking help, and have difficulty with separation, often becoming clingy. In terms of physical problems, they may have sensorimotor development problems, hypersensitivity to physical contact, somatization, increased medical problems, and difficulty with coordination and balance. With regard to affect regulation, they may experience difficulty in emotional regulation, easily getting upset and/or finding it difficult to calm down; in knowing and describing emotions and internal experiences; and in communicating their needs. With regard to behavioral problems, they may be prone to poor impulse control; self-destructive aggressive or oppositional behavior; excessive compliance; sleep disturbance; eating disorders; the reenactment of traumatic events; and pathological self-soothing practices. Their cognition may also be affected. They may find it difficult to pay attention; suffer from a lack of sustained curiosity; or have difficulty processing information, focusing on and/or completing tasks, planning, and anticipating consequences. They may also experience learning difficulties, developmental delays, and problems with language development. And finally, they may struggle to construct a continuous and predictable sense of self, experiencing a poor sense of separateness, a disturbance of body image, low self-esteem, and shame or guilt. Further research is needed into the nature of such complexity and the corresponding development of treatments that can address both the symptomatology and the disorders of development. THE NEUROBIOLOGY OF STRESS AND OF POSTTRAUMATIC STRESS DISORDER (PTSD) The stress response is a more general adaptation of the body than is posttraumatic stress disorder. Trauma is a special form of stress. Unlike the precur-



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sors of trauma—such as death, injury, or violence—stress does not involve such calamities. However, chronic stress can cause both physiological and psychological damage (Selye 1983). Much research has been done into this issue, with many concepts coined and mobilized. The results sometimes correspond and sometimes diverge. Further research and clarification is needed. Areas of the brain under study are, first, the hippocampus, the function of which includes the memory of facts and the inhibiting of the production of the hormone cortisol; and second, the amygdala, the function of which includes emotional memory, the processing of the affective reactions that accompany experience, and the activation of the production of the hormone cortisol. That is, the experiential facts are recorded by the hippocampus, whereas the processing of the accompanying affective reactions takes place through the amygdala. Last but not least, there is the autonomic nervous system (ANS) of the peripheral nervous system with its two branches, the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS). The ANS is the largely unconscious control center of the organ systems and smooth muscles of the body. The two systems work in a complementary manner whereby the sympathetic nervous system can activate physiological responses that the parasympathetic nervous system can inhibit. The sympathetic system can be seen as the system for activating quick responses. THE BIOLOGY OF ANXIETY AND STRESS Traumatic incidents generate anxiety, and this in turn causes stress. Stress, in its own turn, leads to stress-induced physiological responses. Apart from the well-known psychological symptoms and conditions associated with traumainduced diseases such as PTSD, we can observe all kinds of physiological ailments and reactions generally associated with anxiety and stress. These responses are mediated by various bodily regions and neuronal and hormonal systems (Antonovsky 1979). THE STAGES OF THE STRESS RESPONSE A variety of stimuli—physical, physiological, work-related, or social—may have an impact on human beings that can trigger subsequent stress responses (Hill-Rice 2012). The mechanism of this stress response can be evoked by sensory information, perception, cognitive processes, and the activation of parts of the prefrontal cortex and the limbic system, which then activate the amygdala. This activation, in turn, triggers stress responses that bring about various physiological, somatic, or hormonal reactions in the body.

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THE THREE LEVELS OF THE STRESS RESPONSE In humans, the stress response can be observed to proceed at three different levels: physiological, behavioral, and cognitive-affective reactions. Stress Responses Affecting the Body

As noticed above, the activation of the amygdala triggers stress responses that bring about various physiological, somatic, or hormonal reactions in the body. These physiological responses and symptoms can be made up of a variety of neuro-humoral and vegetal-physiological processes that, again generally speaking, serve to activate the flight-or-fight functions of the person affected. Selye (1956) described these processes as being part of the general adaptation syndrome, in the sense of a nonspecific stress reaction of the organism (Selye 1956). These may include, for example, an increase in cerebral blood flow, respiratory rate and frequency, muscle tension, heart rate, and blood pressure. There is an increased energy supply and, furthermore, symptoms such as sweating, cold hands and feet, or a reduction in salivary flow and digestion. The general physiological stress response, with its peripheral physiological stress reactions, is mediated by two neuro-humoral axes (McEven 2007; Porth 2014). 1.  The sympathetic-adrenal medullary (SAM) axis. This was described by Cannon (1932). The autonomic sympathetic nervous system that controls organs and vessels is activated by the release of norepinephrine (noradrenaline), and this, in turn, leads to the activation or inhibition of the organs and vessels described above. Through information from the sensory systems of the sensory nervous system, the limbic system and the hypothalamus will be activated and in turn will activate the autonomic sympathetic nervous system. Epinephrine (adrenaline) will be released and then secreted by the adrenal medulla. This is the system for quick activating responses and can activate the flight-or-fight functions. 2.  The hypothalamic-pituitary-adrenal (HPA) axis. The hypothalamus controls and regulates cortisol release through a corticotropin-releasing hormone (CRH) and an adrenocorticotropic hormone (ACTH). When controlling the stress response and the cortisol release/production, the amygdala and the hippocampus are neuronal opponents or antagonists: the amygdala activates cortisol release/production, which can be inhibited by the hippocampus through a feedback control loop.



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The Behavior-Related Stress Response

Stress-related behaviors often seen in affected persons can be associated with the following: impatient and hasty conduct, including quickly performed actions such as eating in a hectic manner; behavior that induces stupefying effects, such as excessive smoking or drinking or taking pills and drugs; disorganized, unfocused work habits, such as absence of scheduling or forgetting things altogether; and confrontational interactions with others, including bad-tempered, aggressive, or accusatory behavior. The Stress Response at a Cognitive-Affective Level

Characteristic cognitive-affective reactions in terms of thoughts and emotions that can be triggered in stressful situations include, for instance, feelings of restlessness, anger, and resentment; edginess and nervousness; unhappiness, anxiety, or helplessness; and self-reproachful wandering of thoughts or the inability to stop thinking about the stressful situation. Other Factors That Can Influence the Stress Response

Stress intensifiers, including reactions that are specific to an individual and depend on the combined effect of constitutional and biographical features or characteristics of a particular human being, can also influence the general stress response. Chronic and Acute Stress

Chronic stress and acute stress need to be distinguished from one another (Hill-Rice 2012). For example, pain tolerance and immunological competence are increased in acute stress situations, while they are decreased in situations of chronic, long-term stress. It is possible to make a good and quick recovery from acute stress, but not from chronic stress. Chronic stress is evoked and maintained particularly through incessant stresses and strains caused by occupational burdens, interpersonal strains, or social problems. It can become persistent and occur repeatedly. It can also emerge as a result of mental illnesses, for instance, after experiencing anxiety states or illnesses after traumatic events. Chronic stress of all kinds can finally bring about a condition when the adaptation system of the body collapses. As a consequence, functional failures and serious organic diseases may develop.

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Neuro-Hormonal Changes Associated with Chronic Stress and the Findings of Imaging Techniques

Chronic stress can result in continued cortisol release/production, which, in turn, can damage the hippocampus structures, thus initiating a vicious circle (Conrad 2008). Through an increasingly strong cortisol release/production in connection with over-activation of the amygdala, and in connection with a lack of deactivation of the hippocampus when feedback regulation is disturbed, the hippocampus can be increasingly damaged, resulting in a potential decrease in the volume of the hippocampus as well as impairments of other structures. This explanatory model was discussed in the context of findings in patients suffering from PTSD by using neuroimaging techniques (Geuze, Vermetten, and Bremner 2005; Liberzon and Sripada 2008; Pliszka 2016). However, in recent years, other theories have emerged. These suggest that there could be genetically caused neuronal varieties, perhaps resulting in a smaller, as well as a more vulnerable, hippocampus. On the other hand, it is now recognized that early trauma during childhood can result in a higher vulnerability to later stress or trauma (Gilbertson et al. 2001, 2002). The Neurobiology of Posttraumatic Stress Disorder

Posttraumatic stress disorder can be characterized by different categories of symptoms. Conditions similar to those associated with chronic stress can also be observed. PTSD is, apart from psychological symptoms, particularly characterized by neurobiological changes and physiological dysfunctions and symptoms (van der Kolk 2015). It can be differentiated from a transient form of PTSD, where the symptoms are declining without treatment after a shorter time, and from a chronic form, where the symptoms persist. With respect to the origin of these disorders, there are different explanatory models, as we have seen, for example, in chapter 1. Most of the new theories and models are connected with the results of the new neuroimaging techniques (for example, positron emission tomography [PET], single-photon emission computed tomography [SPECT], or functional magnetic resonance imaging [fMRI]). The following description of the models and concepts is a little simplified, due to limitations of space. For interested readers, I suggest looking to the more recent discussions and publications on this topic (for example, Liberzon and Ressler 2016).



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General Signs of Chronic Stress and Neurocognitive Impairments Associated with PTSD

PTSD can result in long-term consequences demonstrating general signs of chronic stress and can be associated with neurocognitive impairments in areas related to emotions; memory; attentiveness; and, in the Broca area, the language center. The problems and findings, particularly from the field of neuroimaging techniques, have shown that an integration dysfunction of affective and cognitive processes can arise at the very moment of traumatic experiences. This can result in psychological but also physiological changes and symptoms of a more distinct nature. NEUROBIOLOGICAL CHANGES ASSOCIATED WITH PTSD The neurobiological changes associated with PTSD are often connected with the amygdala and hippocampus. Both are connected with the production of cortisol, as described above, and with other cognitive functions, especially with the memory system. Memory can be divided into explicit, declarative memory, on the one hand, and implicit, non-declarative memory, on the other. The former is, at a neurobiological level, assumed to be associated with and connected to the hippocampus and controlled by the conscious mind. The implicit memory, also called emotional memory, is, on the other hand, assumed to be connected with the amygdala and responsive to signals from the environment. Facts are recorded by the hippocampus, whereas the processing of the accompanying affective reactions takes place through the amygdala. FUNCTIONAL DISTURBANCES OF THE AMYGDALA Sensory information, perception, cognitive processes, and the activation of parts of the prefrontal cortex can activate the amygdala. As a result of traumatic experiences, an over-activation of the amygdala (Post, Rubinow, and Ballenger 1984) is assumed to lead to functional disturbances—that is, malfunctions or dysfunctions of the thalamus and cortico-cortical connections, as well as disturbances of the prefrontal and limbic areas and memory dysfunctions. If the acute trauma, the stress response, and the over-activation of the amygdala lead to chronification and permanent activation of cortisol production, then, as described above, a disturbance of the hippocampus and the disturbed feedback regulation without inhibition of the cortisol production can persist. A consequence of this can be that the hippocampus is damaged, with varying grades of severity. For example, this can activate a vicious circle

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with a possible reduction of the hippocampus volume (Lanius et al. 2004; Post et al. 1984). FUNCTIONAL DISTURBANCES OF THE HIPPOCAMPUS The explicit, declarative memory is assumed to be associated with the hippocampus at a neurobiological level and connected with the conscious mind. Another of the physiological functions of the hippocampus is the feedback inhibition of cortisol (LeDoux 1998). Explicit memory refers to facts and events that are consciously perceived, whereas implicit memory includes the emotional responses derived from these events. In extremely traumatic situations, there can be an extreme affective arousal that seems to interfere with the explicit memory function of the hippocampus such that it fails to behave in the usual way. It is assumed that the person involved is unable to develop a narrative about the traumatic situation because no verbal imagery is present once explicit memory fails. The person is thus unable to describe the traumatic experience in words. Implicit memories in the amygdala can be triggered by stress-induced stimuli and can evoke very affecting sensations in the body, such as anxiety states and/or perceptions that appear to be vague. Here it becomes particularly obvious how traumatic situations, anxiety, and stress responses capture the whole body and can have a disintegrating impact on the whole body as a result (van der Kolk 2015). DISTURBANCE OF THE WHOLE PSYCHO-PHYSIOLOGICAL DEVELOPMENT OF CHILDREN DURING SENSITIVE PERIODS Traumas experienced during early childhood are assumed to have a particular and reinforced harmful effect on the whole further development of children and adolescents (for example, Gould et al. 2012). Early affective events are assumed to be stored and recorded via the amygdala, resulting in an overactivation of important neuronal systems. This can cause neuronal developmental disturbances or disorders during sensitive developmental stages (Teicher et al. 2003). Thus, there can be an effect on neocortical development. Neurotransmission and neuro-humoral mechanisms can be altered. This, in turn, seems to have a serious secondary negative influence on the development of the nervous system and the brain (Weber and Reynolds 2004). Neuropsychiatric symptoms can be due to such developmental disorders (see above) or, under extreme conditions, can be seen as alternative developmental trajectories (De Bellis et al. 1999; Fumagalli et al. 2007; Glaser 2000).



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TRAUMA-INDUCED NEURONAL RESPONSE PATTERNS OR SUBGROUPS Using neuroimaging techniques, two different response patterns and subgroups of trauma-induced neuronal reactions at a neuronal level can be found to correspond to the reexperiencing of traumatic situations. On the one hand, there can be a type of hyperarousal and, on the other, a type of hypoarousal (Lanius et al. 2005; Lanius, Hopper, and Menon 2003). IMPAIRMENTS OF NEUROCOGNITION ASSOCIATED WITH PTSD In connection with PTSD, different neurocognitive impairments can be found involving the functional areas of attentiveness, speed, and rate of information processing; declarative memory; and general intelligence (Twamley et al. 2009). According to Elzinga and Bremner, areas of the brain such as the hippocampus, the amygdala, the prefrontal cortex, areas of the cingulate cortex, and/or thalamus can all be affected and disturbed in their neurocognitive functions (Elzinga and Bremner 2002). The hippocampus can thus show, for example, impaired declarative or associative memory, either with memory fragments or trauma-related amnesia, whereas the amygdala can show increased sensitization and enhanced affective memory. The prefrontal areas and those of the cingulate cortex can show, for instance, an impairment of the modulation of affective perception and memory processes; of working memory; or of attentiveness, concentration, and flexibility. The thalamus can show a disturbance of its various functions, and the insula can show, for example, increased perception of pain. At the same time, memory organization in patients with PTSD seems to be seriously disturbed as a whole (McNally, Clancy, and Schacter 2001). AFFECTIVE RESPONSES AFTER SUFFERING TRAUMATIC EXPERIENCES Affective responses after suffering trauma can be divided into primary and secondary emotions (Brewin, Dalgfelsh, and Jospeh 1996). Primary emotions refer to feelings that instantly emerge during a traumatic situation. They can include feelings of helplessness and anxiety. Secondary emotions refer to feelings that arise after the event or after cognitive processing of an event, including assessment of the consequences, and these can result in lasting cognitive changes as a deeper and wider awareness of danger.

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THE POSTTRAUMATIC VULNERABILITY OF THE BRAIN All of these above-mentioned changes resulting from the experience of trauma are based on changes within the neuronal circuits. Notably, stresssusceptible regions such as the hippocampus and areas of the prefrontal cortex and of the amygdala can be affected, as well as areas of the cingulum, or parietal areas (Bremner 2002a, 2002b; Ochsner and Gross 2005). Posttraumatically Disturbed Processes of Emotion Regulation

After traumatic experiences, emotion regulation can be disturbed and result in the incapacity to cope with and regulate trauma-induced aversive arousal and stress by means of appropriate processes of emotion regulation at a psychophysiological level. Early traumatization can markedly further restrict the capacity to regulate emotions (Nemeroff 2004). Areas of the prefrontal cortex seem to be important for the regulation of emotions. TRAUMA RESPONSES ARE DEEPLY CONNECTED WITH BODILY AND NEURONAL CHANGES AND DYSFUNCTIONS All of these statements point to the way in which traumata can affect not only the psychological structures and functions, but also the physiological structures and functions connected with the mind and the body, resulting in dysfunctions in these areas. The studies, especially those using neuroimaging techniques, underlying these concepts are sometimes still controversial and not universally accepted as yet, but they all unfold in a similar direction, as described above, and suggest the need for further research. It is important to add that the growing body of research on genom, genes, epigenetics, gene expression, interactions of genes and environment, and vulnerability to PTSD or other mental health disorders (for example, Caspi et al. 2003) will continue to broaden the spectrum of definition, identification, and causation of these syndromes. REFERENCES American Psychiatric Association. 2013a. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association. ———. 2013b. Desk Reference to the Diagnostic Criteria from DSM-5. Arlington, VA: American Psychiatric Association.



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Antonovsky, Aaron. 1979. Health, Stress and Coping. San Francisco, CA: JosseyBass. Blaz-Kapusta, Barbara. 2008. “Disorders of Extreme Stress Not Otherwise Specified (DESNOS—a Case Study).” Archives of Psychiatry and Psychotherapy 2: 5–11. Brave Heart, Maria Yellow Horse. 2007. “The Impact of Historical Trauma: The Example of the Native Community.” In Trauma Transformed: An Empowerment Response, edited by Marian Bussey and Judith Bula Wise. New York: Columbia University Press. Brave Heart, Maria Yellow Horse, Josephine Chase, Jennifer Elkins, and Deborah Altschul. 2011. “Historical Trauma among Indigenous Peoples of the Americas: Concepts, Research, and Clinical Considerations.” Journal of Psychoactive Drugs 43 (4): 282–90. Bremner, James Douglas. 2002a. Does Stress Damage the Brain? New York: Norton. ———. 2002b. “Neuroimaging Studies in Post-traumatic Stress Disorder.” Current Psychiatry 4 (4): 254–63. Bretherton, Inge. 1990. “Communication Patterns, Internal Working Models, and the Intergenerational Transmission of Attachment Relationships.” Infant Mental Health Journal 11 (3): 237–52. Brewin, Chris R., Tim Dalgfelsh, and Stephen Jospeh. 1996. “A Dual Representation Theory of Posttraumatic Stress Disorder.” Psychological Review 103: 670–86. Briere, John N., and Catherine Scott. 2014. Principles of Trauma Therapy: A Guide to Symptoms. Thousand Oaks, CA: Sage Publications. Cannon, Walter B. 1932. The Wisdom of the Body. New York: W. W. Norton. Caspi, Avshalom, Karen Sugden, Terrie Moffitt, Alan Taylor, Ian W. Craig, HonaLee Harrington, et al. 2003. “Influence of Life Stress on Depression: Moderation by a Polymorphism in the 5-HTT Gene.” Science 301: 386–89. Center for Early Childhood Mental Health Consultation. 2017a. “Module Two: The Impact of Trauma on Infants, Toddlers and Young Children.” Georgetown University Center for Child and Human Development. Accessed January 14, 2018. http:// www.ecmhc.org/tutorials/trauma/mod2_0.html. ———. 2017b. “Trauma Module One: Defining Trauma.” Georgetown University Center for Child and Human Development. Accessed January 14, 2018. http:// www.ecmhc.org/tutorials/trauma/mod1_1.html. ———. 2017c. “Trauma Signs and Symptoms.” Georgetown University Center for Child and Human Development. Accessed January 14, 2018. http://www.ecmhc .org/tutorials/trauma/mod3_1.html. Conrad, Cheryl. 2008. “Chronic Stress-Induced Hippocampal Vulnerability: The Glucocorticoid Vulnerability Hypothesis.” Reviews in the Neurosciences 19 (6): 395–411. Courtois, Christine. 2004. “Complex Trauma, Complex Reactions: Assessment and Treatment.” Psychotherapy: Theory, Research, Practice, Training 41 (4): 412–25. Courtois, Christine, and Julian Ford. 2009a. “Defining and Understanding Complex Trauma and Complex Traumatic Stress Disorders.” In Treating Complex Traumatic Stress Disorders: Scientific Foundations and Therapeutic Models, edited by Christine Courtois and Julian Ford. New York: Guilford Press.

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———. 2009b. “Introduction.” In Treating Complex Traumatic Stress Disorders, edited by Christine Courtois and Julian Ford. New York: Guilford Press. Dass-Brailsford, Priscilla. 2007. A Practical Approach to Trauma: Empowering Interventions. Thousand Oaks, CA: Sage Publications. De Bellis, Michael, Andrew Baum, Boris Birmaher, Matcheri Keshavan, Clayton Eccard, Amy Boring, et al. 1999. “Developmental Traumatology, Part I: Biological Stress Systems.” Biological Psychiatry 45 (10): 1259–70. Elzinga, Bernet M., and James Douglas Bremner. 2002. “Are the Neural Substrates of Memory the Final Common Pathway in Posttraumatic Stress Disorder (PTSD)?” Journal of Affective Disorders 70 (1): 1–17. Florida State University. 2017a. “Trauma and Toxic Stress: Effects of Trauma on Brain Development.” Center for Prevention Early Intervention Policy. Accessed January 14, 2018. http://floridatrauma.org/trauma-brain-development.php. ———. 2017b. “Trauma and Toxic Stress: Trauma and Symptoms by Age.” Center for Prevention Early Intervention Policy. Accessed January 14, 2018. http://floridatrauma.org/trauma-symptoms.php. Foa, Edna, Terence Keane, Matthew Friedman, and Judith Cohen. 2010. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. Second edition. New York: Guildford Press. Ford, Julian, and Christine Courtois, eds. 2016. Treating Complex Traumatic Stress Disorders in Children and Adolescents: Scientific Foundations and Therapeutic Models. New York: The Guilford Press. Ford, Julian, and Phyllis Kidd. 1998. “Early Childhood Trauma and Disorders of Extreme Stress as Predictor of Treatment Outcome with Chronic Posttraumatic Stress Disorder.” Journal of Traumatic Stress 11 (4): 743–61. Fraiberg, Selma, Edna Adelson, and Vivian Shapiro. 1975. “Ghosts in the Nursery: A Psychoanalytic Approach to the Problem of Impaired Infant-Mother Relationships.” Journal of the American Academy of Child & Adolescent Psychiatry 14 (3): 387–421. Fromm, Gerard. 2011. Lost in Transmission: Studies of Trauma across Generations. London: Karnac. Fumagalli, Fabio, Raffaella Molteni, Giorgio Racagni, and Marco Andrea Riva. 2007. “Stress during Development: Impact on Neuroplasticity and Relevance to Psychopathology.” Progress in Neurobiology 81 (4): 197–217. Geuze, Elbert, Eric Vermetten, and James Douglas Bremner. 2005. “MR-Based in Vivo Hippocampal Volumetrics: 2. Findings in Neuropsychiatric Disorders.” Molecular Psychiatry 10 (2): 160–84. Gilbertson, Mark, Tamara Gurvits, Natasha Lasko, Scott Orr, and Roger Pitman. 2001. “Multivariate Assessment of Explicit Memory Function in Combat Veterans with Posttraumatic Stress Disorder.” Journal of Trauma Stress 14 (2): 413–32. Gilbertson, Mark, Martha Shenton, Aleksandra Ciszewski, Kiyoto Kasai, Natasha Lasko, Scott Orr, et al. 2002. “Smaller Hippocampal Volume Predicts Pathologic Vulnerability to Psychological Trauma.” Nature Neuroscience (11): 1242–47. Glaser, Danya. 2000. “Child Abuse and Neglect and the Brain: A Review.” Journal of Child Psychology and Psychiatry 41 (1): 97–116.



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Gould, Felicia, Jennifer Clarke, Christine Heim, Philip Harvey, Matthias Majer, and Charles Nemeroff. 2012. “The Effects of Child Abuse and Neglect on Cognitive Functioning in Adulthood.” Journal of Psychiatric Research 46: 500–506. Gudaite, Grazina, and Murray Stein, eds. 2014. Confronting Cultural Trauma: Jungian Approaches to Understanding and Healing. New Orleans: Spring Journal Books. Herman, Judith. 1992. Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. New York: Basic Books. Hill-Rice, Virginia, ed. 2012. Handbook of Stress, Coping and Health: Implications for Nursing Research, Theory, and Practice. London: Sage. Horowitz, Mardi. 2011. Stress Response Syndromes: PTSD, Grief, Adjustment, and Dissociative Disorders, Fifth edition. New York: Jason Aronson. Lanius, Ruth, James Hopper, and Ravi Menon. 2003. “Individual Differences in a Husband and Wife Who Developed PTSD after a Motor Vehicle Accident: A Functional MRI Case Study.” American Journal of Psychiatry 160 (4): 667–69. Lanius, Ruth, Eric Vermetten, and Clare Pain, eds. 2010. The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. Cambridge: Cambridge University Press. Lanius, Ruth, Peter Williamson, R. L. Bluhm, Maria Densmore, Kristine Boksman, R. W. Neufeld, et al. 2005. “Functional Connectivity of Dissociative Responses in Posttraumatic Stress Disorder: A Functional Magnetic Resonance Imaging Investigation.” Biological Psychiatry 57 (8): 873–84. Lanius, Ruth, Peter Williamson, Maria Densmore, Kristine Boksman, R. Neufeld, Joseph Gati, et al. 2004. “The Nature of Traumatic Memories: A 4-T FMRI Functional Connectivity Analysis.” American Journey of Psychiatry 161 (1): 36–44. LeDoux, Joseph. 1998. “Cognition and Emotion: Listen to the Brain.” In Emotion and Cognitive Neuroscience, edited by Richard Lane and Lynn Nadel. Oxford: Oxford University Press. Liberzon, Isreal, and Kerry Ressler, eds. 2016. Neurobiology of PTSD: From Brain to Mind. Oxford: Oxford University Press. Liberzon, Israel, and Chandra Sekhar Sripada. 2008. “The Functional Neuroanatomy of PTSD: A Critical Review.” Progress in Brain Research 167: 151–69. Luxenberg, Toni, Joseph Spinazzola, and Bessel van der Kolk. 2001. “Complex Trauma and Disorders of Extreme Stress (DESNOS), Diagnosis, Part One: Assessment.” Directions in Psychiatry 21: 373–93. Luxenberg, Toni, Joseph Spinazzola, Jose Hidalgo, Cheryl Hunt, and Bessel van der Kolk. 2001. “Complex Trauma and Disorders of Extreme Stress (DESNOS), Diagnosis, Part Two: Assessment.” Directions in Psychiatry 21: 395–415. McEven, Bruce S. 2007. “Physiology and Neurobiology of Stress and Adaptation: Central Role of the Brain.” Physiological Reviews 87: 873–904. McNally, Richard, Susan Clancy, and Daniel Schacter. 2001. “Directed Forgetting of Trauma Cues in Adults Reporting Repressed or Recovered Memories of Childhood Sexual Abuse.” Journal of Abnormal Psychology 110 (1): 151–56. National Child Traumatic Stress Network. 2017a. “Child Welfare Trauma Training Toolkit: Comprehensive Guide.” Accessed January 14, 2018. http://www.nctsn .org/nctsn_assets/pdfs/CWT3_CompGuide.pdf.

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———. 2017b. “Early Childhood Trauma.” Accessed January 14, 2018. http://www nctsn.org/trauma-types/early-childhood-trauma. ———. 2017c. “Types of Traumatic Stress.” Accessed January 14, 2018. http://www .nctsn.org/trauma-types. Nemeroff, Charles. 2004. “Neurobiological Consequences of Childhood Trauma.” Journal of Clinical Psychiatry 65 (1):18–28. Ochsner, Kevin, and James Gross. 2005. “The Cognitive Control of Emotion.” Trends in Cognitive Science 9 (5): 242–49. Perry, Bruce, Ronnie Pollard, Toi Blaicley, William Baker, and Dominico Vigilante. 1995. “Childhood Trauma, the Neurobiology of Adaptation, and ‘Use-Dependent’ Development of the Brain: How ‘States’ Become ‘Traits.’” Infant Mental Health Journal 16 (4): 271–91. Pliszka, Steven. 2016. Neuroscience for the Mental Health Clinician. New York: Guilford Press. Porth, Carol. 2014. Essentials of Pathophysiology: Concepts of Altered Health States. Fourth edition. Philadelphia: Wolters Kluwer. Post, Robert, D. R. Rubinow, and J. C. Ballenger. 1984. “Conditioning, Sensitization and Kindling: Implications for the Course of Affective Illness.” In Neurobiology of Mood Disorders, edited by Robert Post and James C. Ballenger. Baltimore: Williams and Wilkins. Rakoff, Vivian, John Sigal, and Nathan Epstein. 1966. “Children and Families of Concentration Camp Survivors.” Canada’s Mental Health 14: 24–25. Schore, Allan. 2001. “The Effects of Early Relational Trauma on Right Brain Development, Affect Regulation, and Infant Mental Health.” Infant Mental Health Journal 22: 201–69. Schupp, Linda. 2015. Assessing and Treating Trauma and PTSD. Second edition. Eau Claire, WI: PESI Healthcare. Selye, Hans. 1956. The Stress of Life. New York: McGraw-Hill. ———. 1983. “The Stress Concept: Past, Present, and Future.” In Stress Research Issues for the Eighties, edited by Cary L. Cooper. New York: John Wiley. Shengold, Leonard. 1989. Soul Murder: The Effects of Childhood Abuse and Deprivation. New Haven, CT: Yale University Press. Teicher, Martin, Susan Andersen, Ann Polcari, Carl Andersen, Carryl Navalta, and Dennis Kim. 2003. “The Neurobiological Consequences of Early Stress and Childhood Maltreatment.” Neuroscience and Biobehavioral Reviews 27 (1–2): 33–44. Tronick, Ed. 2007. The Neurobehavioral and Social-Emotional Development of Infants and Children. New York: W. W. Norton & Company. Twamley, Elizabeth, Carolyn Allard, Steven Thorp, and Sonya Norman. 2009. “Cognitive Impairment and Functioning in PTSD Related to Intimate Partner Violence.” Journal of International Neuropsychological Society 15 (6): 879–87. US Department of Veterans Affairs. 2016a. PTSD-Overview. Accessed February 23, 2018. http://www.PTSD.Va.gov/professional/PTSD-Overview/index.asp. ———. 2016b. “Complex PTSD” Accessed February 23, 2018. http://www.PTSD .Va.gov/professional/PTSD-overview/complex-PTSD.asp.



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van der Kolk, Bessel. 2005. “Developmental Trauma Disorder: Toward a Rational Diagnosis for Children with Complex Trauma Histories.” Psychiatric Annals 35 (5): 401–8. ———. 2015. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Penguin Books. van der Kolk, Bessel, David Pelcovitz, Susan Roth, Francine Mandel, and Alexander McFarlane. 1996. “Dissociation, Affect Dysregulation and Somatization: The Complex Nature of Adaptation to Trauma.” American Journal of Psychiatry 153 (7th Festschrift Supplement): 83–93. van der Kolk, Bessel, Susan Roth, David Pelcovitz, Susanne Sunday, and Joseph Spinazzola. 2005. “Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma.” Journal of Traumatic Stress 18 (5): 389–99. Volkan, Vamik. 2012. Enemies on the Couch: A Psycho-Political Journey through War and Peace. Durham, NC: Pitchstone. ———. 2014. Animal Killer: Transmission of War Trauma from One Generation to the Next. London: Karnac. Volkan, Vamik, Gabriele Ast, William Greer, and Ira Brenner. 2002. The Third Reich in the Unconscious: Transgenerational Transmission and Its Consequences. New York: Brunner-Routledge. Weber, Deborah, and Cecil Reynolds. 2004. “Clinical Perspectives on Neurobiological Effects of Psychological Trauma.” Neuropsychology Review 14 (2): 115–29.

II DIMENSIONS OF TRAUMA

In part II, the understanding and the context of trauma is deepened. The influence of trauma on human development is explored by Louise Newman. Yolanda Gampel discusses and illustrates human-made disasters, collective persecutions, genocides, and the meaning of historical and intergenerational trauma. Louise Newman then addresses the consequences of massive trauma and Margaret Crastnopol explores seven different types of what she terms “micro-trauma.” Finally, Pauline Boss explains and demonstrates the importance of resilience.

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3 Development and Trauma Recapitulation of Traumatic Themes in Early Interaction Louise Newman

Freud described the earliest relationship as “unique, without parallel, estab-

lished unalterably for a whole lifetime as the first and strongest love object and as the prototype for later love relations” (Freud 1938). With this use of language, Freud heralded the later developments of Bowlby’s attachment theory, with its emphasis on internal representation of relationships and the way in which real interactions in infancy evolve into prototypes or inner working models, impacting representation of self and other, understanding of relationships, and emotional regulation. The historical infant and infantile states are core elements of all forms of psychodynamic psychoanalytic work. There are multiple theoretical models of infancy and early development, ranging from the infant of psychoanalysis, evolving from Freud and Klein, to the contemporary social infant, the infant of research who is an observable infant with social capacity and the ability to communicate complex emotional states. The analytic focus on the infant’s experience and interaction has contributed to a model of the infant subject as one who is intrinsically involved in shaping a social world. Finally, the therapist works with the original infant’s experience of the parent/attachment figure and the relationship that infantile self has with both the adult self and the figure of the therapist. In transgenerational work with parents and their infants, we focus both on the infant and on the infantile experience of the parent, looking at the way in which repetition of themes from the parental past, and particularly the reenactment of early unresolved traumatic attachment experiences, shapes their understanding of and interactions with their current infant. This chapter explores the way in which infantile traumatic experience resonates with adult borderline states.

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THE SIGNIFICANCE OF EARLY INFANTILE EXPERIENCE Current models of infant development focus on the development of the self and the regulation of self-experience. The infant as described by Daniel Stern (1985) initially experiences in an unrepresented way with self-consciousness and self-cohesion as emergent properties. Disruptions of early attachment and care have the potential, then, of disturbing or derailing the emergent sense of reflected self and understanding of self and other in relationships. Very commonly, the adults we work with in psychotherapy who have had traumatic early interactions demonstrate fundamental dysregulation, both in their self-experience and in their capacity to regulate self-experience. This is commonly reflected in difficulties in regulating and maintaining a cohesive and coherent sense of self with reflective functioning and the ability to maintain cohesion of self-experience over time particularly in the face of traumatic experiences. During infancy, the individual develops—in the language of attachment theory—internal working models of attachment and models of relational functioning. These models include the representation of the self and other and a complex structure that influences perception and feelings about relationships. As Jeremy Holmes has described, the individual experiences the existential dilemma of maintaining a sense of individuality and self-cohesion, while at the same time desiring a sense of intimacy or connection. Disruption of early understandings of relationships and experiences in reciprocal relationships will clearly have a long-term potential impact on the individual’s capacity to engage in reciprocal relationships with others, while resisting symbiotic fusion and risking a loss of sense of identity and coherence. An important developmental outcome of early infancy is the development of reflective functioning, the capacity to understand self and others in terms of mental states, and the component development of a theory of mind. Described by Fonagy and Target (1997), reflective functioning is the basis of social cognition and social interaction and allows for sophisticated components such as empathic functioning and the ability to regulate affective states and elements of self-experience. Reflective functioning essentially develops from the early relationship with the carer where the carer has the capacity to label and think about the interiority or mind of the infant. The parent literally holds the baby in mind, thinking about the infant as having wishes, desires, beliefs, mental states, and intrinsic psychological motivation. It is this capacity to see the infant as separate from the self, with a unique developmental agenda, that is the basis of attuned and synchronized early interactions and what may become a secure attachment. All these key developmental outcomes of infancy occur in the context of the attachment relationship with the primary carer and are obviously laid



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down in the developing brain, becoming the fabric of neurodevelopment. It is from the building blocks of early minute emotional interactions and their regulation that the infant comes to experience them in relationship with someone else who has the capacity to respond and share positive affective interactions. The internalization of these positive emotional experiences and regulated interactions is central to the development of what is termed in contemporary psychological theories a notion of resilience, or the capacity for managing self-states and interpersonal stress. It is also the basis of the infant’s emerging positive self-evaluation or self-esteem, which Winnicott elaborates as a notion of the true or authentic self in which individuals are able to develop a coherent emotional life and a language for describing their inner world in relationship to the other. The capacity for empathic functioning and reciprocal relationships is obviously one of the key developmental outcomes related to the interaction with the primary carer or attachment figure. The securely attached infant develops a self-representation of being worthy of care and love, and a representation of the other as basically trustworthy and available. It is from this core sense of security that the individual elaborates a sense of the positive self in relation to the other. This is the basis, as described by Freud, of the capacity for healthy psychological functioning for love or connection with others, for creativity and the capacity to work, and for the capacity for play and spontaneity. Infancy, then, is seen as a foundational developmental period. It is a critical period where certain experiences are required for psychological organization and for healthy development across the life span. It follows that deprivation of critical experiences during infancy may have long-term impact on psychological development. As Winnicott described, infant development occurs only in the context of care-taking relationships—the self develops as the infant is thought about in the mind of someone else. “There is no such thing as an infant,” as Winnicott ([1960] 1965, 39n1) states. RELATIONAL TRAUMA Trauma during the infant period of development is usually that occurring in the context of caregiving and attachment relationships. It may be manifest in subtle disruptions of emotional interaction and regulation—the so-called hidden traumas of infancy. This may result from factors in both the infant and in the mind of the parent who has difficulty in reading and responding to the infant’s emotional communication, or difficulty in thinking about the infant as a separate psychological being. Regardless of the underlying aetiology of the disturbance, the infant experiences high levels of stress, confusion,

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and essentially unresolvable or inescapable fear. The infant is dependent for both physical and psychological survival on the primary carer regardless of the quality of those interactions. The infant will show signs of physiological stress in interactions with the carer if these are disturbed, but will also work to signal and communicate desire for social connection and interaction with the attachment figure. This situation for the infant has been described as a psychological paradox, where the infant has no choice but to try to obtain feelings of safety and security from the attachment figure when the latter is also frightening and confusing. In learning-theory terms, this is known as an approach-avoidance conflict, and at a basic neurodevelopmental level, it sets up a chronic state of disorganization and stress for the infant, who feels trapped in an unresolvable situation. Neurodevelopment is directly impacted by stress-related hormones and experiences of both under- and over-arousal. The infant is dependent on the carer for the regulation of levels of arousal and of affective states. The development of stress regulation may be disrupted by persistent exposure to cortisol and related hormones during rapid periods of neurological organization and growth, essentially sensitizing the infant brain to the impact of trauma and establishing ongoing dysregulation of affect and stress regulation. Thus, early traumatic experiences are inscribed into the fabric of the developing brain and may be seen as underlying aberrant developmental pathways and disruption of the underpinnings of self-functioning, as is seen in severe personality disorder and borderline states. Early interactions between parent and infant are based on mirroring and the reflection of emotional states. William Carlos Williams described these interactions thus: “Look at them looking, their eyes meeting the world” (Williams quoted in Ayers 2014, 35) Similarly, Stern describes the state of mutual gaze between infant and parent as the infant seeking a world within a world. Winnicott ([1960] 1965) also described the way in which infants seek for themselves in terms of their gaze with the parent—the infant sees his or her own states reflected in the eyes of the mother. In healthy relationships, this process of mirroring and reflection allows for the positive sharing of emotional states and a gradual and appropriate psychological separation of self and other (mother). As Fonagy (Fonagy and Target 1997) describes, in situations where the parent’s mind and mental state are not able to connect with or reflect the infant, the situation can be very anxiety provoking and fearful for the infant. The infant may see not his or her own state reflected back but the state of the mother; be it despair, depression, or anger. In extremely disturbed early relationships, the infant may have nothing reflected back or nothingness reflected back in the eyes of the mother and may experience the emergence of self as dead or organized around pathological affective responsiveness.



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The complex tasks of birth revolve around the meeting and greeting of the new infant. Psychologically, the parent must cope with the loss of fusion experienced during pregnancy and deal with the actuality of the particular infant who is born. Parents must cope with fears of harming the infant and also tolerate both dependency and the physical nature of the holding relationship with the new infant. The baby at birth, then, represents the fusion of the baby of the Imaginary—the baby of wish and fantasy—with the actual infant and his or her own specific characteristics and behavior. The intensity of the moment of greeting the new infant is clear in healthy relationships, where the baby, having a personal capacity for social interaction gazes with intensity at the face of the new parent. In relationships where the parent has experienced his or her own early trauma or is, for other reasons, overwhelmed emotionally at the time of birth, the baby’s gaze is met with a range of sometimes negative associations and meanings attached to them. This is the beginning of the notion elaborated by Fraiberg of the “ghosts in the nursery” (Newman 2008) or the unresolved traumatic attachment figures in the mind and history of the parent that literally haunt the emerging relationship between the parent and infant. In these situations, the infant is misrecognized or caught up with unresolved traumatic attachment figures from the past of the parent. The infant is an ideal projective focus for both the reenactment and recapitulation of traumatic attachment themes and, in some cases, becomes confused with, or identified with, particular characteristics of frightening or traumatizing abusive figures experienced by the parent. Examples of these sorts of dynamics are commonly seen in disturbed infant-parent relationships and might include for example situations where the infant is literally seen as having inherited the family badness or madness and can become a terrifying or frightening figure for the parent. EARLY MATERNAL DISTURBANCES In high-risk relationships, frequently where parents have experienced their own early attachment trauma, we can identify very early disturbances of emotional interaction between parent and infant. Typically, the parent has difficulties in tolerating the infant’s negative states and may variously reject or else over-identify with the infant’s emotional communication, becoming distressed as well. The baby may be perceived by the parent as attacking, hostile, rejecting, or overwhelming, and the infant may then experience a range of confusing and miss-attuned emotions, based on the parent’s negative reaction. The parent may describe being overwhelmed and unable to care for the baby, and at times might be distancing or avoidant of interaction with the

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baby due to the issues that are precipitated in those moments of connection. On occasion, the baby might literally be labeled as similar to the traumatic figure in the life of the parent or as having very similar negative characteristics. The reverse and/or related dynamic occurs when the parent needs the infant to reflect back his or her own emotional states and, in essence, be the parent of the parent. In these cases, the parent might wish for the imaginary relationship with the baby, in which all their emotional needs are met in a way in which they have not been able to achieve in other relationships. The net result of these early maternal disturbances for the infant is a range of confusing and conflicting emotional states, including high levels of stress and anxiety, and sometimes feelings of anger and rage at having been rejected or fundamentally misunderstood by the parent. Clinically, the infant may appear to be variously withdrawn from the parent, with obvious signs of withdrawal, such as gaze avoidance and head aversion, or they may work very hard in a hypomanic sense, with excessive gesturing and vocalizations, to express a need for connection with the parent. These states may be changeable and shifting, resulting in a confusing pattern for both infant and parent. In situations where the extremely traumatized parent is overwhelming for the infant, the infant at some point will withdraw from the interaction. Such infants may fail to grow and may be diagnosed with nonorganic failure to thrive. The impact of these early disturbances varies according to the degree of disruption of some of the core tasks of early parenting. The parent has a central role in modulating the infant’s overall level of arousal and in helping the infant to regulate internal affective states. Healthy enough parents focus on the infant’s communication and begin an active process of thinking about and reflecting back to the infant their own affective states, providing a language for feelings. Parents with unresolved issues of their own may be insensitive to the infant’s signals and have core difficulties in labeling and regulating these affective states. This can reflect their own difficulties in affect regulation and reflective capacity. The basis of this understanding of the infant is, as described by Fonagy and colleagues (Fonagy et al. 1991), the parental process of reflection on the infant’s inner experience. This is a mentalization or hypothesizing process, where the parent thinks and wonders about the infant and provides a process of containment of the infant’s emotional states through language and touch. At the same time, essential for the development of the infant’s sense of self, is a process whereby the parent marks the communication from the infant as different and begins to establish a sense of separation between self and other. Central to these early processes is the parent’s capacity to read and respond to affective signals and to literally process the emotional communication of the infant by observing the infant’s face, an active process of interpretation



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of communicative states. On a neurodevelopmental/brain level, the parent’s brain, face recognition, and affiliate pathways are involved in responding to the emotional communication of the infant. The process of affective attunement as described by Stern (1985) is essentially based on these neurological resonances and involves the maternal brain matching the infant’s affective state and on a psychological level, interpreting, responding, and communicating a sense of emotional resonance or connection. It is from these basic experiences of emotional and social connectedness that the infant self emerges as having a valued core of affective experience. In situations where there is mis-attunement or a disconnect between parent’s and infant’s emotional communication, there is disruption of the infant’s emerging regulatory capacities and of self-development. Psychic trauma in infancy essentially overwhelms the infant’s capacity and defensive operations, creating feelings of utter helplessness. Winnicott ([1945] 1982) describes the unspeakable and unthinkable anxieties of infancy—the fear of being alone forever, of being fragmented, and of a profound inability to go on being. These emerge in the context of a relationship where the parent’s own unresolved trauma negatively impacts his or her interaction and representation of the infant. Traumatized parents with limited reflective functioning are disrupted in terms of their own self, with limited capacity to reflect on the history, memories, and emotions of their own early attachment experiences. Their own trauma has impacted in a negative way— the reworking of their own early relationships in the transition to parenthood and in terms of their representation of the child. The capacity to think about the baby is crucial in establishment of attachment organization and emotionally attuned early interaction. It gives the infant the profound experience of being validated and contained and is the beginning of self-development. Early emotional trauma, then, is directly involved in disrupting emerging capacities for interaction and self-regulation, and may variously result in disturbances of self-experience in an ongoing way. The misperceived infant experiences a lack of sense of authenticity and ongoing fears of abandonment and annihilation. The infant has core confusion about emotional states and their expression and a disturbed sense of being with others. TRAUMATIZED AND TRAUMATIZING PARENTS Parents with unresolved traumatic attachment issues and histories of maltreatment/neglect have a range of issues and conflicts when they attempt to parent—manifested in reactions from anxiety to avoidance and, in some instances, the repetition and reenactment of abusive scenarios. For the infant,

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as the subject of traumatic interactions, traumatic experiences are directly inscribed in the fabric of the developing brain. “The brain” remembers trauma in the developing pathways and functions that are emerging in these highstress situations. In transgenerational trauma, we see the repetition of disturbed interactions and patterns of relationships in family themes of trauma and neglect and abandonment. On occasion, there is direct repetition of abuse and maltreatment in terms of harm to the infant. In less extreme situations, the parent who has been abused will grapple with a range of issues from his or her own anxiety about being able to be a safe parent to the desire to make reparations and to recover from the early abuse. Sometimes adults who have been deprived or hurt in childhood are fundamentally envious of their own infant’s positive experiences and may undermine or devalue the infant’s drive toward development and autonomy. Very disturbing are the sometimes obvious reenactments of unresolved attachment trauma. The infant’s situation in these scenarios is like being a compulsory player in a Greek tragedy. The themes repeated in early relationships shape infant psychic development and involve parents’ attempts at reworking their own early trauma. Infants develop psychological problems when their parents cannot see them as separate and communicating, and when unresolved parental attachment trauma permeates the parent-child interactions. In many of the more severe disturbances of early interaction, the disruptions to emotional regulation, self-development, and self-cohesion are the origins of later borderline states. The earliest origins of the classical borderline difficulties of self-regulation and affective regulation can be seen in these disturbed early relationships. BORDERLINE PERSONALITY DISORDER AND EARLY ATTACHMENT DISRUPTIONS Disturbances in interpersonal relationships and attachment are essential to current models of borderline personality disorder. Borderline individuals are preoccupied with early traumatic attachment issues that have been left unresolved. The legacy of attachment disorganization is seen in their ongoing difficulties in maintaining a cohesive model of self with other. On a basic level, the borderline individual’s difficulties in understanding interpersonal interaction, and thinking about their mind in relation to the mind of the other, is based on the disturbances of early emotional interaction and attunement described above. As Winnicott ([1960] 1965) described, when infants gaze into the eyes of their mother, they are looking for themselves; in the situation where the



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mother herself is overwhelmed by primitive emotional states, the baby sees reflected back an unprocessed and uncontained affective state. The baby’s mind is essentially unrecognized and remains unrepresented and unknowable. This has been described as the baby being seen as the hostile part of the parental self, or as the uncanny and unknowable (das unheimliche), something that is both familiar and strange simultaneously, which signifies the potential of loss of self-autonomy and meaning (Lacan [1960] 1962). For the borderline parent, the infant is an uncanny and unknowable object, full of potential risk. Several psychoanalytic writers describe the early disruptions of emotional interaction and the way in which this disrupts self-development. Bion (1962) described the parent who had difficulties tolerating the infant’s negative affect, providing an affective regulation and language, and accepting the individuation of the infant. This theme of the lack of support for the infant’s emergent self and its role in the development of borderline personality disorder is elaborated by Masterson (1976). For Lacan ([1936] 2006) the child in the mirror stage of development identifies with a coherent image of the self that the body belies. Presumably, in the identification with the distorted gaze of the borderline parent, the infant may fail in the process of identification and remain in a state of unprocessed and fragmented experience. The meaning of the infant in the mind of the parent is described in several theoretical accounts and is one of the core tenets of infant-patient psychotherapy, which focuses on freeing the infant from negative or hostile identifications in the mind of the parent. All infants are born to and given a place in the system of intergenerational meaning and relationships. The infant has a name, a family story, and a potential for reworking intergenerational themes. For parents, this is the opportunity to rework their own infantile experiences, expectations, and desires through the relationship with the new infant. The notion of the false mirror is an important one in understanding transgenerational distortions. The infant in this situation has to mirror the mother rather than experience the self reflected in her. This is the process in which infants identify with their mother’s state rather than having a relationship in which their own emotional experience is validated. Thus, the mother’s desolation or lack, and in some cases her anger or hatred, forms the kernel of the infant’s self-organization. In this model, the core deficits of severe personality disorder revolve around an existential lack of connection with a validating other and the ongoing implications that this has for understanding the mind and interpersonal functioning. The “symptoms” of borderline personality disorder are sometimes described as ways in which one attempts to fundamentally maintain homeostasis or a sense of

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connection with one’s own affective experience. The individual with borderline personality disorder remains preoccupied with traumatic attachment issues and may experience a lack of capacity to resolve that trauma, resulting in what are described as features of posttraumatic stress disorder and mental disorganization. The capacity to think about, remember, and process early adversity and experience is limited, with frequent distortion, minimization, and idealization of early experiences. And core conflicts around nurture, dependency, and aggression will potentially impact on the capacity to parent and to become an attachment figure to a new infant. IMPLICATIONS FOR PSYCHOTHERAPY: WORKING WITH INFANTILE TRAUMA Working with the legacy of infantile trauma in psychotherapy is complex. It requires close attention to both the patient’s capacity to focus on painful experiences of early trauma and rejection and the therapist’s own capacity to reflect on and contain the infantile states of need and anger. The borderline adult in the psychotherapeutic relationship is essentially seeking and recapitulating the earliest relationship with the Other and is engaged in a process of attempting to rediscover the mother and the self through intense experiences of gaze and reflection. Focusing on neutral affective interaction and reflective processes, as emphasized in some schools of self psychology, is helpful when we think about these intense fluctuations of emotional experience and the difficulties the borderline patient faces in reflecting on their own affective processing. Some of these difficulties may be reflected in the overwhelming nature of some emotional experiences that the patient cannot regulate, a lack of language and impaired capacity for reflection and representation of emotional states, and the experiences of the overwhelming need to repeat and communicate unprocessed negative affect. In practice, the essential therapeutic role is that of reflecting and processing these raw and un-metabolized emotional states. In the same way that Winnicott described the infant searching for the self by looking into the face of the parent, the patient searches for the meaning of his or her own emotional experience in terms of the therapist’s response. The therapist, as an attachment figure, plays a role in providing the scaffolding or regulation of affective experience, and the beginnings of a language of the self, which the patient can then use to represent and reflect on his or her inner world and mental processing. Similar concepts are used in mentalization-based approaches, as described by Bateman and Fonagy (2004), where the mutual task of the therapeutic relationship is to explore the mind and mental state operations of the patient and the relationship between



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patient and therapist, thus building up or developing the patient’s capacity for reflective functioning. The needy infant in psychotherapy raises significant issues in the therapeutic relationship. The overwhelming desire of the uncontained and abused infant for maternal care, the never-ending fantasy that the figure of the therapist/mother will be ever present and able to make reparation for the unthinkable pain experienced in early life, places the therapist in a position, by definition, of having to help the infant/patient cope with anger and disappointment over the loss of the perfect and never-failing attachment figure. In terms of the patient’s external and other relationships, this same neediness is enacted in situations of revictimization, retraumatization, and sadomasochistic interaction with others, which are then seen as the fault of the flawed parent/therapist. Maintaining a focus on infantile pain and the emergent capacity to reflect on this is the essential task of psychotherapy. In terms of countertransference, the notion of therapeutic empathic attunement, along with concepts such as Bion’s (1962) notion of containment and processing of infantile states, are very helpful in understanding the early phases of therapy. The model of transgenerational trauma also opens up the possibilities of discussing with the patient the ways in which current real relationships, including those with a child, need to be understood in terms of traumatic themes and their recapitulation. While traditional individual psychoanalytic and psychotherapeutic approaches perhaps have seen this as a nonessential task or a secondary focus, as opposed to the intra-psychic, it is the immediacy of recapitulation and the search for the self in relationships with the Other that is perhaps more salient to understanding the borderline personality experience. The search for self in the relationship with the therapist is essentially a search for the infantile self and a quest for meaning in a relationship with the mother. The therapist as an attachment figure (as well described by Holmes [2004]) is also a regulatory figure, with the capacity to hold in mind and withstand the unprocessed negative affect of the traumatized patient. The therapist’s capacity to survive in the face of infantile rage and the onslaught of need is vital in its signification to the patient of the tolerability of their inner world. The borderline patient, often overwhelmed by shame and disgust, can thereby experience both “forgiveness” and acceptance. In this way, we can work toward preventing the repetition of sadomasochistic relational patterns in the therapeutic encounter in which the patient demands punishment and endless rejection by the figure of the therapist. Integrating transgenerational models and themes in psychotherapy and the model of early infant development helps inform psychotherapeutic practice with borderline patients. Working with infantile states in psychotherapy is

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working at the level of affective representation and processing, requiring some focus in the early stages of therapy on processes of mirroring, reflection, and nonverbal experience. Infant research and developmental models have significant relevance for psychotherapeutic practice and our understanding of the intersubjective context of psychotherapy. “Speaking to the baby” is a process of providing scaffolding and words around infantile experience and ultimately in longer-term psychotherapy moving toward the patient’s internalization and creation of a system of coherent meaning around their own early experiences and the capacity to reflect on their significance. The development of a containing narrative or model for understanding subjective experience and its changes over time fundamentally involves incorporation of the infantile and related trauma into models of self and self-functioning. It is in this process that adult psychotherapy is well informed by our understanding of the infant world. REFERENCES Ayers, Mary. 2014. Mother-Infant Attachment and Psychoanalysis: The Eyes of Shame. London: Routledge. Bateman, Anthony W., and Peter Fonagy. 2004. Psychotherapy for Borderline Personality Disorders: Mentalization Based Treatment. Oxford: Oxford University Press. Bion, W. R. 1962. Learning from Experience. London: Heinemann. Fonagy, P., and M. Target. 1997. “Attachment and Reflective Function: Their Role in Self-Organization.” Development and Psychopathology 9: 679–700. Freud, Sigmund. 1938. An Outline of Psychoanalysis. London: Hogarth Press. Holmes, Jeremy. 2004. The Search for the Secure Base: Attachment Theory and Psychotherapy. London: Taylor and Francis. Lacan, Jacques. (1936) 2006. “The Mirror Stage as Formative of the I Function as Revealed in Psychoanalytic Experience.” In Ecrits: The First Complete Edition in English, translated by Bruce Fink. New York: W. W. Norton. ———. (1960) 1962. “The Subversion of the Subject and the Dialectic of Desire in the Freudian Unconscious.” In Ecrits, translated by S. Sheridan. 292–395. New York: W. W. Norton. Masterson, James F. 1976. Psychotherapy of the Borderline Adult: A Developmental Approach. New York: Brunner-Mazel. Newman, Louise. 2008. “Trauma and Ghosts in the Nursery: Parenting and Borderline Personality Disorder.” In Infants of Parents with Mental Illness: Developmental, Clinical, Cultural and Personal Perspectives, edited by Anne Sved-Williams and Vicki Cowling. Sydney: Australian Academic Press. Stern, Daniel. 1985. The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. New York: Basic Books.



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Winnicott, D. W. (1945) 1982. “Primitive Emotional Development.” In Through Paediatrics to Psychoanalysis: Collected Papers. London: Hogarth Press. ———. (1960) 1965. “The Theory of the Parent-Infant Relationship.” In The Maturational Processes and the Facilitating Environment, 37–55. New York: International Universities Press, 1965.

4 Historical and Intergenerational Trauma Radioactive Transmission of the Burdens of History—Destructive versus Creative Transmission Yolanda Gampel

At the end of the day, Shoah survivors, like the survivors of any other disaster of sociopolitical violence, pose a two-pronged question: How will they pass on their traumatic experiences to their children, and how will those children be affected by what is told to them? Auschwitz and Hiroshima have shown us that death and violence belong to the most intimate and concealed parts of our identity. The monstrous and painful memories they left behind overload or destroy the perceptual and representational systems of their victims and bystanders. These memories create a legacy that gives rise to cruel and violent forms of identification in themselves and their children. While the children of survivors do not have their own personal memories of the Shoah, the internal reality of their family’s past loss, suffering, and humiliation has been deposited in them by intergenerational transmission. The use of a psychoanalytical viewpoint makes it possible for the next generation to work through these deposits so that they will be able to distinguish between internal and external reality and to gain the secure identity that will give them some control of their lives Borrowed from the field of nuclear physics, the term “radiation” expresses in metaphor the monstrous, aberrant, and unexpected effects caused by sociopolitical violence. It allows us to reflect on violence, cruelty, and the horror inherent in war, terrorism, and diverse forms of social violence. It allows us to apprehend the war of words and images that the media bombard us with daily. On May 1, 1986, I was in Paris when Europe was shocked by the radioactive fallout produced by the Chernobyl nuclear power disaster in the Soviet Union. The experts advised not to eat milk products or fresh vegetables. The rain that had been falling all over Europe turned out to be radioactive, and Belgium, Switzerland, and Germany were all taking precautions to protect 53

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their citizenry. But on this same date, French newspapers proclaimed in big headlines that the radioactivity had not reached France, certainly not Paris—and that the French had no need to take precautions. Yet a friend who works at the Pasteur Institute told us that she had just finished measuring the radioactivity under her feet and that radioactivity levels in Paris were very high. She assured me that the radioactivity had even reached Israel, despite its distance from Chernobyl, and that precautions would have to be taken—a story confirmed by Israeli news several weeks later. That was the day that “radioactivity” became a metaphor for me—a metaphor for “sociopolitical violence” and for the Shoah (Gampel 2005). The unconscious is transnational and psychoanalysis has no geographical, geopolitical, and linguistic borders. The sociopolitical violence of yesterday, in the form of the mass murders carried out by a Nazified Europe, has been transmitted to succeeding generations throughout the world. How does the collective memory of the mass murder of the past resonate with the nuclear radiation threat of today? What are the effects of this threat, of the fear and dread of death, in the human mind, and what is the place of death itself? The impact of the crime of mass murder affects the unconscious by attacking the human race in the deepest experiences of life and death. I wonder to what extent this attack affects the immanence of life. Another question arises: When we as children, adults, citizens, professionals, psychoanalysts, spectators, witnesses are penetrated and invaded by all those horrors, who and what do we become? The concept of a “radioactive nucleus” allows us to penetrate the thick sociopolitical “screen” constructed in order to avoid and deny the psychic and moral awareness of the reality of violence inflicted by human beings upon human beings. This paradoxical concept of “radioactivity” is entirely undiscriminating: We can all be passive receptors by the simple fact of belonging to a nation or to a territory and by living in society. Similarly, we can all be transmitters by the simple fact of being a social subject. If we carry “radioactive traces” or a “radioactive nucleus,” this nucleus can move unpredictably without being directed to a particular subject. It operates from a distance, and its effects have no limits, either in space or in time. It modifies the links between individuals, and this alteration cannot be attributed to a precise condition. The metaphor of radioactivity, transformed into a “radioactive core” and based on my concept of “radioactive identification” and “radioactive transmission” (Gampel 1992a, 1992b, 2005), has unfolded in the context of my work on the effects of sociopolitical trauma, chiefly those connected to the Shoah. This concept of “radioactivity” is extremely hard to grasp and arouses a lot of resistance. It forces us to become aware of something we have no



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defense against, namely, the effects of events taking place at a distance both in time and place, effects that are not transmitted by known channels of identification. We can be passive “receivers,” but we can also be—and this is entirely a matter of chance—“transmitters.” The metaphor of “radioactive identification” provides a conceptual representation of a specific process: the invasion of the psychic apparatus by terrifying, violent, and destructive elements of external reality, without the individual having the slightest means of controlling this invasion, defending himself against it, preventing it establishing itself or lessening its subsequent effects. This “radioactive identification” consists of unrepresentable vestiges, of “radioactive residues” from the outside world, which become ingrained in the individual without him or her being the least aware of it. It goes without saying that the concept “radioactive nucleus,” when used to refer to sociopolitical violence, leads us to reconsider certain classical concepts of psychoanalysis such as grief or bereavement development. On the other hand, it allows us to penetrate the thick screen built on the sociopolitical level to avoid and deny the psychic and moral awareness of the reality of violence inflicted by human beings to human beings. “Radioactive residues” of social violence can be turned into an identifying core; they manifest themselves in the form of bodily illness, emotional turbulence, unleashed drives, or tyrannical constriction. In the case of real, concrete radioactivity, the radiation physically damages the individual the moment it touches him or soon after. In the same way, sociopolitical violence damages the individual’s psychic apparatus the moment it happens or soon after. However, as happens with certain people exposed to physical radioactivity, the “radioactive residues” can remain latent and not emerge as disorders, physical or mental, in parents or their children until many years later. When we analyze what the victims of sociopolitical violence tell us— victims of the Shoah in particular—we can see how they have internalized these “radioactive residues,” even though they are totally unaware of them and do not identify with them. It is impossible to grasp or conceive of these residues with any precision: they make themselves known in various psychic forms and in a totally random fashion. One noticeable feature is the surprising occurrence in a person’s speech, or in his treatment of others, of a cruelty marked by dehumanizing features and quite at variance with his normal attitudes and behavior. Just as real radioactivity has no shape, smell, or color, so radioactivity in the psyche, like drives, cannot be directly grasped. Drives― the motive forces that push an organism toward some goal―build up within us from our very first days of life. This radioactivity, by contrast, invades us from the outside as a consequence of sociopolitical violence and takes deep root, to the point of becoming part of us. However, since it can also attach

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itself to a drive and manifest itself by that path, it is vital to differentiate between elements stemming from drives and those stemming from “radioactive residues” acting as sources for “radioactive identification.” Given that the radioactive identifications are a product of the unconscious, they are not amenable to remembering but only to “enactment,” to translation into words or acts, by Shoah victims or by their children, through the mysterious process of transgenerational transmission. It is noticeable that they occur at some conjunction of drive-related factors, personal or family issues, and outside events. This alternative path between acting and remembering brings us up against the random nature of the connection between identification and representation. What concepts can we use to understand this “radioactive nucleus”? The meaning that I want to give it is in relation to an infinite acceleration process, where everything can both take form and disappear at the time of its emergence. It is a type of “virtual void,” containing all the possibilities of transformations that appear and disappear simultaneously. Discussing my work, Caloz-Tshopp (2004) says that in philosophical terms it would be as if being and nonbeing coexisted, with a tendency to nonbeing. The dominance of nonbeing would produce a kind of “Destructive be” characterized by a movement of appearance/disappearance that vanishes whenever thinking attempts to seize it. It remains to be discovered how these “radioactive residues” impinge on consciousness, which is constantly working to maintain its organization and to find areas and modes of self-expression. The radioactivity can move around quite unpredictably without touching or affecting any particular individual. “Radioactive identification” is made up of a range of elements of “external” origin, which have been assimilated, incorporated, and internalized in a fantastic manner and which can suddenly assert themselves in moments of severe traumatic tension. When someone is a carrier of this metaphorical radioactivity, be it in the psyche or the body, be it in trace form, as a nucleus of identification, or in any other form, that person will eventually feel boxed in, imprisoned, and unable to live a life. To illustrate the concept of “destructive radioactive transmission—creative radioactive transmission” I would like to give two examples. In response to the publication of my book in Israel, I received numerous phone calls, letters, and emails that made me understand that even today we have a need to know things about the life and history of our parents with a surprising intensity. K., a forty-five-year-old man, called me to tell me that he bought my book. He was not sure that he would read it, but he mainly bought it because of my family name. His mother, whose family name was Gampel and who had died five years earlier, had told him very little about her history during the



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Shoah time. The same was true of his father, who died a few months after the mother. Thanks to other people, he was able to learn and gather some features related to his parents. Except for the name Gampel, he could not find anything. I explained that this was my husband’s family name. Nevertheless, I asked him where his mother came from. His mother was born in Rokitno, the birthplace of my husband. The man reacted with tremendous joy and exclaimed, “What luck, I have a family!” He wanted to know if I had children. When I said that I had three, he said, “Perhaps I have three cousins.” Do you make family gatherings on Friday night? I would really like to come, he told me. “I am married, I have three children. . . . So I found a family!” This exchange happened on the phone. I remained moved by the attitude of this man, an intelligent and socially very well-integrated individual, who works, is married, and is the father of three children, but who is carrying a painful obsession to return to the country of his parents, searching for knowledge about life before and during the war. It is as if he lives his present as a lack, as if whatever he felt during his childhood and adolescence was pushing him indefatigably and by all means to search and find knowledge about his mother and her history. My impression was that his parents had transmitted something without really transmitting it, and this paradox remained in him as a small radioactive nucleus. A woman named Sarah also called me. She lives in the north of the country and told me she found my book at the library of the kibbutz where she lives. She said she would try to read it, but that she borrowed the book primarily because of my name: Gampel. She added “my mother was called Gampel.” I asked her where her mother had come from, and she said Kovna. Another coincidence. My own mother was born in Kovna and lived there. I explained that my surname is the name of my husband and that my mother had lived in the same location as her mother. Very happily, she said, “Oh, I want to know more about your mother, what she did there, until when she lived in Kovna. . . .” We found out that our mothers were in the same Zionist Organization. Sarah thought that we could meet, exchange photos, and talk about the life of our mothers, so I invited her to come to my house. She told me that it was not possible, as she was raising cows in the north and could not leave her home, but that she had a brother who, since the death of their mother, had been collecting everything linked with the history of their mother—the slightest detail, every word pronounced by anyone about their mother, every photo or trace. Since she died, he has been obsessed with this research. She told me: “Me, it made me happy, when I saw your name, I thought, there could be a link to my mother. That’s it, that’s all.” In light of these two stories, we see how psychic radioactivity can be transformed in either a destructive or a creative way. This transformation depends,

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of course, on the social context and especially the modalities (styles) of transmission. Of course, what each survivor has felt, his way of transmitting the Shoah, is as unique as the manner in which the sons and daughters are capable of absorbing what happened to their parents (Gampel 1982, 1992c). The effects are not uniform. This psychic radioactivity can cause an obsession, an illness. It can create toxic psychic effects in the same way that it can “nourish” a “soft memory,” as in the case of this woman of the kibbutz. Finding my name on the book was mainly something exciting for her. Unlike her brother and Mr K. of the first anecdote, she does not have the compulsion to find anything. She is content with taking care of her cows and her present way of life. She is interested in the world of the past, but there is no constraint. During the past half century, radioactivity has become a diagnostic and therapeutic tool in the area of medicine. Nuclear medicine uses radiation both to explore the human body and at the same time to treat it. This is a creative and constructive use of radioactivity. On the other hand, the injurious effects of radiation on the body can be seen in three destructive processes that can occur individually or in various combinations. First, radioactive processes can destroy tissue or skin envelopes, leaving the skin covering full of holes, emptying the organism and leaving only a shell. The second is a process of decomposition or radioactive degeneration. On the surface, the organism is not wounded, but in fact it finds itself in a continuing process of agony. In the third process, the body’s immune system and auto-healing are affected and fail to function, allowing harmful cells to begin to propagate, as in cancerous tumors. Let me go back now to psychopathologies triggered by radioactivity. Fresco (1984) compares survivors’ children to people who have undergone the amputation of a limb they never had in the first place. They inherit the pain, but it is a phantom pain in which amnesia has replaced memory. The only thing they remember is that they don’t remember anything. For survivors’ children, the trauma assumes demonic forms, fantasies of imagined scenes of primal terror, transmitted to them by the parents. For those who have themselves undergone the horrors of the camps, these images reflect actual reality. That is, the images belong to specific feelings, to visual perception, to physical experience. This is the difference between imagined traumatic reality and trauma sprung from reality (Antelme 1966; Appelfeld 2005; Kestenberg 1972a, 1972b; Levi 1958; Wiesel 1980). But how is the imaginary material passed on by the parents? The “radioactivity” that has infiltrated the parent and lies in their unconscious is deposited into the child by some means of nonlinear transgenerational transmission in intersubjective space. Perhaps the parents are unconsciously calling on the child to share their burden of suffering and pushing the child to enter their



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world. The consequence is unwitting “radioactive” identification. With these children, the goal of analysis is to work through these deposits, to enable them to tell internal from external reality and thus gain some control over their lives (Kestenberg 1982, 1989). Recent psychoanalytic research on the consequences of the Shoah has emphasized the negative aspects of this transgenerational transmission and the pain and suffering inherent in it. What is transmitted is, in effect, a lack, a narcissistic failure, a rift or chasm, a “truncation” of continuity. The conceptualizations of these identifications have concentrated on the weaknesses of the earlier generation, the endless mourning, the concealed family secrets, the individual and collective trauma associated with sociopolitical violence (Gampel 1997). Kestenberg (1980) describes a mechanism that goes beyond “identification,” which she calls “transposition into the world of the past.” She was moved to use the term “transposition” by hearing, as a therapist, the anguished cries of the children of survivors, children who cannot stop themselves living “in the past” and who hold on to the dead inside them. This “transposition” into the parents’ past is not to be equated with “identifying” with their past. The purpose of this transposition by the second generation is to supply a sort of replacement or proxy for the loved ones the parents lost forever in the Shoah. The child plunges into the atmosphere of the past, descends into the hell of the Shoah, and takes on the roles of the family members who vanished during those years. In this way he lives―unconsciously―a sort of illusion that he is sparing the parents confrontation with their irreparable loss, at the same time as he “replaces” those lost family members. In this context, Kestenberg talks about a “superposed time,” as though the children have entered a “time tunnel” that allows two realities to coexist, with the coexistence made double by an artificial actualization. In previous writings, I have explored the difficulty that children touched by sociopolitical violence have in entering into love relationships and enjoying the pleasures of life. On the one hand, it is vital for them to keep up the continuity of generations. And for some of them it is important that the names of the dead should be carried by their children, as a sign of that continuity and as a memorial to the dead who have no marked grave. They are, as it were, declaring a defiance of the extermination that the Nazi ideology tried to achieve. On the other hand, something in their being, their psyche and their body, is wounded, shattered, frozen, and their children can sense this without being able to define it (Gampel and Mazor 2004). Some of these children require analytic treatment for symptoms through which they are asking questions of their parents’ past, without even knowing what their questions are reaching for. It is these questions asked by the second generation, by the children of

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parents who were themselves children during the Shoah that led me to reflect on how trauma is transmitted, and on the vicissitudes of that transmission. In many survivors, the symbolization capacity is damaged because they are unable to reject this past, which then remains non-transformed and split. The transmission to the next generation of something fragmented and nontransformed creates in these children their eccentricities and compulsions to embark on strange searches. Between the contingencies and constraints of life, an object, a memory that was not told, bursts and is deposited as a trace in mental space for children and grandchildren (Gampel 2005). These radioactive residues have something evil. They do burst and create disorders in the evolution of the child. The translation will be psychic and somatic and can lead to a state of mental confusion. Communication with the inside and the outside is disturbed, their world is torn apart, and self-awareness and the formation of the symbol are prevented. The child feels that it is carrying a foreign body without knowing where it comes from, to whom it belongs, and especially what to do with it. This way, the son or daughter repeats the traumatic event of social violence in a nonlinear outcome. This is not the return of the repressed, but precisely the return of the non-repressed of the split parts, transmitted previously through the “non-inscription in the unconscious” of the parents. This can manifest itself in problems of separation, phobias, destructive behavior, absences, insomnia, and others symptoms that remind parents of their history and their suffering. It is the “Other” of social violence—that is to say, the child or grandchild— by his oddity, by his psychological or physical symptoms, who repeatedly stages the silenced traumatic experience of the parents. The child’s conflict symbolizes something of the non-representable creating a path to be represented, as in Mr. K., who through my name tried to find something that, as a child and teenager, he felt, without knowing, even today, what to do. This repetition of the traumatic event shapes the lives of future generations. It can lead to trauma or become a threat to life itself. A simultaneous process is the attack on internal objects, especially those representing need, dependence, weakness, and longing. These are also projected outward in their mutilated, injured form, and are paranoically experienced as attacking, persecutory, and deformed objects threatening one’s existence. Bion (1970) pointed out the fact that in the infantile unconscious, death, absence, frustration, and nothingness cannot be represented as such. Therefore, “No breast is a bad breast.” In other words, the void becomes an uncanny (Freud 1917), threatening presence that replaces the background of safety and might be seared radioactively into the psyche and thus transmitted from one generation to the other (Gampel 1992c, 1998).



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We have talked so far about the passing on of the agonies of the Shoah from survivors to their children. Does the horror continue into the third generation too? Can survivors who were children during the Shoah and have come to be grandparents hand on their radioactive residues to their grandchildren? Is such a thing possible? This question nagged at me throughout years of analytic work, and today my short answer is yes, it is possible. A traumatic event whose effects are transmitted unconsciously has an extremely long life span and repeats itself endlessly. And it is often hard for children and grandchildren to access the “symbolization” of this trauma through the spoken word and thus free themselves, at least partially, from its effects. This led me to the hypothesis that in grandparents who lived their infancy during the Shoah, and who have never been able to “speak” or “digest” their past in any way at all, the capacity for symbolization has been damaged. As a consequence, their past remains incised, cleft into their mind, unaltered, and untransformed, with the outcomes I have depicted earlier with respect to the second generation. Between original constraints and current contingencies, unspoken memory makes its way through psychic space and into their grandchildren’s bodies too. In their character, these radioactive residues (certainly those that pass along the parent-child line) approach the diabolical. They irrupt like a disorder into their grandchildren’s orderly development. They can translate into psychic or somatic symptoms and states of mental confusion. The grandchildren’s communication with both their internal and external worlds is disturbed, their awareness of themselves and the world outside is fissured and split, and their symbol-formation blocked and vitiated. By containing and transforming the malevolent (“diabolon” in “symbolon”) (Gampel 1999, 2005; Tustin 1990) in a metaphor (“metabolon”) through a psychotherapeutic dialogue (through the digestive, reflexive function of the mind of the analyst), we try to put an end to this destructive force of history imposed on the human psyche. To embody it, to represent, to speak and write, regardless of the disappearance of the subject, will permit the restitution of a space where the “I” may become. REFERENCES Antelme, Robert. 1966. L’espace humaine. Paris: Gallimard. Appelfeld, Aharon. 2005. “Always, Darkness Visible.” New York Times, January 27. Bion, Wilfred R. 1970. Attention and Interpretation. London: Tavistock. Caloz-Tschopp, Marie-Claire. 2004. Les étrangers aux frontières de l’Europe et le spectre des camps. Paris: Dispute. Gampel, Yolanda. 1982. “The Daughter of Silence.” In Generations of the Holocaust, edited by Martin Bergmann and Milton Jucovy. New York: Basic Books.

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———. 1992a. “I was a Holocaust Child.” British Journal of Psychotherapy 8 (4): 391–99. ———. 1992b. “Psychoanalysis, Ethics, and Actuality.” Psychoanalytic Inquiry 12 (4): 526–50. ———. 1992c. Thoughts about the Transmission of Conscious and Unconscious Knowledge to the Generation Born after the Shoah. ———. 1997. The Role of Social Violence in Psychic Reality.” In The Perverse Transference and Other Matters. New York: Jason Aronson. ———. 1998. “Einige Gedanken zu Dynamiken und Prozessen in einer Langzeitgruppe von Uberlebenden der Shoah.” Psychoanalytische Blatter 9: 83–104. ———. 1999. “Between the Background of Safety and the Background of the Uncanny in the Context of Social Violence.” In Psychoanalysis on the Move, edited by E. Bott Spillius, 59–74. London: Routledge. ———. 2005. Ces parents qui vivent à travers moi: Les enfants de guerres. Paris: Fayard. Gampel, Yolanda, and Aviva Mazor. 2004. “Intimacy and Family Links of Adults Who Were Children During the Shoah: Multi-Faceted Mutations of the Traumatic Encapsulations.” Free Associations 546–68. Fresco, Nadine. 1984. “Remembering the Unknown.” International Review of Psycho-Analysis 11: 417–27. Freud, Sigmund. [1917] 2001a. “The Uncanny.” In Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol. 17, edited by James Strachey. London: Hogarth Press. Kestenberg, Judith. 1972a. “How Children Remember and Parents Forget,” International Journal of Psychoanalytic Psychotherapy 1–2: 103–23. ———. 1972b. “Psychoanalytic Contributions to the Problem of Children of Survivors from Nazi Persecution.” Israel Annals of Psychiatry and Related Disciplines 10: 311–25. ———. 1980. “Psychoanalyses of Children of Survivors from the Holocaust: Case Presentations and Assessment.” Journal of American Psychoanalytic Association 28: 775–804. ———. 1982. “A Methapsychological Assessment Based on an Analysis of a Survivor’s Child.” In Generations of the Holocaust, edited by Martin Bergmann and Milton Jucovy. New York: Basic Books. ———. 1989. “Transposition Revisited: Clinical, Therapeutic and Developmental Considerations.” In Healing Their Wounds: Psychotherapy with Holocaust Survivors and their Families, edited by P. Marcus and A. Rosenberg, 67–82. New York: Praeger. Levi, Primo. 1958. Si c’est un homme. Turín: Giulio Einaudi editore. Tustin, F. 1990. The Protective Shell in Children and Adults. London: Karnac Books. Wiesel, Elie. 1980. “Dialogue with Elie Wiesel.” CenterPoint 4: 25.

5 The Reality of Horror Psychic Survival in the Face of Massive Trauma Louise Newman

TRAUMA AND MEANING

Trauma on a massive scale—such as genocide, holocaust, and mass destruc-

tion—represents a fundamental attack on meaning and existential security. The knowledge that the human capacity for destruction exists and can be acted upon is a profound threat to the individual’s core concept of self (Davonie and Gaudilliere 2004) and attachment to a trusted other. The breakdown of representation leaves the traumatized with a central need to orient around the coexistence of those forces mitigating going-on-being and a deep awareness of incomprehensible and unknowable primitive states. In this sense, we see an analogy with Donald Winnicott’s “unspeakable anxieties” or primitive existential anxieties. In these, the infant experiences a similar existential anxiety that defies representation or meaning. The infant experiences unmetabolized anxiety in the real in a way similar to the trauma victim. Trauma may result in a shutdown of narrative and symbolization (Laub 2012). Attacks on meaning and representation overwhelm the self with resultant regression to primitive states focused on survival attempts in the face of overwhelming threat. In this situation, the individual or traumatized group may variously attempt to survive and adapt to this new reality. They may adopt the ideology of the tormenter—identification with the aggressor—or alternatively, become paralyzed in the face of evil. The central psychological task of maintaining a sense of continuity and memory, and a sense of personal continuity and going-on-being, is a major existential challenge. The adoption of identification with a particular regime, for example, or an opposition to that regime, are both attempts to maintain a sense of meaning and value in a world that is fundamentally stripped of 63

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meaningful identifications. We need to understand the core processes of psychic survival in the many situations of massive and overwhelming trauma confronting the post-9/11 world, and in their historical predecessors. In his reflection on survival in Auschwitz, Primo Levi maintained the fundamental importance of the capacity to refuse to be diminished to a nonhuman life form, and of maintaining the right to resist, while simultaneously reflecting on the long-term dilemma of sustaining a sense of connection to the present time when traumatic experiences overwhelm psychic functioning. He noted that the reality of the trauma was ongoing and timeless and was not able to be repressed or processed in a way that led to its extinction. Ultimately, the trauma takes on its own persistent reality and may overwhelm the safety of the posttraumatic period. Trauma shapes the present as well as the past. Primo Levi’s choice of death over life may be related in part to this knowledge and his awareness of the undeniable and overwhelmingly powerful presence of human evil. DEVELOPMENTAL MODELS AND DEVELOPMENTAL TRAUMA Psychoanalytic models and contemporary attachment theory focus on emergent subjectivity in the context of interpersonal relationships. The notion that the newborn and infant can experience existential trauma and anxiety is, of course, not new, but what perhaps is more recent is an understanding of this experience based on an integration of neurodevelopmental models and models of emergent self-structure. The relationship between individual trauma and mass trauma might be thought of as the impact of large-scale sociocultural trauma on the functioning, both psychologically and socially, of the parent or attachment figure. The capacity of the parent to care for and think about the emerging mind of the infant—the parental reflective capacity—is a fundamental component of early interaction and one that is very much impacted by both the past of the parent as well as current circumstances. An example that might illustrate this would be the impact on parenting of seeking asylum and refuge from overwhelmingly traumatizing experiences, and the way in which trauma in the mind and life of the parent is reenacted or recapitulated in relationship with the infant. The existence in the contemporary world of displacement and trauma on a massive scale perhaps contributes to this need to better integrate levels of developmental theory from the neurodevelopmental and genetic through to the sociocultural and historical. Psychoanalysis and the related field of infant mental health has for some time focused on the need to better acknowledge the complexity of development and the fundamental transactions that oc-



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cur between the infant and emergent self and the social and social context. Psychoanalytically, the influences on infant mental health are profound, and more recent models have also focused on this concept of transgenerational trauma, a historical trauma impacting the life and mind of the parent, the transition to parenthood, and the concept that the parent holds of both parenting and the infant’s mind. These are the core elements of the psychodynamic formulation of distorted infant/parent interactions, and what Fraiberg and colleagues (Fraiberg, Adelson, and Shapiro 1875) focused on with their description of the “ghosts in the nursery”—the unresolved traumatic attachment figures in the psyche of the parent that “haunt” the relationship that parent is attempting to establish with the infant. This notion of historical trauma informs our understanding, not only on an individual or relational level, but also in terms of thinking about massive trauma and sociocultural and historical themes. The example to be discussed here most clearly is perhaps that of the holocaust, where the capacity to remember, process, and think about these events has very much been documented as impacting on subsequent generations, not just the immediate survivors. The experience of trauma both impacts and is reflected in narrative capacity and its lapses. What is spoken and what is not spoken about the trauma and the past has ongoing impact on both the present and the relationship with future generations. Recreating a sense of cohesion and history is a key process of living with trauma that allows the unspeakable to be represented. EMERGENT SELF: INFANCY IN TIMES OF TRAUMA Defining trauma in infancy and early childhood is complex (Terr 1990). A general understanding of psychic trauma describes the infant or child experiencing abandonment and overwhelming feelings of utter helplessness in the face of uncontrollable and inexplicable experience. While this remains a useful approach, we currently have a greater understanding of both the psychological and neurodevelopmental consequences of high-stress experiences. Early trauma directly impacts developmental pathways—psychological and neurodevelopmental—and is a major contributor to ongoing derailment of development and the establishment of vulnerability and risk for a range of psychological disorders. The underlying stress regulatory mechanisms at the level of the brain and neurophysiology are directly shaped by the infant’s experience in the context of their social environment. Infancy is currently seen as a crucial and foundational developmental period. The neuropsychological processes underlying attention, representation of self and other, and attachment are laid down in neural circuitry during this

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period. The infant’s immediacy of experience is affective, and the capacity for affect recognition and regulation is also established in the context of engagement with the adult caregiver or attachment figure. These fundamental capacities for self-regulation, adaptation to stress, and emotional communication underlie concepts of healthy psychological function and a later capacity for intimacy and empathic functioning. Trauma in infancy is fundamentally an attack on attachment. The infant experiences the loss of hearing the Other and the loss of integrative functions reliant on the interaction of the attachment figure. There is a breakdown in the fundamental capacities for regulation of affective states. Massive trauma, as used in this chapter to describe overwhelming experiences without meaning founded on politics of destruction, can set up major negative impacts on developmental pathways, where the infant is caught in a cycle of attempts at mastery and repair in the face of failure of these processes. In essence, the emergent self is a fragmented self, and even if reconstituted at a later time, it will remain vulnerable at core levels of attachment and meaning, with impairment of reflective functioning and regulation of affect and aggressivity These traumatic experiences can underlie the development of a range of mental disorders. Interestingly, data examining rates of abuse and trauma in histories of adults with mental disorders will estimate that around 70 percent of adult mental health conditions are either directly caused or contributed to by histories of early trauma. It is useful to think about the sensitizing effects of early trauma at the level of neuro-vulnerability. At a neurological level, early trauma constitutes a form of toxic stress, where complex developmental pathways are influenced by the breakdown of stress regulation as well as the disruption of attachment relationships. Early trauma, then, can be seen as having a clear relationship with the onset of a range of psychosocial and psychological difficulties related in a core way to the concept of posttraumatic stress conditions such as so-called borderline personality disorder. Traumatic experiences and interactions are directly inscribed in the fabric of the developing brain. As described by Bruce Perry (1995), the brain remembers trauma in the pathways and functions that are emerging in the context of these traumatizing experiences. The field of developmental traumatology has been particularly important in attempting to understand the impact of early trauma and toxic stress on neurodevelopment and the concept of neuro-vulnerability. Developmental risk is seen to be at its highest during periods of rapid neurobiological reorganization, such as in the infant period of development. This project is very much related to and synergistic with a psychoanalytic developmental model, where underlying factors contributing to symptoms and disorder are formulated in the context of early experiences. The development of developmental neuroscience has contributed to this integrative model such as described in the field of neuro-psychoanalysis (Solms 2003).



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The domain of culture and history is also a vital contextual factor in considering developmental pathways and the impact of trauma. The field of infant psychoanalysis and mental health very much operates around a model of understanding traumatic early interactions that an infant experiences in terms of the history of the parent. Parents with their own unresolved traumatic attachment issues and, in particular, histories of abuse or neglect, are understood in terms of the risk of being both traumatized by their own history and traumatizing in their interactions with their infant. These parents experience a range of issues and conflicts when they attempt to parent—from anxiety to avoidance, as well as repetition. The reenactment of traumatic themes in a seemingly repetitive and ongoing way is a major issue in the field of child abuse and the breakdown of care that the traumatized infant might experience. Clinically, in the field of infant mental health, these dynamics are seen as a major opportunity for intervention and formulation. There is increasing interest in the types of clinical approaches and interventions that might actually improve the parents’ own reflective capacity and understanding of their own early dynamics, and the way in which this impacts the troubled relationship that they might have with their infant. The traumatized parent is seen as bringing to the relationship with their child a range of unprocessed and traumatic memories. The infant is a projective focus and is misinterpreted or misunderstood by the parent as the reenactment of early trauma continues. The infant can be variously experienced by the parent as anxiety provoking and/or persecutory and hostile. The language of parents in these disturbed early relationships is a vital focus of attention for the clinician. Parents who feel attacked by their own infant are very much in the thrall of a recapitulation of their own experiences of infantile abandonment and rage. The traumatizing maternal figure has usually experienced her own neglect and abandonment with associated feelings of unresolved and unthinkable anger and hostility. She may have limited access to memories of infancy and childhood, an impaired capacity for self-reflection, and a fragmented self-experience. Envy of the infant’s potential and an unconscious need to devalue infantile experience can permeate the relationship with the child. Underlying these distorted relational dynamics are the prominent features of neuro-physiological dysregulation that are seen in disorders characterized by borderline features. Grotstein describes the symptoms of so-called severe personality disorder as attempts to reestablish homeostasis in the face of dysregulated affect and impulses (Grotstein 2015). This deregulation has its basis in traumatic early attachment experiences and the neurodevelopmental impacts of trauma. The core deficits of the traumatized parent revolve around these difficulties in interpersonal and affective regulation; this is combined with distorted representations of self and other, with attachment relationships

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based around a fundamental mistrust of others, and with core difficulties in reflective functioning and empathic functioning. The recapitulation of traumatic themes with the infant is reflected in the quality of parent-infant interaction. There is a range of inadequate and inappropriate communication and affects in the relationship between carer and infant. These result in an insecure and disorganized attachment, as described in attachment theory (Solomon and George 2011), which involves ongoing existential anxiety about the availability of the carer and the fundamental lack of trust. The disorganized infant essentially experiences unresolvable fear and ongoing trauma in interaction with the unpredictable and incomprehensible carer. The disorganized adult, in turn, is frequently overwhelmed with the task of parenting and with confusion in the relationship with the infant, who is at once an object of hope for the future and a terrifying object. These extreme traumas, as experienced in situations of psychosocial breakdown and mass trauma, have, as previously stressed, a significant impact on reflective functioning itself and the capacity of the traumatized self to reflect on its own psychological processes in a way that would promote regulation. Importantly, attachment disorganization is also reflected in the inadequate development of internal-state language, which refers to the vocabulary to describe emotional states that is essential for self-reflection. The core deficits in empathy seen in attachment disorganization reflect a breakdown in the capacity to think about relationships and to understand the internal world of the Other. The traumatized parent has difficulty in thinking about and acknowledging the inner world of the infant or seeing the infant as a communicating being, and this in turn promotes deficits in the development of self-reflection in the infant. The developmental consequences, from an attachment point of view, of these traumatic relationships lie in the development of confused and contradictory representations of the self and other. The abused or traumatized child oscillates between seeing himself as inadequate and guilty and worthy only of abuse and, in a defensive sense, as a grandiose self who might identify with the abusive behavior of the carer. At a neurophysiological level we see dysregulation of behavior, affect, and impulses. Infants and children process and recall acute traumatic events in a developmentally accessible form. Prior to language, traumatic experiences can be reenacted in play and behavior, and memories of trauma can be experienced on a bodily level. The traumatized child experiences persistently high levels of arousal and anxiety. In the face of an overwhelming experience, the child might exhibit psychological regression including clingy and help-seeking behavior, and sometimes the loss of language itself. These responses have been described frequently in children exposed to conflict, war, and genocide. The availability of diagnoses within the dominant diagnostic framework, such as



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the DSM and the ICD systems, are limited. There is inadequate understanding in these frameworks of the developmental model or the developmental impacts of early trauma. Infants certainly exhibit acute stress responses and are particularly prone to the use of disassociation as a defensive mechanism, as described by Bruce Perry (1995). This is a vital self-protective mechanism in the face of overwhelming stress, and one that is seen in human infants and in infants of other species. The concept of posttraumatic stress disorder certainly has limitations, and a broader description of posttraumatic states in children needs to include nonspecific anxiety; defensive acting out, as in the disruptive behaviors; and posttraumatic play. Attachment disorders are certainly very common in children who have experienced neglect, abandonment, and trauma. These have been extensively described in Romanian and Bulgarian orphans (Nelson and Zeanah 2009). The traumatized parent establishes anxiety-provoking relationships with the infant and child that impact adversely on development and particularly on security of attachment. There is an observable spectrum of parenting behaviors with distorted emotional responses and a series of conscious and unconscious conflicts around care that are traumatizing for the child. They result in disorganization attachment and impact emotional and behavioral regulation. These patterns are influenced by the parent’s own attachment history, reflective capacity and empathic functioning, and current mental state, particularly with regard to issues of depression and anxiety. These so-called high-risk parents might attract many mental health diagnoses and be involved in ongoing reenactments of trauma in their adult relationships, such as experiencing abuse, exploitation, and domestic violence. Many will attract a diagnosis of personality disorder along with depression and anxiety. In addition, social adversity is common, and this range of behavior and relational breakdown is seen in whole communities and societies impacted by war and conflict and in postcolonial situations. Community-level trauma includes high levels of substance abuse, violent behavior, social adversity, and a fundamental lack of any reparative processes to help reestablish social bonds and functioning in the face of overwhelming disruption. Many refugee populations around the world come from these multilayered traumatic experiences and are often attempting to parent in situations such as large destitute refugee camps in impoverished nations. Plagued by memories of their experiences, parents simultaneously see their child as an opportunity for reparation and hope for the future as well as a painful reminder of things that they have lost. This ambivalence about the child in the face of unresolved trauma is very powerful. Borderline personality disorder, then, becomes in many ways a reductive diagnosis or a simplistic diagnosis at the very least. On the basis of available

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research, we have certainly documented that these parents have clear traumatic histories and ongoing neurodevelopmental difficulties, such as limbic system dysregulation and problems in the reading and processing of emotional states and facial affect. Looking at these difficulties in detail in terms of parent-infant interaction is a promising area of research. It is hypothesized that the traumatized parent who has had difficulties in a relationship with an attentive Other will have fundamental affect-processing difficulties and be less able to respond to the emotional communication of the infant. The parent will also experience less reward in terms of engagement with the infant. This in turn will effect infant brain development. In terms of the themes seen in these traumatic relationships, the major effect is ongoing, unresolved early trauma and limited reflective capacity. This has been described in the psychoanalytic approach as a deficit in a containing narrative within which trauma can be reflected on and processed. The infant is caught up as an innocent player in the endless repetition of traumatic themes and can variously represent parts of the parental self, as both good and bad. Parental reflective capacity—or the capacity to understand both one’s own and one’s child’s behavior in terms of underlying mental states—is disrupted by traumatic experience. This results in parental difficulties in holding the infant’s affective experience in mind or in thinking about the inner world of the infant. The normal function of parental reflective capacity is to give meaning to the child’s affective experience and re-present it to the child in a regulated fashion. Without this meaning-making process, the child is at risk of an endless experience of unprocessed and unmetabolized states. Infant development, of course, occurs only in the context of relationships and relational functioning. As Winnicott (1960) commented, “there is no such thing as an infant” but only a relationship in which the infant’s mind is thought about. While the infant has innate abilities to communicate emotional experience and to seek social connectedness, it is only in the context of the responsive attachment figure or carer that there is a move toward internal development and self-regulation. Experiences with the carer promote the development of specific neural networks and connections. The sharing of positive emotional states with a caretaker in a basic sense promotes brain growth and the development of regulatory capacities. What is called security of attachment, or organized attachment, promotes neurobiological functioning, emotional regulation, and adaptation to stress. Within this framework, the attachment relationship is seen as having a core neurobiological function where there is a regulation of emotional experience over all levels of neurophysiological arousal. Extreme trauma in infancy, or ongoing trauma where there is both a psychological and neurodevelopmental impact, results in long-term dysregula-



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tion of affective and stress-regulatory systems. Some specific brain structures and functions may be permanently altered, particularly those structures and functioning of the stress-regulatory mechanisms and affective regulatory processes. Psychologically, the result is damage to the capacity to relate, regulate, and understand emotions, and to manage anger and frustration. The child will adapt to ongoing stress according to developmental stages and capacities, but chronic stress will potentially affect all main developmental zones and neurobiological functioning. It may be more useful to describe a trauma-related syndrome in which there are ongoing difficulties in modulating anxiety and aggression and an overreaction to trauma-associated stimuli. The trauma syndrome also involves disorganized attachment behaviors and anger toward attachment figures who cannot be trusted. In this context, selfdestructive behaviors are both an attempt at self-regulation and maintaining homeostasis, as well as a potent communicative device. Terr describes the impact of trauma on the fundamentals of self-concept, but particularly the affects of guilt and shame and the child’s sense that they have brought the trauma on themselves or perhaps caused it in some way (Terr 1990). The extreme and catastrophic stresses for the infant and the young child include the loss of attachment figures, which in practice may involve care by anonymous and rotating caregivers, as well as situations where whole communities are overwhelmed by war, displacement, and terror. It is well documented that children are the primary victims in these mass social breakdowns and have particular vulnerabilities. The net result for the child in these situations is often one of being abandoned and experiencing gross neglect and underlying, overwhelming anxiety as well as in some situations continued physical and/or sexual abuse. The hallmark of abuse and terror in the infant period is that the infant who is particularly vulnerable to extremes of arousal is also unable to escape stressful and traumatizing interactions. In fact, the infant is sometimes utterly dependent for survival on the very traumatizing adult figures around them. The so-called paradox of infant maltreatment is described as the child’s continued attempts to gain attachment security from interaction even with a traumatizing figure. The infant and child will approach for feelings of security and comfort the very same figure that terrorizes them and who is incapable of providing any sense of security. REFERENCES Davonie, Françoise, and Jean-Max Gaudilliere. 2004. History beyond Trauma: Whereof One Cannot Speak, Thereof One Cannot Stay Silent. New York: Other Press.

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Fraiberg, Selma H., Edith Adelson, and Vivian Shapiro. 1975. “Ghosts in the Nursery.” American Academy of Child Psychiatry 14 (3): 387–421. Grotstein, James. 2015. The Borderline Patient. London: Taylor and Francis. Laub, Dori. 2012. “Traumatic Shutdown of Narrative and Symbolization: A Death Instinct Derivative?” In Lost in Transmission: Studies of Trauma across Generations, edited by Gerard Fromm. London: Karnac Books. Nelson, C. A., and Charles Zeanah. 2009. “The Deprived Human Brain: Developmental Deficits among Institutionalized Romanian Children.” American Scientist 97: 222–29. Perry, Bruce. 1995. “Childhood Trauma, the Neurobiology of Adaptation and UseDependent Development of the Brain: How States Become Traits.” Infant Mental Health Journal 19: 271–91. Solms, Mark. 2003. The Brain and the Inner World: An Introduction to the Neuroscience of Subjective Experience. New York: Other Press. Solomon, Judith, and Carol George. 2011. EDS Disorganized Attachment and Caregiving. London: Guildford Press. Terr, Lenore. 1990. Too Scared to Cry: How Trauma Affects Children. New York: HarperCollins. Winnicott, Donald. 1960. “The Theory of the Parent-Infant Relationship.” International Journal of Psychoanalysis 41: 585–95.

6 The Role of Cumulative Micro-trauma in Psychic Life An Abridged Description of Injurious Relational Functioning1 Margaret Crastnopol

“Oh, sweetheart,” an elderly woman crooned to her grandson, a late adolescent now verging on manhood, “that jacket of your father’s looks marvelous on you—so much better than it ever did on him!” Caught up short by the last phrase—“better than it ever did on him”—the young man inwardly puffed up and cringed at the same time. He couldn’t help but note both the compliment itself and the sideways swipe at his father, who was in the next room and could easily have overheard the grandmother’s words. The inner confusion carried over into his psychoanalytic session the next day, when the young man tried to sort out his response to the unnerving comment. He was proud to have his masculinity savored, pleased at this minor Oedipal victory, and guilty over having been praised at his father’s expense—and having enjoyed it. But further thoughts, some rather insidious, cropped up in his mind. If his grandmother could cast aspersions on her own son’s (i.e., his father’s) appearance behind his back, what might she be saying about the grandson himself when he was out of earshot? Did his grandmother perhaps enjoy elevating him over his father, and if so, why? How much love was actually there, underneath her doting tone? This changing body of his was beginning to feel a bit like a lightning rod. Could he afford to relish its new features, or was that asking for trouble? A throwaway remark like the elderly woman’s can easily be dismissed or go unnoticed entirely. The individuals involved might not notice the aggression in it, the conscious or unconscious effort to create a rift between the son and his father, the bid for an inappropriately shared intimacy that implicitly deprecates the father. Like grossly abusive relating, negative interactions that are evanescent and may go largely unregistered can ultimately also have a strong psychic impact. As a result, these subtler occurrences, especially in 73

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the aggregate, can create psychic bruises that are hard to notice and harder to minister to, with the consequence that they accumulate invisibly. Such injuries can distort a person’s character, undermine his or her sense of self-worth, and compromise his or her relatedness to others. I call such emotional strafing “micro-trauma,” and I argue that discerning the operation of micro-traumas is an important aspect of psychoanalytic work. As Heraclitus (Freeman 1948) observed, “What we saw and grasped, that we leave behind; but what we did not see and did not grasp, that we bring.” Or, as Sigmund Freud famously put it, “A thing which has not been understood inevitably reappears; like an unlaid ghost, it cannot rest until the mystery has been solved and the spell broken” (Freud 1909). It behooves us to facilitate the understanding of those ghosts—even the less overtly monstrous ones—so that, as known, neutralized influences rather than surreptitiously toxic ones, they can be integrated into the richness and complexity of one’s contemporary psychic experience. Many individuals chronically experience a sense of low-level depressiveness, anxiety, and malaise. They express shame at not being able to lay claim to a dramatic, discrete source that could account for their rather quotidian, yet deep and thoroughgoing unhappiness. In fact, such people may attest to having felt more or less well loved within their original family circle; they may recognize their good fortune at having material security and personal success; they may insist that there is nothing really wrong in their lives. This makes them that much more self-critical in relation to their unhappy internal state. These kinds of obscure complaints or self-mystified anxieties are of course not new in psychoanalysis. Indeed, much of the recent interchange between developmental research and analytic theorizing is based on trying to understand patients like these in terms of “insecure attachment” (Beebe and Lachmann 2014), “pathological accommodation” to insufficiently responsive caretakers (Brandchaft, Doctors, and Sorter 2010), or a similar skewing of the self in childhood. While these approaches put great emphasis on development during the childhood years, and large-scale disruptive events within them, I suggest that we also and sometimes instead need to look at smaller scale, repetitive interactive events, and at those that happen not only in the early years, but wherever they’ve occurred in the life cycle. I believe we should concentrate on the residues these particular events leave and on their manifestation or recurrence in the individual’s contemporary way of being. Telling examples of what I have in mind as “micro-traumatic patterns” already exist in our literature and have shown themselves to be profoundly applicable to certain facets of our clinical work. One of these is R. D. Laing’s (1971) study of the “double bind,” which refers to a person’s giving a paradoxical message to both do and not do the same thing, and then shaming



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the other for not succeeding at this. Another example is “gaslighting” (Calef and Weinshel 1981; Dorpat 1996), which involves intentionally and steadily upending the other’s sense of reality and his/her sanity by insisting on an alternate, false state of things. In my view, psychoanalytic theories would benefit from our articulating more such examples of particular patterns that slowly erode an individual’s well-being and disrupt his or her functioning. I myself (2015) have newly identified and described seven specific forms of micro-traumatic patterning, which I will present here in summary form. (To anticipate that discussion: an interaction like the one reported by the young man at the beginning of this chapter has elements of two micro-traumatic patternings, one of which I call “little murders,” and the other, “uneasy intimacy,” to be described later.) To be sure, exploring day-to-day relating in a minute way is scarcely new. It has long been one of the pillars of relational and interpersonalist thinking (for example, see Aron 1996; Bromberg 1994, 2006, 2011; Mitchell 1988, 1993, 2000; Mitchell and Aron 1999; Stern 2010) as well as certain selfpsychological and intersubjective positions (for instance, see Wolf 1995, for the former, and Stolorow and Atwood 1992, for the latter). These approaches concentrate on universal-seeming benchmarks (like separation/individuation, the oedipal passage, etc.) and broad-brush psychodynamics (the drives and other urges, anxieties, and the defenses erected in relation to them). My own work narrows the focus from these general elements to certain specific types of problematic relational experiences. These “micro-traumatic” processes— some operative previously in life, but most also present in an ongoing way— can be hidden in plain sight; since they occur within relationships that are otherwise felt to be valuable, the individual may be motivated to ignore them in the service of not disrupting valued attachments, despite how compromising these injurious occurrences can actually be to others. Whether we think of the benefits of adult relationships in terms of attachment, dependency, self-object needs, or some other dimension, should micro-traumatic experience accumulate, the individual will be burdened by fraught, contradictory feelings about him- or herself in the world. In fact, the unsung factor in much adult depression may be precisely this pattern of small insults or failures that amass to seemingly prove one is inadequate, contemptible, or outright unworthy. These minor injuries may—or may not—trace back to deeper, more malignant ones; vulnerability to these hurts likewise may—but then again, may not—arise from deeper wellsprings. Regardless, the result is a psychic bruising that builds up imperceptibly little by little, eroding a person’s sense of self-worth and well-being. This buildup can happen in the context of a childhood or current relationship with a parent or another close loved one, but it can also develop in long-term educational or work settings, or in other

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social contexts that constitute important parts of one’s life. Moreover, propensities for inflicting or sustaining micro-traumatic damage are underpinned not only by psychodynamic currents (conflict, developmental arrest, and the like) but also by one’s temperament or disposition. To the degree that one person’s dispositional tendencies influence his or her intrapsychic scenarios and defensive structure, he or she may be that much more prone to engage in—or be wounded by—one or another sort of injurious relatedness. Since micro-traumatic experience is by definition underplayed, its impact remains unarticulated, dissociated, or suppressed. In effect, the person comes automatically to overlook or “selectively inattend to,” in Sullivan’s (1953) terms, someone else’s moderately injurious maltreatment, in order to sustain a sense of being a good self loved by a good other. This habitual ignoring results in dissociated anxiety that undermines a coherent and valued sense of self as well as a trusting relatedness to others. Moreover, because one hasn’t seen the cuff coming or registered its full impact, one hasn’t learned how to defend oneself, or take the protective steps that might ease the injury in its aftermath or guard against reoccurrences. So the damage mounts, and the result is a significant impairment to one’s sense of goodness, efficacy, and cohesion. TRAUMA AND MICRO-TRAUMA From a psychoanalytic perspective, the concept of trauma has come to mean, in the words of Laplanche and Pontalis, “an event in the subject’s life defined by its intensity, by the subject’s incapacity to respond adequately to it, and by the upheaval and long-lasting effects that it brings about in the psychical organization” (Laplanche and Pontalis 1973, 465). Laplanche and Pontalis go on to situate the idea of trauma within a Freudian economic perspective, in terms of “excessive excitation” or of an accumulation of smaller excitations, either of which exceeds the tolerance of the psychic apparatus. If that buildup cannot be discharged or worked out and integrated into one’s overall psychic functioning, then it remains present to undermine one’s psychical organization. The idea of an accretion of smaller excitations described by Laplanche and Pontalis anticipates the sense of my term micro-trauma as a way to differentiate repeated, built-up, minor hurts from massive, more egregious ones. The micro version is less intense, less obvious or direct in its destructive quality, and therefore more plausibly (though just as incorrectly) deniable by oneself or the other. The hurtful quality may reside only in the tonal undercurrents or peripheral implications of the act, rather than in its main message. The



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overall interpersonal setting is of course a crucial factor as well—in certain circumstances, a hostile or critical act could be merely troublesome, rather than necessarily being traumatic to either party, to either a micro or macro degree. Much depends on the ongoing characters of the individuals involved, the health of their relationship, and sundry other factors. To theorists whose work emphasizes large-scale trauma, a number of whom are directly represented or referenced in this book, it may seem oxymoronic or seriously misguided to speak of any sort of trauma that could be of micro proportions. My using the term “micro-trauma” might seem to them like a trivialization of something vastly more impactful—Trauma—whose effect should not be watered down. I would counter that micro-trauma is consequential in its own way. It is akin to massive real-world trauma in that it reflects events in the external world and is not merely a private experience involving unconscious impulses or fantasies. The disturbing stimuli that generate micro-trauma, though more minor than full-scale trauma itself, also exceed one’s capacity to tolerate and metabolize them productively. And just as in “capital T” trauma, the real external occurrences are experienced and absorbed to shape the intrapsychic world in particular ways that have lasting negative consequences for one’s sense of psychological well-being, safety, and security. Micro-traumas, like those on the macro scale, call forth defensive operations that themselves often further dampen or distort aspects of self-expression, thwart self-cohesion, and bleed into ongoing relationships as they develop onward into the future. Consider a newly pregnant woman who, let’s say, is someone prone by temperament to be easily made anxious. Let’s say further that her husband responds to her worries and fears about maternity by retreating to his email correspondence, playing an extra round of video games, or spending longer hours at the office. His semiconscious or unconscious withdrawal, or what I call “unkind cutting back,” deprives the woman of the comfort and reassurance that closer contact would likely provide. The husband’s avoidance of his wife and her issues may be no more than his own effort at psychic selfprotection to avoid recognizing his own underlying concerns about parenthood. Yet, she may read it as an implicit rejection of her, as if he viewed her as inadequate for having the worries to begin with, or looked down on her for her inability to quell them all by herself. Should the husband’s withdrawal evolve into a more chronic pattern of cutting back on his wife, both physically and emotionally, it would likely erode over time the wife’s belief in her own competence and worth. This shameful self-diminishment could reflexively undermine her mothering capabilities, thus actualizing the very same dreaded self-image of being inept that the husband’s distancing implied to the wife originally. Of course, any one instance of a spouse’s withholding probably

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wouldn’t be enough to undermine the woman’s psychic security for good, but as a steady drumbeat, it would likely make a major incursion on it over time. And the mother’s demoralization could well have a negative impact on her newborn: an instance of the intergenerational transmission of (micro-) traumatic experience. I believe that, in just this fashion, small psychic abandonments, blows, and betrayals—even if not intended as such—can mount up and combine with one’s underlying psychic tendencies to disrupt emotional functioning in a profound, ongoing way. As I mentioned, my book depicts and discusses seven different types of micro-trauma in some depth, and others more glancingly. This catalog is an idiosyncratically selective list that is necessarily more preliminary or suggestive than exhaustive. The kind of interpersonal, interpsychic, or intrapsychic occurrence that delivers this small jolt to the self can take many guises, some seemingly rewarding and having a predominantly positive emotional tone, others more explicitly punitive and having a predominantly negative one. Among those that have a manifestly upbeat emotional tone are what I call “airbrushing and excessive niceness,” or inflating oneself or the other by minimizing or covering over flaws; “uneasy intimacy,” an intensified closeness that tends toward co-opting the other and eventually thwarts his or her wishes or needs for connection; and “connoisseurship gone awry,” in which one person inculcates the habit of making fine distinctions in another in a way that ends up undercutting the other’s equanimity and sense of self-worth. Four versions of micro-trauma with a largely negative cast are “unkind cutting back” (illustrated above), which is a seemingly arbitrary withdrawal from prior involvement, often motivated by unexpressed anxiety or anger; “unbridled indignation,” a hyper-moralistic stance that backfires, undermining one’s own or the other’s sense of well-meaning, efficacy, and moral goodness; “chronic entrenchment,” being locked into either a selfdiminishing or overly self-contented attitude in a way that generates collateral damage in others; and “little murders,” which can range from simple slights to ample putdowns delivered in an off-hand manner. The grandmother’s comment to her grandson was a potential bid toward a triangulated “uneasy intimacy” with him at his father’s expense; the overhearing father might have experienced it as a “little murder.” Both toxic elements could have stoked the younger and older man’s private insecurities in addition to fuelling intrafamilial competitiveness and strife. Each micro-traumatic pattern is underwritten by its own admixture of narcissistic self-investment, hostility, envy, indifference, anxiety, or shame. But in each, the party inflicting the hurt maintains a semblance of being at least measured and neutral, if not well meaning and benevolent. Some microtraumatic relating is conscious and intentional and some unconscious or in-



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advertent. It may be registered by the injured party or do its damage subliminally. It may occur within a dyadic relationship, a family group or clique, or a larger social system whose policies consistently injure in some fashion. An important instance of the latter can be found in the resonant work of Dewald Wing Sue (2010), whose research tracks the “microaggressions” too often inflicted by members of a cultural majority on those in minority. While we tend to be more aware of injuries inflicted on us than those we inflict, most of us have just as much potential to be a perpetrator of micro-traumatic injury as its victim. An instigator’s hurtful actions harm the other but often inadvertently also deplete him- or herself as well. Elusive and ephemeral as they sometimes are, the micro-traumatic processes I address—and other varieties yet to be formally articulated—beg for our closer attention. A Closer Look at the Micro-traumas Unkind Cutting Back

As I’ve said, by “unkind cutting back,” I mean an unexpected, unilateral bid to attenuate a relationship in a way that engenders hurt, confusion, and frustration in the other. The decision to reduce contact in this situation occurs summarily and without a convincing explanation. By shortening or postponing contact, spreading it out, or minimizing its original importance, the one stepping back from contact inflicts micro-trauma by undercutting the other person psychologically. Clinical examples of this sort of quasi-abandonment can be poignant and extremely troublesome. It is especially of concern in connection with the therapeutic contract and relationship itself, wherein either the patient or analyst may wish to reduce (“cut back on”) the frequency, length, or intensity of the therapy sessions, and may go about it in an indirect, insensitive, or outright rejecting way, which ends up undermining the treatment’s constructive impact. Connoisseurship Gone Awry

A learning or socialization situation, whether formal or informal, often ends up involving a form of relatedness wherein a more knowledgeable person inducts another person—for better or worse—into the intricacies of a given subject matter, field of endeavor, or way of being. The aim may be a circumscribed one—that is, to alter a specific sector of the other’s personality or lifestyle—or may involve the broader mission of attempting to “make the other person over” quite thoroughly. Whatever the extent of the influence, when it’s done in a fashion that unduly frustrates or humiliates the other, I call this type of interplay “connoisseurship gone awry.” The influence of this sort

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of toxic mentorship is usually unidirectional from patron to protégé, though sometimes it is bidirectional, a shared or mutual connoisseurship between peers in which the two alternate between influencing and being influenced. The connection goes sour when the patron is so narcissistically invested in the socializing process that he or she causes the protégé to feel that he or she can never learn the material well enough, or must always stay bound and subservient to the patron. A familiar instance of this can be found in Pygmalion, the play by G. B. Shaw (1916) later to become a musical titled My Fair Lady by Lerner and Loewe (1965). In this story, the linguist Professor Higgins develops a seriously overbearing relationship to the flower girl Eliza Doolittle, as he strives to turn her into someone with the manners of an aristocrat for his own purposes. His dominating approach to training her is effective in its overt goal, but he ends up demeaning and alienating her, temporarily fragmenting her sense of self. Instances of seemingly positive, but ultimately destructive connoisseurship can be often be found in patients’ histories, and analyzing their impact can be quite freeing for the individual. Uneasy Intimacy

This micro-traumatic pattern is the problematic stepchild of intimacy proper. It involves the subconscious or unconscious use of one’s capacity for psychic resonance to co-opt the other into an emotional embrace that is less than truly nourishing and in fact tends to be injurious. I stop short of calling uneasy intimacy “emotional seduction”—though an element of seduction may be present—to avoid the implication of its necessarily being planned out or intentionally undermining the other. Uneasy intimacy is a kind of insecure closeness that can feel thrillingly engaging, but also unsettling. There is a cocoon of supposed mutual rapport and a feeling of specialness in being (again, supposedly) simpatico with that other person. The “target” individual does resonate with that person, but with some degree of hesitation. Like a “siren’s call,” this form of intimacy is an alluring but confusing bond that ends up thwarting more than helping the person, undermining his or her belief in his or her judgment, and weakening trust in others. Because (like the call of the siren) it feels both compelling and rewarding at the outset, uneasy intimacy can be hard or impossible to extricate oneself from on one’s own. A warmly engaging male architect found himself serially involved with less-welleducated women to whom, for this reason and others, he was eventually unable to commit. The man’s intense ambivalence and psychic conflict led ultimately to a rupture in their relationship; this caused the woman concerned extreme pain, and made the man himself feel wretched, wracked as he was by shame and guilt at having damaged her. Analyzing the contributors to this



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patient’s propensity for uneasily intimate relatedness changed this pattern substantially and eventuated in a fulfilling and lasting marriage. Psychic Airbrushing and Excessive Niceness

Some degree of downplaying or sweetening inherent problems or faults, tempering our disappointment in relation to them, understandably has a civilizing role in society. But it can be a short leap from simply minimizing one’s own or another’s shortcomings to blotting them out entirely, from walking around those shortcomings, to paving them over permanently. When the latter happens, the “good-enough self” one presents to the world leaves out too much of one’s actual inner complexity; the darker elements, in particular, drop into obscurity. I consider undue masking to amount to “psychic airbrushing,” something we experience internally and communicate outwardly by embracing half-truths and committing “sins” of omission, commission, and distortion in what we acknowledge about ourselves and others. A partner to airbrushing is a blanket attitude of “excessive niceness,” in which one conveys the impression that any flaws or failings the other possesses are insignificant or immaterial—though this is false. When people engage in either of these sorts of covering up, they and others influenced by them may sense the denied imperfections only dimly, which leaves them unable to grapple effectively with areas of friction. This obfuscation not only undermines psychological attunement to oneself and the other, it also disrupts the emotional communication between the person and his or her significant others. Being airbrushed or treated with excessive niceness may feel no more satisfactory than having one’s real merits overlooked. In one clinical instance (see Crastnopol 2015), a middle-aged businessman’s tendency to prettify or mask areas of strong disapproval from his business partner and other employees, and his unconscious transmission of the disapproval and denigration through subtle, passive-aggressive attacks on them, threatened to cause the dissolution of his firm and the downfall of his career. Chronic Entrenchment and Its Collateral Damage

Certain individuals are mired intractably in their own problematic psychic structure and subjective reality. This condition of “chronic entrenchment” can be ego-syntonic. But even when being stuck in this way feels unpleasant or, for that matter, hellish, such people may be loath to change, and doing so may feel well-nigh impossible. Much of the person’s energy goes into proving that trying to change would not only be folly, but psychologically disastrous. This is resistance taken to its ultimate extreme. What keeps the person trapped is

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a combination of rigid characterological tendencies and resistive psychodynamic elements that militate against constructive influence. Put another way, the chronically entrenched person is shackled by his or her own subjectivity. The psychic intransigence of such individuals may lead to their own enduring misery and the thwarting of their fondest dreams. We see this vividly, for example, in a character like Willy Loman from Arthur Miller’s 1949 play Death of a Salesman, whose fixed illusions regarding happiness, popularity, and success are his ultimate downfall. When a chronically entrenched person is in treatment, the therapeutic pathway is strewn with discarded interpretative approaches. The thwarted psychoanalyst joins a string of significant others in the patient’s life who have been frustrated or worse by this person’s toxic state and inability to change. Whether the entrenchment is manifest in a particular psychic structure, pattern of relatedness, or worldview—or all of the above—it becomes the person’s signature way of being in the world. Others in the person’s sphere can only do their best to withstand its draining, disheartening impact. Unbridled Indignation

Supporting one’s own sense of dignity and self-respect, and perceiving when these have been violated, are essential to good mental health. However, the expression of unbridled, unfiltered indignation at a perceived mistreatment or injustice can be directly detrimental to whoever may be the object of the angry sentiment. Self-righteous anger can stimulate reprisal and retribution rather than correction, and it can also be poisonous to the very one experiencing and expressing the indignation. As is illustrated in the writer Philip Roth’s (2008) succinctly titled novel Indignation, such micro-traumatized and micro-traumatic relating can cause further psychic bruising and eventually lead to full-scale blindness that may indeed instigate trauma with a capital T. Roth’s young male protagonist is counter-dependent and unrelievedly contemptuous of his well-meaning father and college professors, as well as any others perceived to be in authority. The character’s umbrage eventually leads to his alienation from everyone who has loved him. Through various twists of fate, and by default, he enters the armed services and dies a tragic death from wounds sustained in battle. These, Roth seems to be saying, are the wages of unconstrained indignation. Little Murders

Straightforward or oblique onslaughts on another’s sense of personal worth are obviously foremost among injurious modes of relating. This vast and



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various group of micro-traumata includes offhand insults, slights, mockery, backbiting, discounting, damning with faint praise, and backhanded compliments. The phrase was originally drawn from the title of an absurdist play by famed satirist and cartoonist Jules Feiffer (1968). While Feiffer’s play was manifestly addressing the hypocrisy and random physical violence of modern society, the term is now often (and, I think, appropriately) used to represent psychic assaults. Being related to in a fashion that frequently includes such barbs and insults, however much they are dressed up as “just teasing,” can badly erode the self-worth, self-confidence, and morale of the individual, contributing to intense psychic distress and compromises in his or her functioning. SELECTED THEORETICAL PRECURSORS: KHAN, FAIRBAIRN, SULLIVAN, AND BROMBERG My view on micro-trauma has its precursors in the work of many esteemed theorists,2 especially Masud Khan, W. R. D. Fairbairn, Harry Stack Sullivan, and the American relationalist Philip Bromberg. D. W. Winnicott helped set the stage for an appreciation of the disruptive impact of chronic, steadily destructive relating when he observed, “Often, the environmental factor is not a single trauma but a pattern of distorting influences: the opposite, in fact, of the facilitating environment which allows of individual maturation” (Winnicott 1965, 139). Masud Khan (1963, 1964) picked up on this theme in calling the accrual of discrete injurious moments “cumulative trauma.” (I am of course standing squarely on Khan’s shoulders in my formulation of cumulative micro-trauma or psychic injury.) For Khan and Winnicott, such trauma was situated in the early mother-child relationship, representing “breaches in the mother’s role as a protective shield . . . from infancy to adolescence—that is to say, in all those areas of experience where the child continues to need the mother as an auxiliary ego to support his immature and unstable ego functions” (Khan 1963, 290). In other words, by virtue of her or his own needs and psychic makeup, the parent may inadvertently thwart the child’s efforts to cope with the anxieties inherent in psychological development. This maladaptation of the parent to the child’s dependency needs creates a chronic tension that doesn’t inflict dramatic damage but instead gradually undermines or distorts the child’s psychic maturation. Khan goes on to argue that impingements are not necessarily recognizable as traumatic in the context wherein they occur, but may come to light only retrospectively and as they build up. His perspective suggests that we should

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look at the whole spectrum of an early formative relationship—I would add a current one as well—with its varyingly favorable, not-so-good, and unfavorable aspects. In my view, micro-trauma is what it is—undramatic, hidden, cumulative—in part because it occurs in the context of seemingly “good enough” relating. It’s the presence of the good with the bad, the pleasure with the pain, that keeps the damaged one connected and coming back for more. According to Fairbairn’s (1952) view, and in keeping with Ogden’s (2010) exegesis of it, a person wants to preserve a view of the self as being healthily loved by a good other. But as others are imperfect and often frustrate one’s needs and wishes, the child develops ambivalence toward the other that greatly complicates his or her psychic development. To the degree that the other is experienced as hostile or destructive, this “bad other” is controlled by being internalized into the self and split into an inner rejecting object and an inner exciting object. The exciting object is linked to an internalized “libidinal ego,” the latter being the hopeful inner self that seeks to be loved by the object. (It seems to me that it is this attachment of a hopeful inner self to the internalized exciting object that inclines someone to stay close to the outer, not-so-good, “actual” other, a situation that underpins the perpetuation of certain types of micro-trauma—for instance, connoisseurship gone awry.) At the same time, the inner rejecting object is linked to an internalized “antilibidinal ego,” also called quite evocatively the “internal saboteur.” Fairbairn argues that this internal saboteur, the negative aspect of the self, is unremittingly aggressive toward the libidinal ego—that is, the love-seeking aspect of the self. This makes fertile ground for self-disparagement and pessimism. (Here we may have a substrate for certain negatively toned micro-traumata— including, for example, little murders.) Highly ambivalent inner relations that are so adhesive pave the way to interacting externally in recurrently microtraumatic ways. That is to say, variations of this scenario could represent the intrapsychic mechanisms generated by micro-traumatic functioning; these intrapsychic mechanisms would then, in turn, prompt further disordered functioning in the outside world. Harry Stack Sullivan (1953) put anxiety and its interpersonal arousal at the center of his theorizing, unseating sexual and aggressive urges as prime motivators of psychological maturation. For Sullivan, the paradigmatic interaction was feeding, in which the mother might offer a “good,” “bad,” or “wrong nipple.” The good nipple was satiating and therefore gratifying, the wrong one was “unusable” for appeasing hunger, and the bad nipple was one that communicated maternal anxiety and instilled it in the baby. Through experiences with these nipples (which come to stand for “aspects of the other”), the person develops a sense of what is “good-me,” “bad-me,” and “not-me.” (One can consult Klein’s [1946] related thinking here. See “Notes on Some



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Schizoid Mechanisms.”) The self-system, an adaptive/defensive inner structure, seeks to avoid experiences of being either the bad-me or the not-me. The bad-me is an image of oneself comprised of one’s worst, most undesirable qualities, ones that garnered the most disapproval from significant others. The bad-me is the basis on which we hate or reject ourselves, whereas the not-me is so horrifyingly unacceptable that it is unthinkable. For Sullivan, in contrast to the Freudians or object relations theorists of his era, the actual quotidian moment-by-moment interactions between self and other were key to understanding the development of psychic life. In fact, he spoke about the central component for understanding an individual’s character or personality as being a dynamism, which he described as “the relatively enduring pattern of energy transformations which recurrently characterize the organism in its duration as a living organism” (Sullivan 1953, 103). So someone’s individual psyche is not fundamentally a function of a particular drive or drive derivatives, fixed attributes, or intrapsychic agencies. Instead, one’s psyche is a much more fluid and contextualized thing, being a composite of the pattern of one’s customary styles of relating to others (see Jones 1995, 315). In Sullivan’s nomenclature, the term “dynamism” also refers to certain specific patterns of behavior, like obsessionalism or selective inattention, which a person may characteristically overuse in times of stress. Mental disorder is therefore seen simply as reflecting a “misapplied dynamism,” or a “pattern of inadequate or inappropriate action in the field of interpersonal relations” (Jones 1995, 316). The behavior itself may be quite common as part of the human repertoire, but it is misdirected, overused, or employed in circumstances where it cannot possibly further the person’s emotional goals. Sullivan’s view of misapplied dynamisms is excellent grounding for the specifics of micro-traumatic relating. It captures the idea that people have elaborate patterns of relating to others that are not necessarily always injurious, but that can become injurious when the behavior is being employed too actively, rigidly, and indiscriminately in response to a real or imagined threat to one’s sense of security. It’s a misguided effort to stave off the anxiety of stimulating a sense of bad-me (or possibly even not-me) and to preserve a sense of being good-me, with a self-defeating result. Sullivan used the idea of collections of misapplied dynamisms to explain character disorders like hysteria, obsessionalism, and others. In speaking about micro-traumas, I too am articulating dynamisms, but subtler versions of them that combine over time to alter one’s self-image and eat away at one’s emotional well-being, without necessarily creating full-blown characterological distortions—though these can also occur. I see micro-traumatic dynamisms or habitual modes of relating as emanating from or received by an individual’s “psychic center” (Wolstein 1987). This is to say that micro-traumas are enacted by virtue of an

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individual’s inner psychic self- and other-representations, even though they find habitual expression in the interaction with one’s outer interpersonal life. In more recent years, Philip Bromberg has invoked the terms “developmental” or “relational trauma” to explore the role of ongoing detrimental influences in the individual’s psychic evolution. He writes compellingly of this sort of trauma as a function of the “prolonged experience of nonrecognition” (Bromberg 2006, 139) on the parents’ part: “It embodies an act of nonrecognition that is as traumatizing as the pain caused by a parent who is actively abusive, and sometimes it is more debilitating” (Bromberg 2006, 140). In Bromberg’s view, this nonrecognition eventually generates a dissociative structure in the child’s character, one that plagues him or her in an ongoing way in adult life. This theorist explains further that such situations occur when the parents themselves are emotionally damaged, which leads to some degree of shame within the parent that is itself dissociated, but that causes the parent to disavow qualities in the child that he or she finds intolerable in the self. The result is terrible in that the parent will distance from and fail to enjoy the child or the relationship, with a seriously stunting effect. Relational and developmental trauma as described by Bromberg and others overlaps the territory covered by my own term, micro-trauma. While building on Bromberg’s thinking, my work differs in being primarily aimed at trying to articulate specific instances of the ways that one individual can undermine the self-worth and well-being of another—or indeed, how one may do it to oneself. It seems to me that by describing particular ways in which nonrecognition, invalidation, and misattunements are enacted, we offer ourselves and our patients clearer cues as to the sorts of interactions for which they should be on the lookout. Identification of the “dance steps” takes us three-quarters of the way toward forestalling or correcting the troublesome dance. ADDRESSING AND REPAIRING CUMULATIVE PSYCHIC DAMAGE Due to the space constraints of this chapter, here I can only briefly touch on the delicate processes involved in repairing micro-traumatic patterning. While analyzing these damaging experiences draws on many of our standard analytic techniques and principles, the keystone here is to identify and acknowledge the subtly destructive patterning that had hitherto been unknown, to help the patient become aware of all its ramifications and convinced of its impact. This can be thought of as fully witnessing micro-trauma’s impact (see Amir, 2012), just as one must in treating major trauma. Another important element is the identification of social skills and capabilities that may have gone underdeveloped as a function of the disturbed injurious patterning; the analytic clinician must find ways to stimulate learning anew in these realms.



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Adopting the stance of trying to inhabit one’s healthiest self and “beckoning” the patient to do the same (Karen, 2012) can do much to promote effective working through. In my experience, the process of exploring and resolving micro-traumatic patterning does not always have a linear trajectory, or one that seems immediately remediable. As this pattern reemerges in the therapeutic relationship itself, the psychoanalytic clinician struggles to metabolize, process, and give words to what’s occurring, and the patient works to transcend his or her defensive wish to ignore it. It’s a struggle that doesn’t resolve quickly, cleanly, or definitively. The unpacking of micro-traumatic experience involves steady patience and repetitive reexamination to catch the momentary elements that generate the toxic impact. As the psychoanalyst, one must continually ask oneself to what degree this difficult engagement is really expressing something problematic in the patient, and to what degree it is a countertransferential response coming from one’s own area of insufficiently worked-through micro-traumatic history. It will usually be some of both, but the tangle should obviously only become focus of the analytic exchange itself if it is key to the patient’s own psychic issues. Work with micro-trauma, however trying it may be, can end up bringing both the analytic clinician and patient the deep satisfaction of having plumbed a previously unreachable set of psychic issues. Resolving those issues can bring the patient welcome relief from anxiety and dysphoria, ultimately leading to the expansion of the person’s psychic freedom. NOTES 1.  This chapter represents an adapted, edited condensation of the first chapter and small portions of other chapters of the author’s book Micro-trauma: A Psychoanalytic Understanding of Cumulative Psychic Injury, published in 2015 by Routledge. The author thanks Routledge for its permission to use this material. The interested reader can find earlier versions of two chapters that were previously published in Contemporary Psychoanalysis on the PEP-web (Crastnopol 2012, 2013). 2.  Another large contribution comes from self-psychology (Kohut and Wolf 1978; Wolf 1995), whose delineation of a psychically destructive “chronic ambiance” in the family of origin sits well with the idea of cumulative micro-trauma. Also relevant is their explication of the role of narcissistic injury, wherein the vulnerable self can shatter or shrivel in response to recurrent attacks on its cohesion, integrity, and vitality.

REFERENCES Amir, Dana. 2012. “The Inner Witness.” International Journal of Psychoanalysis 93: 879–96.

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Aron, Lewis. 1996. A Meeting of Minds: Mutuality in Psychoanalysis. Hillsdale, NJ: Analytic Press. Beebe, Beatrice, and Frank Lachmann. 2014. The Origins of Attachment: Infant Research and Adult Treatment. New York: Routledge. Brandchaft, Bernard, Shelley Doctors, and Dorienne Sorter. 2010. Toward an Emancipatory Psychoanalysis: Brandchaft’s Intersubjective Vision. New York: Routledge. Bromberg, Philip M. 1994. “Speak! That I May See You”: Some Reflections on Dissociation, Reality, and Psychoanalytic Listening.” Psychoanalytic Dialogues 4: 517–47. ———. 2006. Awakening the Dreamer: Clinical Journeys. Mahwah, NJ: Analytic Press. ———. 2011. The Shadow of the Tsunami and the Growth of the Relational Mind. New York: Routledge. Calef, Victor, and Edward M. Weinshel. 1981. “Some Clinical Consequences of Introjection: Gaslighting.” Psychoanalytic Quarterly 50: 44–66. Crastnopol, Margaret. 2012. “Connoisseurship Gone Awry: A Micro-Traumatic Style of Relating.” Contemporary Psychoanalysis 48: 423–50. ———. 2013. “Unkind Cutting Back and Its Navigation.” Contemporary Psychoanalysis 49: 536–58. ———. 2015. Micro-Trauma: A Psychoanalytic Understanding of Cumulative Psychic Injury. New York: Routledge. Dorpat, Theodore L. 1996. Gaslighting, the Double Whammy, Interrogation, and Other Methods of Covert Control in Psychotherapy and Analysis. Northvale, NJ: Jason Aronson. Fairbairn, W. R. D. 1952. Psychoanalytic Studies of the Personality. London: Tavistock Publications Limited. Feiffer, Jules. 1968. Little Murders. New York: Samuel French, Inc. Freeman, Katherine, ed. and trans. 1948. “Heraclitus of Ephesus.” In Ancilla to the Pre-Socratic Philosophers. Cambridge, MA: Harvard University Press. Available at Internet Sacred Text Archive: http://sacred-texts.com/cla/app/app19.htm. Freud, Sigmund. 1909. “Analysis of a Phobia in a Five-Year-Old Boy.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 10, edited and translated by J. Strachey. London: Hogarth Press. Jones, Daniel F. 1995. “Conceptions of Diagnosis and Character.” In Handbook of Interpersonal Psychoanalysis, edited by Marylou Lionells, John Fiscalini, Carola H. Mann, and Donnel B. Stern. Hillsdale, NJ: Analytic Press. Karen, Robert. 2012. “Beckoning: The Analyst’s Growth as a Therapeutic Agent.” Contemporary Psychoanalysis 48: 301–28. Khan, Masud R. 1963. “The Concept of Cumulative Trauma.” Psychoanalytic Study of the Child 18: 286–306. ———. 1964. “Ego Distortion, Cumulative Trauma, and the Role of Reconstruction in the Analytic Situation.” International Journal of Psychoanalysis 45: 272–79. Klein, Melanie. 1946. “Notes on Some Schizoid Mechanisms.” International Journal of Psycho-Analysis 27: 99.



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Kohut, Heinz, and Ernest S. Wolf. 1978. “The Disorders of the Self and Their Treatment: An Outline.” International Journal of Psychoanalysis 59: 413–25. Laing, Ronald D. [1961] 1971. Self and Others. London: Pelican Books. Laplanche, Jean, and Jean-Bertrand Pontalis. 1973. The Language of Psychoanalysis. New York: Norton. Lerner, Alan J., and Frederick Loewe. 1965. My Fair Lady: A Musical Play in Two Acts. New York: Coward-McCann, Inc. Mitchell, Stephen A. 1988. Relational Concepts in Psychoanalysis: An Integration. Cambridge, MA: Harvard University Press. ———. 1993. Hope and Dread in Psychoanalysis. New York: Basic Books. ———. 2000. Relationality: From Attachment to Intersubjectivity. Hillsdale, NJ: Analytic Press. Mitchell, Stephen A., and Lewis Aron, eds. 1999. Relational Psychoanalysis: The Emergence of a Tradition. Hillsdale, NJ: Analytic Press. Ogden, Thomas H. 2010. “Why Read Fairbairn?” International Journal of Psychoanalysis 91: 101–18. Roth, Philip. 2008. Indignation. New York: Vintage International. Shaw, George B. 1916. Pygmalion. New York: Brentano’s Press. Stern, Donnel B. 2010. Partners in Thought: Working with Unformulated Experience, Dissociation, and Enactment. New York: Routledge. Stolorow, Robert D., and George E. Atwood. 1992. Contexts of Being: The Intersubjective Foundations of Psychological Life. Hillsdale, NJ: Analytic Press. Sue, Derald W. 2010. Microaggressions in Everyday Life: Race, Gender, and Sexual Orientation. Hoboken, NJ: John Wiley & Sons. Sullivan, Harry S. 1953. The Interpersonal Theory of Psychiatry New York: Norton. Winnicott, Donald W. 1965. The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. London: Hogarth Press and the Institute of Psychoanalysis. Wolf, Ernest S. 1995. “Psychic Trauma: A View from Self Psychology.” Canadian Journal of Psychoanalysis 3: 203–22. Wolstein, B. 1987. “Anxiety and the Psychic Center of the Psychoanalytic Self.” Contemporary Psychoanalysis 23: 631–58.

7 Building Resilience The Example of Ambiguous Loss Pauline Boss

OVERVIEW OF THEORETICAL FRAME

The trauma of loss has long been the subject of mental health literature, but

only recently has ambiguous loss become part of the psychological lexicon (Boss 1999, 2006, 2016). Ambiguous loss is a loss that has no closure. Unlike with death, families have no official verification of their loss; this lack of congruence between absence and presence remains. A loved one goes missing in body or mind but with no certainty about their whereabouts or fate. (Think of the families of passengers and crew on Malaysian Airliner 370 missing since 2014, or families where a loved one is psychologically absent due to dementia from Alzheimer’s disease, or a serious mental illness, addiction, or brain injury.) Because ambiguous loss is often long term in its inability to be resolved, it is traumatizing for individuals and families who must live with it. Yet, without verification of death or return to the status quo, there are no rituals of support for the suffering, or memorials for the missing. Instead, people experiencing ambiguous loss are often criticized for not “finding closure.” Isolated and trapped between hope and despair, they manifest lingering grief symptoms, often mistakenly diagnosed as personal, marital, or familial pathology (Boss 1999, 2006, 2007). Ambiguous loss is a relational disorder—that is, an external force of unrelenting ambiguity, ruptures relationships. In the absence of clarity about a family member’s absence or presence, people are immobilized, holding on to hope that a missing person will return or a person psychologically absent will go into remission and come back as before. While no death has occurred, symptoms of grief are like those of complicated grief (Shear, Boelen, and Neimeyer 2011). The culprit here, however, is not death but the traumatizing 91

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context of ambiguity. Diagnosing and treating therefore requires our assessment of the larger context surrounding a loss, not just the relational symptoms (Boss 1999, 2006, 2012a). To clarify my therapeutic focus, it is one that takes into account both the family and its individual members. This may reflect my multidisciplinary training in developmental psychology, psychiatry (with Carl Whitaker), sociology, and child development, where I learned that individuals are socialized by their family, whether it be biological or chosen, physical or psychological. As a psychotherapist, I cannot fully understand individuals until I know about their family context. For this reason, the ambiguous loss theory and its clinical application involve both individuals and their families as a whole. In other words, even when we are working with an individual patient or survivor after disaster, we need also to consider their context and environment of loss. They may be experiencing traumatizing loss even when no death has occurred. STRESS AND RESILIENCE BASE The basis of ambiguous loss theory is the contextual model of family stress (Boss 1988, 2002b; Boss, Bryant, and Mancini 2017), thus providing a resilience-based lens for the treatment and intervention. With ambiguous loss, the stressor lies in the social context of ambiguity, resulting in immense confusion and feelings of helplessness. Rather than focusing solely on eradicating symptoms, the therapeutic goal is to strengthen the family’s resilience to live with the stress of ambiguity, which may go on for years or even a lifetime. While more will be said about intervention later, suffice it to say here that the ambiguous loss approach is not about having patients surrender to the ambiguity or accept the loss, but rather to provide them with a different way of thinking about ambiguity, a way that represents an intentional choice that leads to a measure of peace and manageability despite unanswered questions. This way of thinking, however, is a challenge for both patients and therapists in Western cultures, where high value is placed on mastery, problem solving, and finding precise answers to questions. Across cultures, regardless of beliefs and values, the therapeutic goal is to build resilience in order to live well despite the continuing stress of ambiguity. In this chapter, we discuss the definition and types of ambiguous loss; its theoretical premise and assumptions; its effects and symptoms for individuals and families; assessment questions on multiple levels; and, finally, the six therapeutic guidelines for strengthening individual, couple, and family resilience to live well, despite the lack of closure or resolution of loss.



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DEFINITION AND TYPES OF AMBIGUOUS LOSS Ambiguous loss, a term coined by this author in the 1970s, is defined as a situation of unclear loss that remains unverified and thus without resolution. (For review of publications since 1975 to present, see Boss 2016.) Ambiguous loss is assessed as the lack of congruence between a loved one’s absence and presence. There are two types of ambiguous loss. Type 1 is physical absence with psychological presence: a loved one disappears physically, may be kidnapped, vanishes at sea or in an airplane, or is declared missing owing to war or terrorism. More common examples of physical ambiguous loss include divorce, adoption, immigration, and migration. Type 2 is physical presence with psychological absence: a loved one is present physically but has “vanished” psychologically due to cognitive or emotional impairments from illnesses or conditions such as Alzheimer’s disease, Creutzfeldt-Jakob disease, Parkinson’s, autism, serious mental illness, addictions, stroke, or traumatic brain injury. More common examples of psychological absence with physical presence include homesickness, preoccupation with work, obsession with computer games or the internet, or an affair. In many cases, families experience both types of ambiguous loss simultaneously. For example, after the terrorist attack on the World Trade Center Towers in New York on September 11, 2001 (9/11), several spouses of the missing reported to our team that they had a spouse missing in the smoking rubble as well as an elderly parent at home with dementia. This double load of ambiguous loss in one family is not uncommon and increases the level of stress and trauma. In addition to the Type 1 and Type 2 ambiguous losses, my clinical observations over the past forty years suggest a third type. Ambiguous loss is a phenomenon experienced by families with any loss that never makes sense— even with clear verification and a body to bury. Here, the stressor is not the lack of a death certificate or a body to bury, but rather, having no rational explanation for the loss—for example, an unsolved murder, a suicide with no explanation, or a baby who dies of sudden infant death syndrome. With such unanswered questions, meaning making and coping processes cannot begin because patients have no name for the problem. Labeling their plight as “ambiguous loss” helps them name their stressor and begin the coping and grieving processes despite not having the facts. With ambiguity named as the culprit, self-blame is lessened. Before proceeding to effects and interventions, and because linguistics may confuse across languages, we need to clarify the differences between ambiguous loss and posttraumatic stress disorder (PTSD) and between ambiguous loss and ambivalence.

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Ambiguous Loss Is Not PTSD

While both ambiguous loss and PTSD can lead to symptoms of depression, anxiety, guilt, psychic numbing, flashbacks, and distressing dreams, the two are conceptually and realistically different. Ambiguous loss is a relational rupture that has no resolution or closure. PTSD is a medical disorder, medically defined, individually diagnosed and individually treated. While the goal for treatment of PTSD is to return the patient to health, the therapeutic goal for unrelenting ambiguous loss is resilience. That is, when the ambiguity continues without facts or finality, the only option for treatment is to build enough resilience to live without knowing the precise answer. In sum, the goal is to increase the tolerance for ambiguity in the people left behind. While these constructs are different, there is nevertheless some crossover. Ambiguous loss is a traumatic loss and thus carries with it the possibility of some PTSD symptoms in those left behind. Patients diagnosed with PTSD may also be suffering from ambiguous loss. For this reason, there may be PTSD in families suffering from ambiguous loss. Mental health specialists should be aware of these differences and the crossover in order to provide the most effective treatments. Ambiguous Loss Is Not Ambivalence

Ambiguity and ambivalence are not synonymous, but ambiguous loss often leads to ambivalence. While ambivalence is a feeling or emotion, ambiguity is a cognitive state of having no answer. Ambivalence means having simultaneous positive and negative feelings about a person or object, such as the opposing states of love and hate. Although much is written about ambivalence in psychiatric manuals, here we refer to sociological ambivalence (Merton and Barber 1963) where the mixed emotions are caused by ambiguous loss, a social rupture, not a psychiatric condition. To repeat, the ambiguity is the culprit. For more about the theoretical linkage of ambiguity to ambivalence, see Boss (2006) and Boss and Kaplan (2004) regarding marital partners where one spouse has been institutionalized due to Alzheimer’s disease, and Roper and Jackson (2007), the family scientists who discovered themes of ambivalence (and guilt) in mothers of profoundly disabled children who were placed in out-of-home care. Such examples emphasize the need to differentiate between psychiatric and social causes of ambivalence. THE PSYCHOLOGICAL FAMILY Core to the theory of ambiguous loss is the assumption that families can be both physical and psychological entities and that both are sources of resil-



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ience. A psychological family is the family in one’s mind. It is comprised of loved ones near or far, related or not related, alive or dead. The psychological family is made up of people one leans on (physically or symbolically) in times of adversity or celebration. For example, a bride and groom light candles at their wedding to symbolically acknowledge the presence of a deceased parent; a student, far away from home, texts or phones a parent for help. A traveler is invited into the home of strangers to celebrate a religious holiday they share. Or close friends become family in lieu of biological families unavailable or unsupportive. To assess the presence of a psychological family, we ask: Who is there for you now? Who is there for you in times of sadness or joy? Who do you want to be present at your special events—birthday, graduation, wedding—or holiday gatherings? Who do you not want to be there? Who can you call when you need help? Cross-culturally, the answers vary and often surprise us. Recently, I learned that many families who survived the tsunami of 2011 in Japan find comfort now in the belief that their ancestors are now looking after their missing loved ones (Boss and Ishii 2015). Once again, I was reminded that the psychological family manifests itself differently across cultures. EFFECTS OF AMBIGUOUS LOSS The effects of ambiguous loss are viewed differently based on a therapist’s discipline or training. From a sociological perspective, the clarity needed for boundary maintenance is problematic or unattainable with ambiguous loss. The problem is structural—not knowing who is in or out of the family circle—and this leads to a high degree of boundary ambiguity, a perceptual outcome of “who is in the family” after an incident of ambiguous loss (Boss, Bryant, and Mancini 2017; Boss and Greenberg 1984). The effects of structural ambiguity are indicated by unfilled roles, delayed decisions, undone tasks, and all too often, canceled rituals and celebrations. The family no longer functions (Boss 2006). From a psychological perspective, the resolution of loss and grief is impossible without knowing the status of a loved one as absent or present, dead or alive (Boss 1999, 2004b). Here, the problematic effects of ambiguous loss are emotional. There are feelings of hopelessness and helplessness with symptoms of unresolved grief and often depression. There is also ambivalence (caused by the ambiguity), which involves guilt, anxiety, and immobilization. Overall, however, and whatever the discipline, people experiencing ambiguous loss experience both social and psychological effects (Boss 1999, 2004a, 2006, 2016).

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Individual Effects and Symptoms

For individual family members, ambiguous loss creates symptoms of depression and anxiety as well as feelings of hopelessness and helplessness; confused identity, for example, “I am neither wife nor widow since my husband has been missing”; and anxious attachment with ambivalence and guilt. There may also be stress-related illnesses, substance abuse, abuse of self or others, and suicidal ideation. The constant searching for a loved one also increases what looks like an anxious attachment, and finally, there is the frozen grief and depression that are akin to symptoms of complicated grief. Yet, there is a difference between depression and the normal sadness of ongoing grief with ambiguous loss. While depression is a sadness so deep that one cannot function or care for the self or others, sadness involves mild grieving, being unhappy but still functioning. There are ups and downs to living with loss, what researchers now call “oscillation” (Bonanno 2009; Kissane 2003, 2011). We need to be careful in diagnosing whether symptoms are the normal sorrow of unresolved loss or a depression disorder that needs medical attention. The former—sadness—can be eased by human connection, for example, peer groups, social supports, and group activities; the latter—depression— requires professional psychotherapy using a systemic and contextual lens and perhaps medication (adapted from Boss 2011). Family Systems Effects

Overall, the stressor of ambiguous loss ruptures marital and family relationships and thus the systemic processes of grieving, coping, decision making, and transformation in the face of change. Conflict emerges when one spouse or sibling views the missing person as dead while the others think he may be alive somewhere and possibly returning some day. Due to the lack of factual information, we predictably see family conflict about the meaning of the situation. Without intervention to reinforce that it is typical to see the situation of ambiguous loss differently, the conflict will intensify and lead to family rifts and alienations. In addition to perceptions, the structure of family roles, rituals, and rules must be revised. After a family member disappears, family and couple roles need to be clarified regarding who does what in order to continue functioning as a family system. Family rules about who is in charge need to shift to prevent immobilization of systemic processes that must continue despite the ambiguity. Family rituals and celebrations must also be revamped to accommodate for the missing person. While it is typical for families to cancel their rituals and celebrations after a member goes missing, it is essential that such gatherings continue for the



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social support and human connection they provide. To revise family rituals, having children in the therapy rooms is especially helpful; they are imaginative and not so bound by tradition. Change in the family comes easier for the young. With our focus on family roles, rules, and rituals, the family therapy approach becomes more structural than psychodynamic. Such intervention is, however, essential for the forward functioning of the family system and thus for the psychological health for its remaining members. RELATIONAL ASSESSMENT, DIAGNOSIS, AND TREATMENT Because ambiguous loss is a relational disorder, assessment, diagnosis, and treatment require a more systemic and contextual approach. We recommend the following questions for assessment: For Assessing Family Roles: What marital/family roles or tasks have you lost? What roles or tasks have you gained? How do you manage the change? For Assessing Family Rules: Who makes the decisions and plans for daily routines? Is gender, race, age, class, or religion affecting your ability to cope? Is safety or poverty an issue? Is economic security an issue? For Assessing Family Rituals: What family and community celebrations, holiday events, and religious rituals did you observe before your ambiguous loss? How did you and your family adapt your usual rituals and celebrations since your ambiguous loss? Did your community help memorialize your missing loved one? (See Robins 2013; Saul 2013.) Perspectives for Treatment and Intervention

With ambiguous loss, the goal of therapy and interventions is, as I have previously said, to build the resilience to live with the ongoing ambiguity. Based on a stress and resilience model, rather than assuming pathology, the preferred treatment is family therapy using a systems theory approach. The system can be a couple, a family, or a community of peers suffering from similar ambiguous losses (a disease, having a child with autism, or a natural disaster such as a tsunami, mountain slide, earthquake, etc.). Systems thinking is not linear (find a cure or fix for the situation), but rather, requires “bothand thinking” within a contextual framework whereby the situation is the cause of symptoms, not the individual’s psychic deficiency. The pathology lies in the situation of ambiguity and not in the person or family left behind.

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Building Resilience

With ambiguous loss, resilience means increasing one’s tolerance for ambiguity (Boss 1987, 1988, 1999, 2002a, 2004b, 2006, 2012b, 2014, 2016). We assume a natural resilience in families (Masten 2007, 2014) and that this resilience toward ambiguity is influenced by the family’s cultural beliefs and values. Dialectical or Both-And Thinking

Depending on cultural and religious perspectives, people often respond to ambiguous loss with absolute thinking. They insist on a clear answer even if it is not realistic—acting as if the missing person is definitely dead or denying their loss as if nothing has changed. Neither binary is helpful. Instead, we recommend dialectical or both-and thinking (Boss 2006, 2012b, 2016). That is, the only way people can lower the stress of ambiguous losses is by holding two opposing ideas in their mind at the same time; for example, he is both dead, and maybe not; she is both here, and also gone. See the following chart for more examples.

Examples of Both-And Thinking • She is both gone—and still here. • He is both here—and gone. • I must find a way to both hold on—and let go. • I have both the anxiety of no closure—and the opportunity to move forward with new relationships and interests. • I am both sad about my lost hopes and dreams—and happy about some new ones. • He is probably dead—and maybe not.

Increasing Tolerance for Ambiguity

To increase one’s tolerance for ambiguity, it is good to do something spontaneous—have a meeting without an agenda, go for a drive without a plan, ease up on perfectionism and the desire to control, take a theater class on improvisation, travel to a new place.



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Embracing unanswered questions is an idea that has long been alive in the arts (Boss 2006). One example comes from the poet John Keats in his 1817 letter to his two brothers, advising them about life, to be comfortable with the uncertainty, mystery, and doubt—“remaining content with half knowledge” (Forman 1935, 72). What the poet Keats recommends to his brothers is “negative capability,” precisely the resilience in thinking needed to live with ambiguous loss (Boss 2006, 179). Being able to hold on to the paradox of absence and presence, rather than insisting on one absolute truth, is a more useful approach to helping people who are suffering with ambiguous loss. Indeed, absolute thinking often reflects authoritarian thinking and is not helpful when one’s loss has no clear answer. Instead, we learn to hold two opposing ideas in our mind at the same time: gone but also here, here and yet so far away (Boss 2008). Given this dialectical way of thinking, how do we proceed with therapy and intervention? QUESTIONS TO GUIDE RELATIONAL THERAPY AND INTERVENTIONS Early on, as we meet with families suffering with ambiguous loss, I ask what it is they have lost in order for me and their family members to hear each others’ views. The following are examples of responses from family members when we ask: “What has been lost?” Answers vary: The loved one as he or she was; certainty about the future of the missing person and thus about one’s own future (caregiver tasks, new roles, new identity, no free time, no sleep); loss of a dream and thus loss of hope for a good future; loss of identity—am I still the child if I am now parenting my parent? Am I still married if my spouse no longer knows who I am? We also ask: 1. Questions to enhance individual and family resilience: What does this situation mean to you? Is there disagreement in the family about this? How do you see your loved one’s physical and psychological presence now? Before? What have you lost? What do you still have? How do you see your role in the family now? How do you feel about change? 2. Questions about community support: Who do you see as your community now? Have some other people become like family to you (your psychological family)? Does your community offer spiritual support, recreation, and respite support and information support? 3. Questions about family roles: What family roles and tasks have you lost as a result of the ambiguous loss? What family roles and tasks have you gained? How do you manage these changes? What would help?

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4. Questions about family rules: What family rules have changed? Do rules about race, religion, class, age, or gender create stress for you? Who is allowed to do what in your family now? Is there a family team approach or does the stress fall to you alone? 5. Questions about family rituals: What family rituals did you celebrate as a couple or a family before the ambiguous loss occurred? Now? How can you reshape your family rituals and celebrations to fit the circumstances now? (Note this is often a good place to begin.) With both-and thinking, loved ones can be gone and still here, here and still gone. Presence is not an absolute; it is not a binary (here or gone; gone or here; dead or alive). COMMON TREATMENT ELEMENTS AND GUIDELINES Based on research beginning in the 1980s to the present (Boss 1977, 1980, 2006, 2016; Boss et al. 1990; Boss et al., 2003; Boss, Bryant, and Mancini, 2017) and working with families of ambiguous loss in Fukushima, Tbilisi, Bern, Zurich, Mexico City, and here in the United States regarding the trauma of ambiguous loss (family members missing physically or psychologically), the treatment elements of meaning, mastery, identity, ambivalence, attachment, and hope were found to be central in regaining resilience while living with ambiguous loss. Following are brief descriptions of each of these common treatment elements used in cases of ambiguous loss. Note that elsewhere (Boss 2006), a full chapter describes each: 1.  Finding Meaning: Making sense of a mysterious loss that has no official verification. What Helps? Giving the problem a name, “ambiguous loss”; talking with others; both-and thinking (he’s alive and maybe not; she’s here and also gone); spirituality. What Hinders? Blaming oneself, seeking the certainty of closure, denial of the loss, or premature extrusion of the lost person from the family. 2.  Adjusting Mastery: Recognizing what can be controlled and what cannot. What Helps? For people with little power and agency, we increase their power to take care of themselves, depending on their gender, age, culture, etc.; empowerment increases when peers can meet to-



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gether; family meetings are highly recommended. Also, recognizing that the world is not always fair, externalizing blame (the culprit is the ambiguity), mastering the internal self (meditation, prayer, mindfulness, physical exercise, the arts). What Hinders? Believing that bad things only happen to bad people; believing that the harder you work, the more you can avoid pain and suffering from loss (Boss 2015a); isolation from others experiencing the same kind of loss, being alone. 3.  Reconstructing Identity: Who are you now? (For example, are you a widow or a widow waiting to happen? Are you still married?) What Helps? Redefining family/marital boundaries: who is in, who is out, who plays what roles now, who am I now? What Hinders? Isolation, disconnection from the society of other people. 4.  Normalizing Ambivalence: Tolerating the tension of mixed emotions. What Helps? Normalizing anger and guilt, but not harmful actions; considering conflicted feelings as normal, talking about them with someone—a professional, a peer. What Hinders? Denying your ambivalent feelings and mixed emotions about a loved one who is still missing. 5.  Revising Attachment: Letting go while remembering your lost person. What Helps? Recognizing that your loved one is both here and gone (grieve what you lost, celebrate what you still have), and most important, find new social connections. What Hinders? Expecting some kind of finality or closure, for example, either returning to the status quo or having proof of death. 6.  Discovering New Hope: Imagining something new to hope for. What Helps? Becoming more comfortable with ambiguity (a kind of spirituality), laughing at absurdity, redefining justice (bad things can happen to good people; the world is not always fair and just), imagining new options, finding something to control in order to balance the ambiguity. What Hinders? Insisting on an end to the suffering, having control over relationships, resisting change. For more discussion of each of the six guidelines, see Boss (2006) or its German translation (Boss 2008) or Japanese translation (Boss 2015b).1

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Family Therapy: Individual or Multiple Family Groups

1.  Gather the family (self defined). 2.  Label their experience. “What you are experiencing is ambiguous loss, the most difficult kind of loss because there is no closure.” 3.  Normalize. “What you are feeling is not your fault.” Minimize blame and guilt. 4.  Encourage them to seek as much information as possible. 5.  Elicit and share their perceptions of the loss. “What does this situation mean to each of you?” 6.  Expect disagreements, but prevent family conflict and alienation by saying, “It is not necessary for you all to see the situation the same way at this time.” In the absence of facts, it is expected for family members to have different perceptions of the loss. 7.  Help clients/patients reconstruct family rituals, rules, and roles so that they can move forward with their lives despite the ambiguous loss. 8.  Help people imagine something new to hope for as their ambiguous loss may remain. 9.  Encourage social connections and activity, talking with others who have similar experiences and avoiding isolation. 10.  While the clinical connection is important in the healing process, it is essential that terms such as “termination” are not used when therapy is complete. We highly recommend an “open door” so that the client(s) can return if and when needed. This prevents the possibility of the therapist inadvertently becoming another ambiguous loss for the client/patient. (Boss 2006)

These research-based guidelines inform our practice with individuals and families of the missing. Influenced by more Eastern as well as artistic perspectives regarding the stress of ambiguity, the assumptions for intervention are (1) that when a loved one is missing and no absolute answers are available, stress is lowered by holding two opposing ideas in one’s mind at the same time, and (2) that accepting this paradox of ambiguous loss can lead to increased growth and strength in individuals and families left behind.



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NOTE 1. A review of Loss, Trauma, and Resilience (Boss 2006) by Helm Stierlin is available in German (Stierlin 2009).

REFERENCES Bonanno, George A. 2009. The Other Side of Sadness: What the New Science of Bereavement Tells us about Life after Loss. New York: Basic Books. Boss, Pauline. 1977. “A Clarification of the Concept of Psychological Father Presence in Families Experiencing Ambiguity of Boundary.” Journal of Marriage and the Family 39 (1): 141–51. doi: 10.2307/351070 ———. 1980. “The Relationship of Psychological Father Presence, Wife’s Personal Qualities, and Wife/Family Dysfunction in Families of Missing Fathers.” Journal of Marriage and the Family 42 (3): 541–49. doi: 10.2307/351898. ———. 1987. “Family Stress: Perception and Context.” In Handbook of Marriage and Family, edited by Marvin B. Sussman and Suzanne K. Steinmetz. New York: Plenum. ———. 1988. Family Stress Management. Thousand Oaks, CA: Sage. ———. 1999. Ambiguous Loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University Press. ———. 2002a. “Ambiguous Loss: Working with Families of the Missing.” Family Process 41 (1): 14–17. doi: 10.1111/j.1545-5300.2002.40102000014.x. ———. 2002b. Family Stress Management. Second edition. Thousand Oaks, CA: Sage. ———. 2004a. “Ambiguous Loss.” In Living Beyond Loss: Death in the Family, edited by Froma Walsh and Monica McGoldrick. New York: Norton. ———. 2004b. “Ambiguous Loss Research, Theory, and Practice: Reflections after 9/11.” Journal of Marriage & Family 66 (3): 551–66. ———. 2006. Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss. New York: Norton. ———. 2007. “Ambiguous Loss Theory: Challenges for Scholars and Practitioners.” Family Relations 56 (2): 105–11. doi: 10.1111/j.1741-3729.2007.00444.x. ———. 2008. Verlust, trauma und resilienz [Loss, Trauma, and Resilence]. Translated by Astrid Hildenbrand. Stuttgart, Germany: Klett-Cotta. ———. 2011. Loving Someone Who Has Dementia: How to Find Hope While Coping with Stress and Grief. San Francisco, CA: Jossey-Bass. ———. 2012a. “The Ambiguous Loss of Dementia: A Relational View of Complicated Grief in Caregivers.” In A Psychodynamic Understanding of Modern Medicine: Placing the Person at the Center of Care, edited by Maureen O’ReillyLandry. London: Radcliffe. ———. 2012b. “Resilience as Tolerance for Ambiguity.” In Handbook of Family Resilience, edited by Dorothy S. Becvar. New York: Springer.

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———. 2014. “Family Stress.” In Encyclopedia of Quality of Life and Well-Being Research, edited by Alex C. Michalos. Dordrecht, Netherlands: Springer. ———. 2015a. “Coping with the Suffering of Ambiguous Loss.” In World Suffering and the Quality of Life, edited by Ronald E. Anderson. New York: Springer. ———. 2015b. Aimaina soshitsu to torauma karano kaifuku: Kazoku to komyuniti no rejiriensu [Loss, Trauma and Resilience: Therapeutic Work with Ambiguous Loss]. Translated by Satomi Nakajima and Chikako Ishii. Tokyo: Seishin Shobo. ———. 2016. “The Context and Process of Theory Development: The Story of Ambiguous Loss.” Journal of Family Theory & Review 8: 268–86. doi: 10.1111/ jftr.12152. Boss, Pauline, Lorraine Beaulieu, Elizabeth Wieling, William Turner, and Shulaika LaCruz. 2003. “Healing Loss, Ambiguity, and Trauma: A Community-Based Intervention with Families of Union Workers Missing after the 9/11 Attack in New York City.” Journal of Marital and Family Therapy 29 (4): 455–67. doi: 10.1111/j.1752-0606.2003.tb01688.x. Boss, Pauline, Chalandra Bryant, and Jay A. Mancini. 2017. Family Stress Management: A Contextual Approach. Third edition. Thousand Oaks, CA: Sage. Boss, Pauline, Wayne Caron, Joan Horbal, and James Mortimer. 1990. “Predictors of Depression in Caregivers of Dementia Patients: Boundary Ambiguity and Mastery.” Family Process 29 (3): 245–54. doi: 10.1111/j.1545-5300.1990.00245.x. Boss, Pauline, and Jan Greenberg. 1984. “Family Boundary Ambiguity: A New Variable in Family Stress Theory.” Family Process 23 (4): 535–46. Boss, Pauline, and Chikako Ishii. 2015. “Trauma and Ambiguous Loss: The Lingering Presence of the Physically Absent.” In Traumatic Stress and Long-Term Recovery, edited by Katie E. Cherry. Cham, Switzerland: Springer International. Boss, Pauline, and Lori Kaplan. 2004. “Ambiguous Loss and Ambivalence When a Parent Has Dementia.” In Intergenerational Ambivalences: New Perspectives on Parent-Child Relations in Later Life, edited by Karl Pillemer and Kurt Luescher. Oxford, UK: Elsevier. Forman, Maurice Buxton, ed. 1935. The Letters of John Keats..Second edition. New York: Oxford University Press. Kissane, David W. 2003. “Family Focused Grief Therapy.” Bereavement Care 22 (1): 6–8. ———. 2011. “Family Therapy for the Bereaved.” In Grief and Bereavement in Contemporary Society: Bridging Research and Practice, edited by Robert A. Neimeyer, Darcy L. Harris, Howard R. Winokuer, and Gordon F. Thornton. New York: Routledge. Masten, Ann S. 2007. “Resilience in Developing Systems: Progress and Promise as the Fourth Wave Rises.” Development and Psychopathology 19 (3): 921–30. doi: 10.1017/s0954579407000442. ———. 2014. Ordinary Magic: Resilience in Development. New York: Guilford. Merton, Robert K., and Elinor Barber. 1963. “Sociological Ambivalence.” In Sociological Theory, Values, and Sociocultural Change, edited by Pitirim A. Tiryakian. Glencoe, IL: Free Press.



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Robins, Simon. 2013. Families of the Missing: A Test for Contemporary Approaches to Transitional Justice. New York: Routledge. Roper, Susanne O., and Jeffrey B. Jackson. 2007. “The Ambiguities of Out-of-Home Care: Children with Severe or Profound Disabilities.” Family Relations 56 (2): 147–61. Saul, Jack. 2013. Collective Trauma, Collective Healing: Promoting Community Resilience in the Aftermath of Disaster. New York: Routledge. Shear, Katherine, Paul Boelen, and Robert A. Neimeyer. 2011. “Treating Complicated Grief: Approaches.” In Grief and Bereavement in Contemporary Society, edited by Robert A. Neimeyer, Darcy L. Harris, Howard R. Winokuer, and Gordon F. Thornton. New York: Routledge. Stierlin, Helm. 2009. “Boss, Pauline: Verlust, Trauma und Resilienz. Die therapeutische Arbeit mit dem ‘uneindeutigen Verlust’” [Review of the book by Pauline Boss: Loss, trauma, and resilience: Therapeutic work with ambiguous loss]. Familien Dynamik 34 (4): 411–12.

III SOCIAL PSYCHOLOGICAL ASPECTS OF THE TOTALITARIAN COMMUNIST SYSTEM

The

social psychological aspects of the totalitarian communist system is identified and illustrated by me. A short sociohistorical overview of Germany also by me gives a taste of the historical context, particularly with regard to the periods of division and reunification of Germany. The development of the False Self in the context of a form of “self-brainwashing” is elucidated by Adrian Sutton. Ways in which the totalitarianism can remain encrypted in post-totalitarian social matrices, in specific psychosocial pathological organizations, or hidden subsystems—“social-psychic retreats”—will be discussed, and ways in which these hidden forms of survival may be maintained are illuminated by Marina Mojović. She illustrates how these can be revealed and transformed by a new methodology: that of large-group work around the subject of citizenship—“Reflective Citizens.” Earl Hopper’s and Vamik Volkan’s theories and the role of trauma within group creation are discussed by Helena Klímová, as well as certain specific aspects of culture resulting from historical traumata.

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8 Political Psychology, Effects of Historical Processes, and Cultural Trauma Bernd Huppertz

Observation of historical events from the standpoint of the psychodynamic

theory of groups may lead to the study of political dynamics, and may also warrant the application of the field of political psychology to the situation. Political psychology involves a concentration on political processes and issues whereby both psychic and political processes are seen to be influenced by unconscious intra- and interpsychic processes. According to the theory of group dynamics, the psychodynamics of larger social units encompass the dynamics of whole societies and their international and intercultural relations. Behaviors and structures within larger societies, and the relevant unconscious and conscious processes, appear to be analogous to and comparable with smaller social systems. As with the latter, it is important to consider the individual conditions and structure of the groups, and the group dynamic issues concerning the individual strengths of the group, taking into account rivalries, the power issues, roles, fields of activity, and privileges. All of these may play a critical role. Collective anxieties are managed by social systems in order to achieve system coherence. The behavior of the individual members of groups will be supported in society, often through corresponding reference groups within that society, and vice versa (Cohen, Fidler, and Ettin 1995; Ettin, Fidler, and Cohen 1995; Moses 1995). Thus, group dynamic knowledge of small social systems can be extended to political processes (Ettin and Cohen 2003). Furthermore, process-oriented therapy groups may be seen as micro-political cultures where leadership issues are studied. Emerging micropolitical developments may help to view macro-political developments as being analogous.

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“MACRO-POLITICAL EVOLUTION” OF POLITICAL CULTURES According to this method of comparison, it is possible to see a “macropolitical evolution” of political cultures that has developed over centuries and even millennia (Cohen, Ettin, and Fidler 2002). It began with clans and tribes, as an extension of familial or ethnic models. The earliest political systems functioned in the form of tribal chiefdoms. What followed was authoritarian monarchism, transitioning to anarchy or revolutions, often as a reaction to authoritarian reality. This may lead to totalitarianism and authoritarian forms of collectivism, as exemplified by fascism or communism, whereby “the ruling group” could be a “new monarch.” This may then lead on to democracy, either liberal or social democratic. The steps of political evolution in government forms may be seen as in some ways comparable to the developmental phases of process-oriented therapy groups. In these therapy groups, it is possible to compare the phases of dependency with the circumstances of macropolitical cultures in the monarchic phase, and to liken the phases of counterdependence with the macro-political situations of anarchism or revolution. Comparisons can be made with the so-called dystopian phases and authoritarian collectivism. The utopian phase within authoritarian collectivism can also be seen in macro-political systems, and the phases of independence within the macro-political conditions may be comparable to liberal democracy; the phases of interdependence can be compared to social democracy, whereby both last phases are organized around individual or collective rights. Thus, if we look at political forms in group-dynamic terms, monarchism may imply dependence, and anarchism or revolution may translate into counter-dependence. Totalitarianism may signify a collective identification with fascism, as an internalization of dystopian fantasies; communism may be identified with an internalization of utopian fantasies; liberal democracy may be related to independence and social democracy to interdependence. If applied to German history, dystopian fascism can be seen as a form of authoritarian collectivism that uses the key concept of difference as its organizational principle. The state possesses collective power, and the predominant climate is nationalism. The image of a uniformly aggrandized group must remain intact, and national culture as a result becomes overly simplified. Everything undesirable will be projected or split off. A concordant dependence on authoritarian leaders then prevails. The meaning of the national in-group elevates the people through identification with it. An “us-over-them” mentality prevails, and the so-called in-groups can become overly aggressive toward the “out-group,” or the not-us groups or outsiders. Authority has a “battle” leader and respective followers. The fascistic mind is attuned to differences, and people who are different will be punished.



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Under utopian communism, however, there is a collectivism that is organized by equalities and similarities. Utopian ideology seeks egalitarianism in society. The Communist Revolution was a revolution without national or state boundaries. The masses of workers from all around the world were part of this movement. Differences rooted, for example, in race, class, religion, or family, were meaningless. Fundamental agreements and similarities were celebrated, and inclusion was prioritized. In the utopian phase of the group illusion, allimportant differences were denied. What followed was a merging or overidentification with the group as an idealized political culture. Similarity and denial of difference were predominant. Whoever was of a different opinion was either coerced or oppressed. To belong to the group, with a concomitant “sense of belonging,” was more important than work, and cooperation was valued more highly than competition. The cooperative spirit of collective workers and consensus was more important than an open discussion. Group identity became more important than personal identity. Consequently, “we-ness” became more important than one-ness. The people fused their group-selves together into a whole. Everyone was the same; inequality was ignored and denied. Utopian ideology and its illusions were consolidated in totalitarian regimes after the revolution and the dictatorship of the proletariat. These were able to form closed systems with centralized leaderships. These totalitarian regimes were monitored by an elite party structure and governed by a central committee or an absolute leader. Such imperialistic communist regimes claimed revolutionary communist legitimacy for themselves. They sought to enforce their authority by suppressing desires for self-determination, traditional values, national needs, and by artificial homogenization of an ethnically and culturally heterogeneous population. The ideology was bent on de-differentiation. Furthermore, all the human and material resources belonged to the state, which in fact became the ruling group. These were used to form the regulatory structures for the assignment of training and disciplining of the workers in order to achieve pre-established economic goals that the state needed for its survival. The people were supposed to serve either the state or its leaders. Dependency on a monarch was supplanted in totalitarian communism by a dependency on the state, which was personified by an absolute dictator, who was the head of the Communist Party. His power consisted in control of the politburo, which represented a small group that administered the entire political system (Cohen, Ettin, and Fidler 2002). THE CONCEPT OF “SOCIAL/CULTURAL TRAUMA” Nowadays, modern social theorists have extended the application of the concept of trauma from the individual psychological trauma to the field of

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social sciences, where a social trauma is seen as “trauma in a whole culture” (Gailienė 2015). A cultural trauma means a terrible historical event or process that results in a permanent change within the group consciousness. The effect is a changed memory and identity. It can hit a society, groups within a society, or a prevailing culture (Alexander et al. 2004; Gailienė 2005). The effect of such a potentially traumatic, historical disaster, or process of largescale social change or repression, sometimes functions only as disorientation. But this, however, can develop further, depending on individual and/or social factors, into a major social trauma (Alexander 2004; Sztompka 2000) that “alters the basic structure of the cultural system as a whole. . . . Cultural trauma disrupt the continuity of the collective memory and the transfer of historical memory from generation to generation, as well as relations between the family and society, and between different social groups and generations” (Gailienė 2015). Thus, the traumatic feelings are not only generated by the possible traumatic events, but also from the anxious feelings that arrive as a result of keeping such feelings suppressed. “Trauma is overcome when repressed memories are integrated into the collective consciousness” (Gailienė 2015). The problem of such social traumas is that these can, on occasion, be of long duration, sometimes over decades and generations. Such cultural traumas and consequent disintegrations can have a variety of effects on individual people. Some of the ways in which social upheaval on the level of historical trauma (in the case of Germany’s two world wars, together with the effects of the Nazi and the Communist totalitarian systems) may affect the individual will be shown in the following chapters. The important and interesting questions asked by Dr. Wallerstein—a psychoanalytic commentator on the psychiatric patients in my first book, Psychotherapy in the Wake of War (Huppertz 2013)—as to whether there might be a link between the passive inhibited character constellation of those patients and their exposure to authoritarian regimes will be explored in subsequent chapters. The patients in the present book are even more obviously traumatized, with fuller clinical psychopathology. Nevertheless, it is important to consider that many other people never referred for psychiatric treatments may have developed subclinical personality characteristics and symptomatology similar to those I shall describe. REFERENCES Alexander, Jeffrey. 2004. “Toward a Theory of Cultural Trauma.” In Cultural Trauma and Collective Identity, edited by Jeffrey Alexander, Ron Eyerman, Bernard Giesen, Neil Smelser, and Piotr Sztompka. Berkeley: University of California Press.



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Alexander, Jeffrey, Ron Eyerman, Bernard Giesen, Neil Smelser, and Piotr Sztompka, eds. 2004. Cultural Trauma and Collective Identity. Berkeley: University of California Press. Cohen, Bertram, Mark Ettin, and Jay Fidler. 2002. Group Psychotherapy and Political Reality: A Two-Way Mirror. Madison, CT: International Universities Press. Cohen, Bertram, Jay Fidler, and Mark Ettin. 1995. “Introduction: From Group Process to Political Dynamics.” In Group Process and Political Dynamics, edited by Mark Ettin, Jay Fidler, and Bertram Cohen. Madison, CT: International Universities Press. Ettin, Mark, and Bertram Cohen. 2003. “Working Through a Psychotherapy Group’s Political Cultures.” International Journal of Group Psychotherapy 53 (4): 479–504. Ettin, Mark, Jay Fidler, and Bertram Cohen, eds. 1995. Group Process and Political Dynamics. Madison, CT: International Universities Press. Gailienė, Danutė ed. 2005. The Psychology of Extreme Traumatization: The Aftermath of Political Repression, Genocide and Resistance. Vilnius: Research Center of Lithuania. ———. 2015. “Trauma and Culture.” In Lithuanian Faces after Transition: Psychological Consequences of Cultural Trauma, edited by Danutė Gailienė. Vilnius, Lithuania: Eugrimas. Huppertz, Bernd, ed. 2013. Psychotherapy in the Wake of War: Discovering Multiple Psychoanalytic Traditions. Lanham, MD: Jason Aronson. Moses, Rafael. 1995. “Foreword: The Pitfalls and Promises of Group Psychotherapists Addressing the Political Process.” In Group Process and Political Dynamics, edited by Mark Ettin, Jay Fidler, and Bertram Cohen. Madison, CT: International Universities Press. Sztompka, Piotr. 2000. “Cultural Trauma: The Other Face of Social Change.” European Journal of Social Theory 3 (4): 449–66.

9 Sociohistorical Overview of Germany The Development of the Federal Republic of Germany (GFR) and the German Democratic Republic (GDR) Bernd Huppertz

HISTORICAL AND SOCIAL CONTRIBUTIONS TO CURRENT STATES OF MIND

The anonymized case histories and treatments recorded in this book come

from my work with patients in a particular context. The patients were all from the former German Democratic Republic in East Germany and were treated by me, a medical doctor from the former Federal Republic of Germany— West Germany, in the East Germany area. As will be evident in the case histories presented here, the turbulent and traumatic events in Germany’s history have had an intense impact on the daily lives and the inner worlds of those subjected to them, as it did on those of depressed and traumatized people the world over. CASE HISTORIES IN THE HISTORICAL CONTEXT OF TWO TOTALITARIAN SYSTEMS In this chapter, I hope to give a sense of some of the ways in which people who have lived under totalitarian conditions appear to have functioned. After the Nazi dictatorship, under which they experienced war, migration, and flight, my patients lived under the Communist dictatorship from 1945 until 1989, a system that attempted to penetrate every aspect of an individual’s life. During these forty years of the GDR, everything was extremely well organized “from the cradle to the grave.” Everything was in the power of the one party, the SED, and its police state organized by the Stasi. Under strict control—so-called Lenkung (guidance)—there was only one way possible, 115

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and no deviation from the norm was permitted. Here I would like to focus only on the “typical” results of repressive systems and how my patients experienced—either during or after these two totalitarian systems—war, flight, and migration, or other primary or secondary traumata. When I began to consider that I had focused relatively late in my work on the context of my patients in this respect, it became clear that one of the reasons was that my patients did not themselves seem to reflect on their own place—surely a traumatic one—in the context of a totalitarian society. On the contrary, they seemed to think of it as quite normal and unproblematic. It remained unclear for me for many years whether this position/stage was only an effect of socialization, in the sense of feeling this was “normal,” or whether it was a question of collective denial. This repression would then prevent mourning for the lost years under such a repressive regime. Thus, in reading the cases, you will notice that the patients’ own thoughts about this are missing. In all the hours of treatment, these thoughts were not spoken. When you read the case histories, it is essential, nevertheless, to bear in mind the traumatic German backdrop. “We cannot take the case history out of history, and . . . we cannot take history out of the individual case” (Lifton 2014). BACKGROUND: A SOCIAL HISTORY OF GERMANY This broad outline of recent German history, which infused the lives of the people with whom I have worked, gives a context to the treatments described in this book. For an overview of these issues, see Wehler (1987–2008). While some of my patients were traumatized by their experiences, either directly or intergenerationally, for others it simply remained the background against which they have lived their lives. In early times, living spaces for eating and sleeping and for human beings and their livestock were largely undifferentiated. Gradually over the centuries separated spaces evolved, and so did the furniture within these spaces, which had formerly been fixed to the structure of the house (Fuhrmann et al. 2008). Things were on the move, both physically and psychologically as well as politically. From 1800 onward, German society was marked by tremendous upheavals (Rosenbaum 1982; Wehler 1987a, 1987b). The economy struggled to provide for the needs of a rapidly rising population, as a result of early industrialization and the advances and revolutions in medicine, transport, and agriculture. The country at that time was divided broadly into three classes: the upper class, that is, the king and the aristocrats; the church; and the ordinary German citizen. It was largely a patchwork of small states, where the majority



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of people were agricultural laborers, and the working class served the needs of the masters. Ultimately, the pressure of these social problems led to the Revolution of 1848 and the formation of the Frankfurt Parliament. The Birth of the “New Era”

Following a subsequent counterrevolution in 1850 (Rosenbaum 1982; Wehler 1995), society continued to transform itself from a largely agricultural base. In the wake of the first World Exhibition, which displayed the very latest in industrial developments, modes of production and urbanization changed the face of society. The economy boomed, living standards improved dramatically, and there was general prosperity. These changes, however, brought in their wake new social problems and new class distinctions, based on wealth rather than birth. In the countryside, farmers and large landowners lived side by side with workers, who looked after their own small potato patches, and landless peasants, who provided piecework when needed (Rosenbaum 1982). The Aristocrats

As in all Western societies at that time, the upper classes possessed both political and economic power. They took up major military, judicial, and civil service positions, made tax provisions to suit themselves, and lived life according to their own social rules embedded in the developing constitutional state. These rules were especially embedded in the Sachsenspiegel, one of the oldest medieval law books; the Stein-Hardenbergschen Verwaltungsrformen, which reformed administrational practice; and the Preussisches Landrecht, which was a complete codification of civil, criminal, and public law. The Farmers

Meanwhile, in the small world of the individual village, a strict hierarchy was maintained between farmers and those who actually worked the land. The aim was to perpetuate what might be termed a family unit of household and production, where craftsmen and laborers provided the labor required in a landowning society, from those with large holdings down to those whose plots amounted to a few fields. On these family farms, which were nonspecialized and largely self-sufficient, there would be a considerable group of laborers and their wives and children, who from as young as ten years old worked the land and saw to the daily tasks alongside the farmers’ wives. It was vital to ensure continuity of land ownership, so marriage contracts were entered into with neighboring families. It was only after the Second World

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War that this picture changed. Two or three generations lived together in these almost tribal groups. The farmer’s wife was a key figure. As well as working and supervising in the house and garden, she made clothes and worked in the fields alongside the men. The farmer—the only one in this hierarchy to have political and legal power—worked in the fields and the woods, as well as for his local community, and bought and sold his goods at local markets. Children learned from an early age to herd cattle and to do other necessary tasks around the farm. They did not have much time to play, and if by the age of twelve there was no work for them at home, they were sent away to be servants elsewhere. Education for these children was rudimentary, and the only career choice on offer was to work in agriculture when they grew up. Sociological research has revealed that the farming community and rural society in Germany was divided roughly into three groups and subdivided into four regional types (Bohler and Hildenbrand 2006). The northwest was the area where the wealthiest farmers (Grossbauern) lived, alongside the less wealthy tenant farmers (Heuerlinge). The northeast was the area of landlords and their farm workers (Gutsherrn and Landarbeiter). In the southwest were gathered smallholders (Kleinbauern) and day laborers (Tagelöhner), and in the southeast what you might call the bourgeoisie of the farming class (Mittelbauern), with their servants (Gesinde). The Craftsmen

While life in the towns was beginning to thrive, and administration grew up around the growing structures they provided, craftsmen were busy developing both their skills and their business acumen (Rosenbaum 1982). Highly protective professional guilds ensured that traditions were maintained, standards upheld, and small businesses nurtured. It was a conservative world where new ideas were frowned upon. Apprentices had to serve under the master in their chosen profession for several years before they could officially enter the field in their own right, after obtaining a master’s degree. There was complete ignorance of modern management methods. Master craftsmen tended to live in rather cramped, rented accommodation for the whole of their lives. As in the countryside, the head of the household was the only one to have any legal or political rights, and many remained sole practitioners, rather than go through the procedure of taking on apprentices. The master craftsman’s wife had to have some rudimentary education and it was essential that she work to earn her keep as a married woman. Children, only given the most basic education, were usually apprenticed in their own turn by the time they were



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twelve. Before they went away, they had to work at home too and physical punishment for any misdeeds was considered the norm. By the beginning of the 1860s, there were more journeymen than master craftsmen, and these “Bonhaasen” worked on a freelance basis rather than being tied to a guild. A split developed between the two groups, and the master craftsmen were forced to fight for survival in an increasingly unregulated world. In country districts, self-employed craftsmen had to supplement their small incomes by taking on work as day laborers, either on the land or in the breweries. Thus, the split between traditional cottage industries and industrial production increased, in what could be thought of as the widening gap between pre- and post-capitalism, from feudalism to private enterprise. But demand for the work of craftsmen decreased in the face of the rise of industrial production, and cottage industries would not be able to exist for much longer. The Rise of the Middle Class

The eighteenth century had seen the beginnings of the rise of the bourgeoisie, later within a wider frame called the middle class, in other words, a new social class growing up between the very rich and the very poor. In Germany, this was the time of the biedermeier and the rise of the concept of romantic love. These educated, cultured bourgeois people were in themselves divided into higher and lower levels. At the top were the wealthy businessmen, entrepreneurs, writers, lawyers, academics, and religious leaders. Beneath them were the petit bourgeois, those who were occupied in trades of whatever size and description. Beneath them were the workers. The middle class were concerned to maintain their status, and education became a sine qua non for personal fulfillment. Increasing value was put on thinking and the interior life. It was indeed a combination of valued work and cultural accomplishment that became the hallmarks that separated the upper bourgeoisie from the aristocracy. Marriage and the rearing of children in the family became major concerns. Meanwhile some impoverished people still worked from home while the country gradually evolved from being a feudal to a capitalist state. As separation nevertheless increased between home and workplace, the woman became the center of the breadwinner’s life, and it was her responsibility to raise her children well. Opportunities for girls increased, but largely a woman’s only recourse in life was to marry. Children, previously considered merely as future adults, now became recognized as being central to a family’s emotional life. They were now encouraged to address their parents by the affectionate du rather than the formal Sie, were given their own rooms and separated from

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the servants. While boys went to school at the age of six, girls largely stayed at home to be educated in domestic science and their future roles as wives and mothers. As the importance of emotional life and relationships increased, so women were recognized as being central to this sphere. So now three new classes were developing. Prosperous professionals, bankers, civil servants, and the military were very clearly divided off from the blue-collar workers who were on the factory floor. Between them were the white-collar middle managers. By now, many old specialist trades had been taken over by mass production, although a few survived. The petit bourgeoisie were in a sense trapped between the world of big business and that of the organized work floor, occupied by the wage slaves of developing industries. Towns changed dramatically, becoming overcrowded and breeding social problems. This is, of course, the background that gave rise to such political thinkers as Marx, Engels, and Lasalle. Unification of Germany (1866–1871), the “Delayed Nation”

Finally, after three wars, the last of which was the Franco-Prussian war of 1870–1871 (Wehler 1995), Germany became a nation-state, following unification in 1871. From then on, Germany underwent profound changes, evolving from an agricultural to an industrial society. Unlike England or France—where an acting bourgeois class took control, as in the reign of Cromwell and the French Revolution—economic modernization in Germany took place under feudal conditions. The idea of a German nation developed much more slowly. While France and England had a parliament and kings or emperors, the German-speaking people lived in many smaller administrative areas, smaller kingdoms, as it were, not as one unified German kingdom. Consequentially, there was no sense of thinking as a nation. With the early stage of industrialization (Frühindustrialisierungsphase), industrial urbanization developed, and by 1871, about 40 percent of the total population lived in cities. The developing rail networks connected distribution centers throughout the country. Industrial cities inexorably grew, where gas, water, and electricity supplies serviced the factories and the workers. More and more people moved into towns—in total perhaps around 50 percent of the population was on the move. Nothing could now stop the migration from the land (Reulecke 1985; Rosenbaum 1982). During Bismarck’s chancellorship, the whole social and economic landscape was reformed (Rosenbaum 1982; Wehler 1995). Health insurance was introduced, together with a state pension, and there was an overall reform of the tax system. Under Bismarck’s leadership, the free trade policy was



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revoked. He introduced protectionism and fought for social policy in his own way in his struggle against the Social Democratic Party of Germany (SPD). However, when Kaiser Wilhelm II took up office in 1888, Bismarck soon resigned. Under Kaiser Wilhelm there grew much more of an interest in international politics, and Germany sought to establish overseas colonies and to build up a navy. As previously stated, the rise of the solid bourgeois class meant that they were now a dominant force to be reckoned with. The army and the officer corps under Kaiser Wilhelm’s command became much more dominant as a subclass. By now, the bourgeoisie were a solid and established social class whose power and influence were demonstrated by impressive property, grand houses, and many servants, including a governess for the children. Any selfrespecting family had to display itself at home and was also obliged to widen social contacts: wives had drawing room gatherings and men joined casino clubs. Summer months were spent traveling to seaside resorts where there were also casinos and racecourses. The now necessary cost of educating one’s children increased. As the speed of industrialization increased, so did the power of industrial entrepreneurs, bankers, and businessmen. As people flooded into the towns from the countryside to support the new ventures, the transformation from an agrarian to an industrial society was complete. It was a revolution. The development of urban infrastructures, communications, and increased capital investment also brought refrigeration, canned food, and mass production of clothing, and restaurants and canteens sprung up in the early 1900s. The road was now fully paved, as society developed from complex traditional communities to nuclear families. The majority of the population nevertheless still lived in poverty, in small one- or two-room houses or apartments, often also with night lodgers (Schlafgänger) (Mooser 1984). It was only the rise in bourgeois living that created the idea of separate living spaces for house owners and their servants. Even here there was little modern sanitation and scarce electricity or central heating. Urbanization was on the rise however, and by 1914 over 60 percent of the population lived in towns and had achieved greater social mobility (Reulecke 1985). First World War (1914–1918)

After the assassination of the Austro-Hungarian archduke in 1914 in Sarajevo, Serbia, the First World War started (Wehler 2003). This was a war on two fronts: against Russia on one side and Belgium, Luxembourg, France, and Britain on the other. When in 1917 unrestricted submarine warfare began,

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the United States joined the war too. Clearly, this conflict was not going to be won by Germany. There were many victims as a result of the Allied blockade, and economic problems escalated. An “Auxiliary Labor Law” came into being and a Joint Committee was created in order to build a responsible parliamentary government. Imperial Germany was collapsing and fundamental reforms were urgently needed. The aristocracy had lost their old power and the formation of a newly structured class society meant that it was inevitable that this would happen: constitutional monarchy and parliamentary government took over. After the 1918 Revolution and the Kaiser’s abdication, a federal German Republic was founded. Then followed an armistice, and with the Treaty of Versailles in 1919 the war was over. The 1914–1918 war was the first industrialized war, waged on a large scale, and it exacted a heavy toll. Thousands were killed in huge battles and this brutal mass destruction traumatized and numbed people. By the end of the war in Germany, approximately 2 million people had been killed and 4.3 million wounded or injured by gas attacks. There were around 500,000 widows and over 1.2 million orphans, as well as 1 million German prisoners of war. The Weimar Republic (1919–1933)

After elections in January 1919, the Weimar Republic was founded. The state was heavily indebted in the 1920s because of the high costs of repairing war damage, inflation was dangerously high, and there was a similar dangerous level of discontent among working people. Nevertheless, the structure of the existing social hierarchy remained remarkably resilient throughout the depression and the world economic crisis, despite mass unemployment. The Weimar Republic failed because of the inability of the parties to enter permanently in a parliamentary-democratic process. Postwar society in the Weimar Republic was marked by rapid changes. No longer were those of noble birth accorded automatic privileges, only the large-scale farmers (Grossagrarier) and members of the officer class still had influence. For the most part, the educated and cultured bourgeoisie (Bildungsbürgertum)—the judges, lawyers, teachers, journalists, writers, and artists—had lost their capital during the war, as well as their ability to earn to their previous capacity after the war. The petit bourgeois (Kleinbürgertum) also suffered severe setbacks. Small tradesmen were badly affected: as old crafts gave way to industrialized processes, there was high unemployment. The only ones who gained were the large and middle-rank farmers (Vollbauern and Mittelbauern), who benefited from the increased prices in food. There were radically different life experi-



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ences between this wealthier class and its subdivisions and the six million landless peasants and servants who struggled to keep themselves alive after the war. About a third of the total German workforce worked on the land at that time, dependent on part-time work when they could get it. The global crisis in agriculture in the 1920s did not bring about any structural transformation, but there was nevertheless a demand that agricultural workers should be protected and that the industry itself should be prevented from further decline. Agricultural workers earned about half the wage of industrial workers as the rural economy dwindled. This caused mass protests and threats of open revolt. The war years had caused mass hardship for the blue-collar workers too, especially those working in trades, transport, and domestic labor (Mooser 1984). Over 60 percent of them ended up living in small towns. After the 1918 revolution, there had been a steep increase in their wages, but in 1924, there was another huge rise in unemployment. Trade unions were growing, both in size and power, and had developed a proletarian subculture (Arbeiterschaft). White-collar workers too—industrial, commercial, and state employees—were striving to improve their positions with such innovations as regular monthly salaries and paid holidays. The higher echelons of the bourgeoisie (Wirtschaftsbürgertum) with their upwardly mobile aspirations continued to grow and thrive (Wehler 2003). Council housing was introduced and people dreamed of garden cities with all modern conveniences. Yet some people remained homeless, or else gathered together in small settlements in order to earn their livings as best they could. This was a situation where hyperinflation brought both recovery and also painful deprivations, which resulted in the world economic crisis and mass unemployment. By 1920, there was no consensus between the parties of the Weimar coalition, the Weimar Republic was in decline, and Nazism and communism were on the rise. People became more and more attracted to the ideas promulgated by the NSDAP (Nationalsozialistische Deutsche Arbeiterpartei), and by 1933 the party only needed some seats in order to attain an absolute majority. The era of “the German Millennial Reich” had begun. Nazi Dictatorship (1933–1945)

These difficulties set the scene for the rise of Hitler, who was elected chancellor in 1933. Professional organizations were now under NSDAP control, and this had a profound effect on the whole country. The aim of National Socialism was to create a harmonious “racial community.” Road construction, the manufacture of armaments, and the creation of new government buildings aimed to put the whole country back to work. While an economic recovery

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followed, there still remained the pressing problem of the shortage of foreign exchange. The so-called question of “Lebensraum”—the creation of space for Germans, and the provision of raw materials and food—resulted later in the outbreak of World War II in 1939. From 1933 onward, all German social classes existed under the sway of this policy. Charismatic domination and totalitarian dictatorship were merged in this new regime. The ideals of socialism were now limited to the boundaries of the nation: the aim was that a German people of pure Aryan race should arise. The Nazi regime was aided in this aim by the collapse of the Weimar Republic, and there was a growing feeling that equality should be the watchword. People should rise on their merits rather than because of class distinctions, in the move toward this “association of Aryan Volksgenossen.” It took only three years for the Depression and mass unemployment to be overcome, in this new conjunction between the party and the state. For the bourgeoisie and educated and cultured people, life went on largely as before. But anyone who dissented or happened to be of Jewish descent became more and more isolated and displaced. Thousands of democrats were removed from their professional positions. So-called antisocial elements received “special treatment” with the rise of labor and concentration camps. Thus, while entrepreneurs were thriving under this “BetriebsführerIdiologie,” others were inexorably being cut off from democratic processes as the functions of the state extended. Thousands of jobs seemed to spring up suddenly for the petit bourgeois and the number of white-collar workers rose to over four million. Farmers became celebrated as those who provided the food for this new millennium: they were the true “Lebensborn” of the nation and underpinned its success. Many of these ideas about purity and supremacy were very attractive, particularly to young men, who were especially vulnerable to Hitler’s ideas. By now, the National Socialist miracle recovery was well under way: incomes rose and even relatively low-paid workers could buy radios, save for their Volkswagen cars, and go traveling. There was a fixed-wage policy, and union power had been destroyed. In its place, the DAF (Deutsche Arbeitsfront), the National Socialist trade union organization known as the German Labor Front, controlled the entire situation. The party oligarchy of the NSDAP (Nationalsozialistische Deutsche Arbeiterpartei) merged with the traditional power elites and there evolved an ever-stricter discrimination between those in agreement with the Nazi ideals (Volksgenossen) and any “others” (Gemeinschaftsfremde). The NSDAP rose over time from seven hundred thousand party members to about seven and a half million. Now two and a half million men were in party uniform, allied with the top positions of the Nazi organizations. There were concomitant



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adjustments in the power base. The NSDAP regime exerted control of the press and other media and the membership of the officer corps grew almost as much. As for women, they were to carry on the pure bloodlines and look after the children and the home, although because of labor shortages, they also worked outside the home and calls for more emancipation grew. Small housing settlements (Kleinhaussiedlungen) were promoted, with the idea that people should once again be rooted in a secure base. “German style” furniture was manufactured, and more building was encouraged. Everyone between the ages of ten and eighteen had to belong to the Hitler Youth organization, which held mandatory meetings twice a week. Loyalty to the Imperium, the Third Reich, was imperative (Wehler 2003). Second World War (1939–1945)

Between the Treaty of Versailles in 1919 and the end of the war (1945), Germany had undergone an unimaginable process of upheaval and change. The German occupation of the Rhineland in 1936, which had been demilitarized since 1919 by the Allies, followed by the annexation of Austria in 1938, heralded the beginning of the Great German Reich. This power base increased with the later annexation of the Sudetenland, absorbing the Germanspeaking people from northern Czechoslovakia, followed by the destruction of Czechoslovakia, the annexation of the Memel area, and the war with Poland. Then Alsace-Lorraine and Luxembourg were annexed, Belgium occupied, and Holland taken into German control. Following the Hitler-Stalin pact, Yugoslavia and Greece capitulated. The attack on the Soviet Union took place in June 1941, resulting in exploitation, enslavement, and annihilation. It seemed to be an inexorable march and, at this point, the Third Reich dominated millions of people. After the occupation of Poland, so-called foreign workers (Fremdarbeiter) were carried off for forced labor in Germany. This nation of leaderless Polish workers provided new slaves for the Master Race (Herrenrasse). By 1944, over 7.5 million foreign and female workers, more than 5.5 million other civilian workers, and about 2 million prisoners of war lived in the German Reich. This new sub-proletariat needed new inspectors and supervisors. Following the ethnic cleansing of the Slavic peoples, there was more settlement in the annexed areas of West Prussia and the so-called Reichsgau Wartheland. The residual Polish area in the south came under German administration and was the first established colony of the Reich, with more than ten million Polish citizens, the “Generalgouvernement.” At the beginning of 1940, the occupied territories were rendered “free” of Jews, and the Holocaust was on the road. Systematic industrialized murder of Jews, gypsies, handicapped people, Poles, and Russians began.

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In December 1941, Hitler declared war on the United States. The end of the North Africa campaign began at the end of 1942, and in the east, the battle of Stalingrad saw a turn of the tide. The landing of the Allies in Normandy in June 1944 was the beginning of the end for Hitler and for Nazi-Germany. Hitler finally committed suicide, and in May 1945, Germany surrendered. By the end of the war there were more than 55 million people dead or missing, both soldiers and civilians, particularly racially and politically persecuted people. Altogether, more than 24 million soldiers and more than 23 million civilian victims were killed in battle, murdered, or went missing. Of these, there were more than 5 million Jews, more than 5.5 million Poles, and more than 25 million Russians. The End of the War 1945

After the war, Germany was no longer dominant in Europe. The country was bankrupt, in ruins, under four-power control, and full of terrified people. There were millions of refugees, homeless, and displaced persons, indeed up to one hundred million of them. These were comprised of German-speaking people who had lived in Eastern European countries before the war, the socalled Volksdeutsche, German foreign workers, prisoners of war, soldiers, displaced persons, refugees, and those who had been evacuated. This led to increasing social problems over subsequent years. Silesia, East Prussia, and Pomerania were given over to the Russians. Many fathers never returned home and refugees and displaced people moved throughout the country in fear and bewilderment. The final death toll for Germany itself was around nine to ten million people, victims of war or the consequences of war. And Red Army reprisals resulted in more death as well as a stream of refugees from the Soviet occupation zone, with a flight to the West before the Red Army’s orgies of revenge began. Costs rose steeply after the war ended. There was loss of land, loss of resources, and the escalating costs of reparation in a country torn apart both externally and internally. From 1945 to 1989 about $30 billion were needed—over $12 billion from the West and more than $18 million from the Eastern Bloc—to repair the damage. Germans were expelled from previously occupied territories, and Germany itself was divided by the occupation authorities into four zones, controlled by the Russians, the British, the Americans, and the French, respectively. The frontiers were moved, and these arrangements were subject to further revision after a peace treaty, when Germans in the east would be permitted to return to the rest of Germany as it had been configured before the war. The Allied Control Council demilitarized the whole country, and there was long-term food rationing. The process



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of “De-Nazification” was pursued to different degrees in different zones, and frontiers were redrawn so that Germans could resettle in their old lands. The pressing need to rebuild this shattered land overcame and buried feelings of guilt, and this was something that the Russians used in order to advance their own communist agenda. A number of parties were founded in Germany at this point: The Christian Democratic Union (CDU), the Bavarian Christian Social Union (CSU), the Social Democratic Party (SPD), and later in 1948 the Free Democratic Party (FDP), which was a unification of a number of local liberal parties. Prior to this, however, the Communist Party (KPD) had been reconstituted in 1945. In 1946, a breakup occurred between the Allies, and the inevitability of the longterm division of Germany became a fact. The Soviet authorities continued to exert massive pressure, and in 1946 the Socialist Unity Party (SED, Sozialistische Einheitspartei Deutschlands), a unification between the KPD and the SPD, was founded in the Soviet zone (SBZ). Other parties were there permitted to exist as long as they agreed to concede final authority to the SED. June 1947 saw the emergence of the U.S. “Truman Doctrine,” which promised economic and military aid to all those resisting communism. Europe joined in with their support, and as a direct response to this, the Soviet Kominform was formed. A European military alliance, the Western European Union (WEU) caused the Soviets finally to withdraw altogether from the council and the four-power control arrangement ended at that point in March 1948. The situation continued to be fraught with political divisions and various plans, culminating in the Marshall Plan of 1947, which supported “Trizonia” (the British, French, and the American zone). The SBZ were forced to pay a much higher reparation price to the Soviets than the western zone paid to the Western Allies. The result of this was that East Germany had no money left over for development purposes. In 1948, the German Mark was introduced in “Trizonia,” whereupon the Soviets introduced a different currency in their own zone and in Berlin. This was followed by the drastic action of the Berlin Blockade, where two million Germans were threatened with starvation as all access to the western section of Berlin was cut off by the Soviets. The Berlin Airlift subsequently came to the aid of the beleaguered population for eleven tense months. An end came one month after the foundation of NATO (North Atlantic Treaty Organization). The Division: Federal Republic of Germany (FRG or BRD) and the German Democratic Republic (GDR or DDR)

During this time a “basic law” (Grundgesetz) was established in the western zones by the Parliamentary Council, which was elected by the provincial

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governments (Wehler 2003, 2008). Bonn became the capital of this new dispensation, and in May 1949, the Federal Republic of Germany (FRG) was founded, which was later under the leadership of President Heuss, Chancellor Adenauer, and Ludwig Erhard, who created the “social market economy.” Development of the German Democratic Republic (GDR or DDR) (1949–1990)

For years following the end of the war, society continued, under the auspices of the SBZ and GDR, to be in a state of near collapse. Displaced persons and refugees still made up nearly a fifth of the total population. The German minorities in eastern and southeastern Europe, who were not able to stay in these countries, became known as “Umsiedler” because it became taboo to use the term “refugee.” Anarchy ruled, with no food and communications to speak of, no effective administration, and no control of the constant terror of the Red Army and what they might do. When in time the Soviets finally realized that there was no chance of establishing a united Germany under their own leadership, they opted instead to establish their own communist regime in the SBZ, the SED dictatorship. This had already begun in the spring of 1945. In June of the same year, the SMAD (the Soviet military administration) brought the Communist party of Germany (KPD) into being. Meanwhile the Red Army continued their orgy of mass raping and looting. Already in September 1945, the so-called land reform proceeded with the same steely determination. Over seven thousand landowners—including those with more than one hundred hectares—lost their lands without compensation; all state and Nazi farms were also confiscated. Thus, 35 percent of all the land was taken immediately into party control. It was then distributed to 250,000 new farmers (“Neubauern”), peasants, and displaced persons. These farms, however, were not large enough to make a living for a family. Industry was nationalized, and banks and insurance brokers too were brought under state control. All property and goods of war criminals were automatically seized. This amounted to some ten thousand holdings and formed around 40 percent of the East German industrial base. It was intended that all this would lead to the creation of a socialist society and would include reparation to the Soviet Union. The German Communist party leadership expanded and the SMAD and KPD put pressure on the SPD to merge with the KPD. In April 1946 in the Soviet zone (Sowjetische Besatzungszone, SBZ) a new party, a socialistic union party, the SED (Sozialistische Einheitspartei) was founded as the vanguard of the proletariat. The same draconian rules held sway: a rigid hierarchy with all orders descending from the central group, no subgroups



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to be formed, and all voting to be unanimous. In a new “cleansing,” many former SPD members were expelled until only a small group of their former members remained. This was a wholesale political rebuilding of East German society, on the road to Stalinist “Volkdemokratie”—an ironically titled people’s democracy where the centrally planned economy actually took no account of the will of the people. The KPD and SMAD plowed on with their project of the “Entnazifizierung,” and by August 1947, over five hundred thousand people had lost their jobs. More than ten thousand members of the SS, the Gestapo, and the NDSAP had been convicted and over one hundred individuals had been put to death. This was all done with barbaric determination. The Soviet internment camps were full of Nazi suspects and at least seventy thousand people in the German Gulag died of illness and starvation or were simply either deported or murdered, guilty or not guilty, either real or alleged Nazis. A People’s Council of Germany convened in June 1948, and a Constitution for all of Germany was worked out. Though this could only actually apply to the area of the SBZ, it was nevertheless adopted on May 1949. After the Allies recognized the Federal Republic of Germany as a semi-sovereign state on September 1949, a state known as the German Democratic Republic (DDR) was formed and a constitution was passed on October 1949. Wilhelm Pieck was elected first president and Otto Grotewohl first minister-president. Thus two separate political entities were formed: the Federal Republic of Germany (FRG or BRD) and the German Democratic Republic (GDR or DDR). The DDR was seen as a provisional state like the FRG, but it had more rural areas than the FRG and a significantly higher proportion of farm workers, specifically in the Ostelbien region. Historically, this area of the GDR was known as the German “new tribe” area (Neustammgebiet). During the twelfth and thirteenth centuries some one hundred thousand people in the countries east of Elbe, Saale, and Umava, had arrived from the German old tribe area (Altsiedelland) and mixed with the local inhabitants (Dralle 1991). The huge reparation payments and dismantling of the Soviet zone (SBZ) led later to a bleeding to death of the GDR, while in the FRG, on the contrary, dismantling resulted in an unprecedented phase of modernization (Wehler 2003, 2008). An overarching trade union (Einheitsgewerkschaft), the free German trade union federation (Freier Deutscher Gewerkschaftsbund, FDGB), the Free German Youth (Freie Deutsche Jugend, FDJ), the German culture union (Kulturbund, a mass cultural organization), and the German women’s union (Deutscher Frauenbund) were the necessary official mass organizations—institutions of the state’s authority—set up to organize so-called spontaneous demonstrations in order to underline the regime’s power. Any free ideas,

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free speech, or free meetings were forbidden. Every sector of life had to be controlled. The SED dictatorship became a single-party dictatorship that worked together with the occupying Communist regime, as a product of them. Because there was an absolute unwillingness for the Eastern Bloc to abandon this nexus of power, which was of course completely incompatible with the aims and political structure of the Western zone, there had been wholesale killings of those opposed to the regime, as well as those who had previously been in power. The Soviets possessed a single mindedness that enabled this to take place with no compunction on their part. After the process of “deNazification,” a centralized administration of faithful state employees was installed, replacing old workers with new: judges, teachers, and other officials were all replaced. Any form of resistance by other political forces outside the SED and the mass organizations of its allies were vigorously suppressed. The SED reigned supreme, undisputed, and omnipotent. A new corps party (Kaderpartei) was adapted according to the Soviet model. All social forces had to conform and be brought into line, under the control of the German Bolschewiki. A dictatorship with a centrally planned economy was installed without the democratic consent of the people. In 1950, the Waldheim trials against war criminals summarily sentenced over thirty people to death and over twenty of those were actually executed. All aspects of life in the GDR were now tightly controlled by the privileged state party, the SED, via the Central Committee (Zentralkommite, ZK) with a powerful secretariat and a “Politbüro.” The SMAD (Soviet military administration) was dissolved and transformed into the new Soviet Advisory Committee. In 1950, the SED created a ministry of State Security (MfS, Ministerium für Staatssicherheit, or Stasi) whose instruments of suppression issued in a direct line of command from the politburo: show trials immediately followed. A heavily armed People’s police (kasernierte Volkspolizei) was, in effect, the new GDR-military. By 1950, its numbers had swelled considerably. The personality cult of Stalin continued up to his death, and his terrorist methods were readily adopted. The 1950 “election” (Einheitslistenwahl, where only one party could in fact be chosen) allegedly obtained more than a 99 percent majority for the sole party registered. This of course meant an absolute majority for the SED. The non-Communist parties were permitted to remain solely in order to provide a show of “democracy” rather than to exist as any real force in society. The new mass organizations became carbon copies of the SED in their principles. The SED’s aim was to create the perfect man, the new Adam, in order to build up a total classless communist society. During the following years, the DDR was consolidated as a one-party Stalinist dictatorship based on the Leninist principle of “democratic central-



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ism” with Ulbricht at its head. The “People’s Democracy” was quickly transformed into a one-party dictatorship and the SED and state became a single entity. In 1950, following Ulbricht’s election as secretary-general of the SED, a five-year plan was announced, with the aim of doubling the industrial production of the DDR. In 1952, almost all industry had been nationalized as the “Publically Owned Enterprises” (VEBs, Volkseigene Betriebe). What this actually meant for most people was that there was a chronic lack of raw materials and consumer goods were scarce, prohibitively expensive, and of extremely poor quality. Bourgeois children were barred from all forms of higher education, and the new faculties for Marxism-Leninism and “Scientific materialism” were founded at the universities. Although many people were also fleeing wholesale from the DDR, the industrial demands were increasing there. People were forced to work even harder for the same pay. On June 17, 1953, the first mass protest against the Communist regime was organized. The tanks rolled into Berlin, demonstrators were killed, and thousands were arrested. The DDR became more than ever a police state. A “cleansing” of the corps and functionary apparat followed, with more huge changes in the SED party leadership. The year 1954 brought the Paris treaties. Rearmament was ratified, and the Federal Republic joined the WEU, subsequently joining NATO in 1955. The Soviet Union responded by forming the Warsaw Pact. It was clear that the division of Germany was now accepted by both sides in the Cold War. The Soviet Union granted the DDR “full sovereign rights,” and in January 1956, the moderately armed police force was formed into the National People’s Army (NVA) and integrated into the Warsaw Pact. Military education took place in schools and universities alongside sports and technology, as well as among the millions of FDJ (Freie Deutsche Jugend) members. SED members had to go through a quasi-military training and form fighting groups (Kampfgruppen, KG) in anticipation of internal conflict in the country. By the 1980s, around 10 percent of the whole adult population was involved in military and paramilitary organizations, needing more than 10 percent of the state budget for their maintenance. The NVA expanded and was particularly reliable in its staunch protection of the Communist regime. The SED was preparing for the advent of some kind of class warfare, for war against the class enemies, if not for total rebellion. All the various instruments of suppression were linked directly to the politburo in order that total control should be maintained. The Stasi’s surveillance and direct intervention intruded deep into the heart of society. Any “dangerous critic” or commentator of the current regime was immediately criminalized and sent to jail. Around one in sixty members of society was either a formal or informal employee of the Stasi, offering information to the officials

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about neighbors, work colleagues, and even a husband or wife. In all, more than three hundred thousand people were subjected to interrogation, torture, and imprisonment in the red Gestapo’s grim prisons. It was a painful and intolerable situation. A climate of fear ruled over ordinary people’s lives. The Stasi were omnipresent, using the Soviet style of control. In effect, any good that might have been obtained by a socialist policy was entirely overruled by this brutal and oppressive regime. In October 1956, the Hungarian uprising occurred, which was summarily stopped by tanks. Many Hungarians then fled to the West. After the de-Stalinization storm, Ulbricht was in full command. The economy was steadily improving, and the majority of people had come to terms with the regime, even though the stream of refugees remained huge. At the end of 1958 came the “Berlin Ultimatum.” After the fifth Party Congress of the SED in 1958, the process of collectivization was completed, and by 1961, almost 90 percent of the farmland was in the hands of the Agricultural Production Cooperatives (LPGs). A large number of small enterprises was nationalized, and over two hundred thousand people left the DDR in 1960. Refugees continued to flood to the West, and the East German economy was on the verge of collapse. Eventually the Warsaw Pact allowed Ulbricht to seal off West Berlin with an “antifascist defensive wall” on August 13, 1961. Thus, the mass flight was forcibly ended, and now two societies were firmly established, growing steadily apart from one another. Each took on a distinctive identity, separated by barbed wire, minefields, and machine-gun posts. In 1963, West Berliners were at last permitted to visit East Berlin. In the same year, a “New Economic System for Planning and Direction” (NÖSPL) was proclaimed in the DDR. It allowed the use of “economic levers,” and even profit, to bring a degree of flexibility into the planned economy. A degree of decentralization was also permitted, and thinking based upon concerns of efficiency and performance was introduced. After this, the economy improved substantially. The DDR also began to see a revolution of young people, as was happening at the same time in the West, and this culminated in the “Beat Demonstration” in Leipzig in 1965. Ulbricht’s concept of a “socialistic human community” (sozialistische Volksgemeinschaft), with a degree of social security traded for a loss of freedom, ruled ever more extensively. But East-West relations were once again put into a deep freeze after the Soviet intervention in Czechoslovakia, crushing the “Prague Spring” in 1968. In 1971, Ulbricht was replaced by Honecker as leader of the DDR. Honecker dropped the “socialist economic system” idea, and in a new five-year plan, he aimed to improve the living standards of the whole population. The



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new Soviet leadership under Brezhnev ordered the removal of Ulbricht’s system, yet again putting policy above the economy and the needs of the people. The DDR returned to a system of rigidly centralized planning. An attack began on the last remaining vestiges of private enterprise, and small independent businesses were converted into “Publically Owned Enterprises” (VEBs). A disastrous drop in productivity was the result. In West Germany, Brandt became chancellor in 1969 and had his own Ostpolitik. He proposed to Stoph, the chairman of the DDR’s Council of State (Staatsrat), that normalization of relations should be established between the “two German states.” Each state now accepted the existence of the other. In 1970, a treaty outlawing the use of force in a revision of the Federal Republic’s frontier with the DDR was signed. In the same year, there emerged a treaty about acceptance of the Oder-Neisse frontier with Poland. In 1971, a four-power agreement about Berlin was signed, which guaranteed unhindered passage between the Federal Republic and West Berlin. The three Western powers nevertheless insisted that West Berlin was not to be considered as an integral part of the Federal Republic. A treaty ratified in 1973 further paved the way toward recognition and eventual integration. The oil crisis also had a shattering effect on the GDR’s economy. Mounting economic problems led to increasing criticism of the regime’s ossified ideology and to the rise of dissident elements. After the Helsinki agreements, dissidents and political criminals were allowed to leave the DDR on receipt of a handsome payment from the Federal Republic. The DDR had increasing trouble with their critics, and Honecker, like Ulbricht before him, tried to offset ideological rigidity by concentrating the economy on the production of much sought-after consumer goods, such as cars and washing machines. But the DDR was nevertheless on the verge of financial collapse. When the last of the gerontocrats of the Soviet Union died, Gorbachev took over the reins of power. He reopened disarmament talks in Geneva and reached an agreement on intermediate-range missiles. Something had to be done to stop the Soviet Union’s decline. Openness (glasnost) and restructuring (perestroika) followed. In 1988, Gorbachev disowned the “Brezhnev Doctrine” and allowed the members of the Warsaw Pact a degree of freedom to do things their own way. In Hungary, reformers came to power, and Poland too seemed to start a process of genuine democratic reform. But in the DDR, any sign of opposition was still suppressed. Radical Changes in Class Structure in the GDR

Although in the mid-1940s landowners had been stripped of wealth and power alongside industrial chiefs, what arose in their place was a new kind

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of power base, where acquisition and control still obtained, but under a different name. A New Ruling Class, the Monopolelite

Top of the tree were the Monopolelite of the SED, who controlled the entire means of production in the whole country (Wehler 2008). This comprised five hundred to six hundred members, with a leadership of less than fifty. It included the members and candidates of the ZK, the heads of the ZK-apparatus, the first secretaries of the district boards, and members of the supreme boards of the mass organizations. This represented both control by a dominant class and also something that functioned as a collective enterprise. A so-called Kompetenz-kompetenz had oversight of the project. Thus, it is clear that a very small amount of people managed to retain the right to control production and workers in an absolute way. While there were still pockets of acquisition and some remnants of the professional classes, these were all strictly controlled by those now in power. The SED were the supreme masters of the project and sixteen million East Germans lived within a rigid, planned, Soviet-type economy. The party heads grew older, and over the decades, the country was run by a group of steadily aging leaders. The mass organizations under control of the SED were the trade union, the Free Trade Union Federation (FDGB), the Free German Youth (FDJ), the German culture union (Kulturbund), and the German women’s union (Deutscher Frauenbund). Administrative and Operative Service Class (Dienstklasse)

Second in the hierarchy of power came the “administrative service class” (Administrative Dienstklasse), which had to put all these plans into action both at state and local level. They comprised various organizations, such as the State Planning Commission and the Volkskammer (akin to a parliament), as well as various conglomerates made up of lower-ranking Stasi officials, mass organizations, and scientific institutes. Just below the upper echelons of the “administrative service class” came the “operational service class” (Operative Dienstklasse), former middle managers who now comprised one element of the two hundred fifty thousand people who were part of the party or state apparatus in this huge socially owned enterprise. They included professors, doctors, engineers, and teachers, as well as highly specialized state employees (Staatsangestellte). Just below them came the administrative staff, alongside the rest of the scientific staff of the universities and research institutions.



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The chief requirement for these jobs was absolute loyalty to the party cause, whatever this might entail. A vacuum was created as people either fled or were eliminated if they did not conform to this ideology. Thus, there was a huge upwardly mobile population as people rose to fill the vacuum, and this in turn created another huge social upheaval, this time in an upward direction, with a comprehensive change of the elites (Elitenwechsels). A few years after the building of the Berlin Wall, some 80 percent of the so-called new intelligentsia, “Neuintelligenz,” had been trained in this system of state Communism. People rose with great rapidity up the career ladder, but this then left a vacuum lower down, and efficiency and output were consequently reduced. This was reinforced by the very low wages at the level of actual production. These new intelligentsia were now in management positions of the operational service class, enjoying such perks as cars, better living conditions, and access to Western consumer goods. Thus, they were held hostage by their good fortune, and this prevented their flight from the Republic. The Working Class, Industrial and Agricultural

At the bottom of the social heap came the industrial working class, ironically those who were supposed to be the most privileged under the new “socialist” system. In reality, they were excluded from all forms of control in society, even though as a whole they made up three-quarters of the entire GDR. They included not only white-collar employees, but also Stasi security staff, those in the defense industry, miners, and the leaders of social organizations. This constituted about 55 percent of workers. Before the building of the Berlin Wall, there had been a mass exodus of the population, and thus women were the only group available to fill the gap. By 1989, over 90 percent of women were employed. For a working week of just over forty-three hours, they received less than half of what those working at the same jobs in West Germany received, with their pension rights diminishing to a third of that of their counterparts on the other side of the Wall. Every aspect of people’s lives was strictly regulated in the name of “egalitarianism.” Banned travel to the West meant that people were in effect prisoners in their own country, where everything from kindergartens to holidays were strictly overseen by the State. This was the forced equality in this socalled socialist society. The work ethos was dominant, and the various newly formed brigades were local substitutes of the trade union. These small units were multifunctional organizations, acting as social controls, educational tools, and communication centers. They regulated management conflicts, organized health care, child care, and accommodation, as well as holiday and

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leisure planning. Almost all those employed were controlled by the FDGB, state, and party. Such control applied to nursery school, kindergarten, grade school, and after-school care. When a working woman gave birth, she could—or even had to if she wished to remain professionally employed—send her newborn baby to an external daycare facility at the age of eight weeks (after 1972 at the age of twelve weeks), where it was cared for and looked after. Such facilities included a day nursery (from 6 a.m. to 7 p.m.) or a weekly nursery, from when the child is six months to three years of age (from Monday mornings to Friday evenings). The daily flow there was structured around cohabitation, with an emphasis on the collective. In accordance with state regulations, everything was regimented, disciplined, and done collectively. This even included toilet training, where children would sit in line on their potties and await their turn to be potty-trained. At age three, children of working mothers could then be admitted to a kindergarten. At age six, which coincides with the schooling age, working mothers would have the option of sending their children to an after-school program until the evening, where they would eat their lunch, be able to do their homework with supervision and instruction, and later play while being looked after, all under control of state and party. Meanwhile, the rural working class of cooperative farmers (Genossenschaftsbauern) had taken over from the landed class. In 1945, anyone owning more than one hundred hectares had had it confiscated and the gradual collectivization of agriculture via agricultural cooperatives, or LPG’s (Landwirtschaftliche Produktionsgenossenschaften), started in 1952 and reached its height at the beginning of the 1960s. There were three LPG types: with type I, the land went into the LPG and the cattle were still managed at home; with type II, machines were taken into the LPG; and with type III, land, machinery, and cattle were managed jointly. This collectivization and industrialization of agriculture often caused great hardship for the individual. There was no choice in these matters, and over five hundred thousand farmers were forced to adapt to the new circumstances and become expropriated state employees. If they objected, they were either fined or removed from what had previously been their own land, which they now had to work as a peasant laborer force. Their numbers dwindled, and in effect, the previously stable agricultural society was totally destroyed. Stubborn farmers were accused of not fulfilling the socialist plan and were faced with high penalties or with their farms being expropriated. In the 1970s, there was a push to establish agricultural factories in the countryside, with more than four thousand redeployed state employees in each unit. At this point, there was only a small group of smallholders left. The factory initiative proved to be a failure, however, and the land was sub-



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sequently given over again to plant and animal production. There was now an itinerant band of farmworkers, who differed little from those who worked on the collective farms in the Soviet Union. They were overseen by collegetrained agricultural technicians or managers. In spite of the difficulties that made many flee to work in the towns, in 1989, fewer than 10 percent of East Germans were still working in agriculture. The Remains of the Bourgeoisie

As previously stated, one of the consequences of this East German social revolution had been the dismantling of the educated and economic bourgeoisie class, which had been replaced by functionaries of the State. The SED succeeded in removing all their power and relatively few self-employed members of the old bourgeoisie remained. Even those who managed to eke out a small living, mostly master craftspeople, had to live in severely straitened circumstances. After the building of the Berlin Wall, a process of change was put in motion that slowly undermined all former stability. The SED, who masterminded the process, promoted atheism in the place of any kind of faith. Consequences of the SED Dictatorship

With the SED having a monopoly on power, everything was controlled, from the media to finance, the law, and even the right to political processes— unlike in the West, where there were generally separate controls in place for these different functions. There was no long-term view and there was a total disregard of the ordinary person’s rights and absolute repression of any dissenting voices. Regulation and control became the SED obsession. By the end of the 1980s, there were over ninety thousand full members of the Stasi, supported informally by over one hundred seventy thousand unofficial collaborators (inoffizieller Mitarbeiter, or IM). Over half a million informants were now ready and willing to report any infringements of state control— either in thought, word, or deed—to the Office for National Security. More than three hundred thousand East German citizens had suffered under the oppression of the Stasi, an organization that had reached into all corners of society, relying on an army of informers and breeding suspicion in their neighbors. In the years from 1950 to 1970, there were more than one hundred thousand outrageous judgments by arbitrary law (Willkürrecht) for political offences. All the GDR’s grand plans were far outweighed by their existing financial commitments, since over a quarter of total government spending needed to be used to subsidize basic foodstuffs, rental, and transport costs. Everyone had

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to pay a contribution to the centralized union insurance, and by 1989, more than four hundred thousand employees of the FDGB, the state trade union, had the task of managing all this, supported by government revenue. In 1989, nearly half the total state budget was taken up in maintaining this system, with a planned economy and state care, which operated by exclusion, repression, and monopoly of supply. Since there was no separate judicial system, which remained a totally alien concept and practice in the GDR, there was absolutely no right of redress, and the SED continued to maintain total control over the whole country. Pensions were wholly inadequate, being much less than previous incomes, and women still received less than their male counterparts. The elderly and the disabled were in an even worse situation, and many lived below the poverty line with no support or protection. By 1989, this sorry state of affairs affected 10 percent of all households. In addition, huge industrial-type blocks (Großplattenbau) of flats were built in satellite cities. This meant that old city apartments were neglected and entire areas were “restored” in this way. This situation amounted to a double experience of dictatorship, and between 1933 and 1989, the people who lived in the SBZ and the GDR, which subsequently became East Germany, endured continuous totalitarian regimes—first Nazi and then Communist—and had a continuing authoritarian political socialization. It had been a smooth and seamless transition, and two full generations of East German citizens lived without choice or freedom in a state where the fantasy of utopia was in complete and ironic contradiction with the reality of how people lived their lives. The “reward” for the people of this system seemed to be some kind of feeling of warm security from fulfilling socialist ideals, and the feeling of being protected by a paternalistic state. This feeling was obtained at the price of total obedience, loyalty to the political ideal and the social system, and abrogation of all personal responsibility. Under the leadership of first Ulbricht and then Honecker, this brutal, repressive, and militarized regime held sway. There was a lack of basic human rights of liberty and justice, and those who complained were thrown into the dreaded Bautzen jail, or were shot by the border guards if they attempted to flee. Over a thousand people nevertheless made the attempt to cross the border and were killed in their attempts. Day-by-day and year-by-year, the Stasi administered the brutal suppression of human rights. All this only underlined the totalitarian nature of the East German party dictatorship. The SEDdictatorship wanted, by the operation of totalitarian forces, to manage the tools of coercion (the army, police, bureaucracy, and justice). The dictator ruled the whole of society and the private lives of those within it through absolute control of education, communications, and economic institutions. The aim of the SED was that society should be transformed into a police state, where the individual was isolated, culture was transformed into propaganda,



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and terror was installed as a permanent and effective threat. The GDR was in a state of despotism (Willkürstaat). The state equaled society, and society equaled the state in this terrifying and absolute situation. This Bolshevik or fascist-styled dictatorship maintained a state of permanent revolution, with a total absence of any idea of human and civil rights for the individual. In short, it was the most repressive of all social systems. The Development of the Federal Republic of Germany (FRG or BRD) (1948–1990)

Meanwhile, beyond the wall in West Germany things were taking a very different turn (Wehler 2003, 2008). From the beginning, the FRG had the impetus to change, and the Western drive for integration and development continued. There was an economic boom, the so-called economic miracle (Wirtschaftswunder) and a subsequent dramatic expansion of the economy occurred. This expanding economy aided integration and a change in the social structure of the country took place. But the flight from the land continued, and Germany became a society of office workers and government employees. A class-conscious proletariat gradually metamorphosed into a society of unpretentious petit bourgeois individuals, happy to have modest homes and to secure pensions and their own little Volkswagen cars. Real incomes quadrupled between 1950 and 1973, half of the skilled workers now considered themselves to be middle class, and there was a premium put on the development of the life of the individual. There was increased social mobility, and even the more than twelve million refugees found themselves integrated and able to be part of this drive for modernity and improved standards of living. Women began to be employed again—now over 50 percent—and could now look forward to employment for life. With the economy continuing to flourish under the BRD, millions of “guest workers” flooded in from other parts of Europe. Destroyed cities were rebuilt, the process of building suburbs started, and everyday life became more liberal. With this liberalization came the benefits of reduced working hours, proper labor laws, and an increase in life expectancy as well as in the number of divorces, single-parent households, and nonmarital partnerships. Many people now lived until their eighties within this vastly improved society. The Beginning of the Breakdown of the GDR, the Reunification, and Afterwar

In 1989, a series of dramatic events in Eastern Europe unfolded (Wehler 2008). In Hungary, discussions about a multiparty system began, and in June, the frontier to Austria was opened. In Poland “Solidarity” was officially

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recognized as a party and reforms were under way. Gorbachev visited the Federal Republic, and following this visit, a joint communiqué was issued referring to the right of all peoples freely to determine the social and political system in which they wished to live. The disenfranchised citizens of the DDR began to vote with their feet and hoped to be able to travel to the Federal Republic. Leipzig with its Monday demonstrations became the center of the opposition. Then, on November 7 of that year, Stoph’s government resigned. The state was virtually bankrupt. On November 9 in the evening, the foreign press was informed that all border crossings would be open effective immediately. The fall of the Berlin Wall became real, and a new government followed. Within this context of imminent reunification, the Stasi started to destroy particularly sensitive documents in an attempt to cover their tracks. After a massive demonstration that got out of control, near anarchy ruled in East Germany, and as a result, a “government of national responsibility” was instituted. The year 1990 marked the reunification of the two Germanys. Reunification was the central issue at stake in the March 1990 elections. How could the two Germanys with their four power bases become reunited? A new People’s Chamber was set up, followed by a national government. The first major problem, of course, was how monetary, economic, and social union could actually be achieved. It was at this time that the Federal Republic paid a very high price. Things were in a disastrous state of decay and collapse and a newly created Public Trust (Treuhandanstalt) took on the job of privatizing state holdings and of returning confiscated property and land back to the previous owners. Property, which had become largely worthless, was sold for derisory sums, and the outcome was that three-quarters of the workforce lost their jobs. In effect, East Germany was de-industrialized, and even today, rising unemployment is one of its greatest social problems. Meanwhile, the Warsaw Pact had virtually ceased to exist. Moscow, too, was desperate for financial assistance and it was agreed that Germany would help Moscow, but only on the understanding that the former would become unified. Even before the State Treaty was signed, negotiations for a unification treaty had begun. There now appeared to be no alternative to unification, given the rapid collapse of the DDR economy, and the People’s Chamber voted overwhelmingly in favor of this option. At this point, the Soviet Union demanded 1 billion marks in order to cover the costs of withdrawing their troops from Germany. On October 1, the four powers formally renounced all occupation rights. Germany now became a fully sovereign state, and following a series of treaties, the election on December 2 was a triumph for the Bonn coalition. Berlin at last became the capital of a unified state, and a unified city in its own right. After reunification



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on October 3, 1990, the “Day of German Unity” became a national holiday. A significant subsequent development was the abolition of the Stasi and the opening up of its archives, when their terrifying reign of oppression was fully revealed. After the collapse of the Iron Curtain, the economic desolation of the East proved to be more disastrous than even the most pessimistic forecast had predicted. Unification in its own turn became an unmitigated disaster at an economic level. Many speculators invested billions in projects that later proved uneconomic and worthless. People began to speak of “Kolonialism.” A billion marks were transferred from the West to the East in the seven years between 1991 and 1998. All promises were broken, the national debt increased, as did unemployment. In 1998, a new chancellor came to power and in spite of continuing rises in unemployment and many alarming bankruptcies, the coalition won the 2002 election. Since that time, the outcome of unification has been mixed. There is more sense of isolated individual lives in front of the television, as well as a dramatic increase in prosperity and a corresponding dramatic increase in the desire for and acquisition of consumer goods. In the twenty years since the fall of the Wall, many developments have taken place in the lifestyles and aspirations of those living in the now-unified Germany. Development proceeded differently in the different locations. Fundamentally, however, the differences between East and West remain. The populations in all counties are dwindling, and the more educated younger people, mostly women, tend to escape either to the West or to the Northern countries. The infrastructure formerly in place to look after the needs of young people in rural areas has largely disappeared. Parts of East Germany are in great danger of being abandoned. With the increase of unemployment in the East after unification, some began to look back on the good old days of the DDR and there was a wave of “Ostalgia.” The Berlin Wall had often been replaced by a wall in peoples’ minds. REFERENCES Bohler, Karl-Friedrich, and Bruno Hildenbrand. 2006. “Nord/Süd.” In Deutschland: Eine gespalten Gesellschaft, edited by S. Lessenich and F. Nullmeier. Frankfurt am Main: Campus Verlag. Dralle, Lothar. 1991. Die Deutschen in Ostmittel- und Osteuropa: Ein Jahrtausend europäischer Geschichte. Darmstadt: Wissenschaftliche Buchgesellschaft Darmstadt. Fuhrmann, Bernd, Wencke Meteling, Barbara Rajkay, and MatthiasWeipert. 2008. Geschichte des Wohnens: Vom Mittelalter bis Heute. Darmstadt: Primusverlag.

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Lifton, Robert. 2014. “History as Trauma.” In Beyond Invisible Walls, edited by Jacob Lindy and Robert Lifton. New York: Brunner-Routledge. Mooser, Josef. 1984. Arbeiterleben in Deutschland, 1900–1970. Frankfurt am Main: Suhrkamp Verlag. Reulecke, Jürgen. 1985. Geschichte der Urbanisierung in Deutschland. Frankfurt am Main: Suhrkamp Verlag. Rosenbaum, Heidi. 1982. Formen der Familie: Untersuchungen zum Zusammenhang von Familienverhältnissen, Sozialstruktur und sozialem Wandel in der deutschen Gesellschaft des 19. Jahrhunderts. Frankfurt am Main: Suhrkamp Verlag. Wehler, Hans-Ulrich. 1987–2008. Deutsche Gesellschaftsgeschichte, Vols. 1–5. München: Verlag C.H. Beck. ———. 1987a. Deutsche Gesellschaftsgeschichte. Vol. 1: Vom Feudalismus des Alten Reiches bis zur Defensiven Modernisierung der Reformära, 1700–1815. München: Verlag C.H. Beck. ———. 1987b. Deutsche Gesellschaftsgeschichte. Vol. 2: Von der Reformära bis zur industriellen und politischen Deutschen Doppelrevolution, 1815–1845/49. München: Verlag C.H. Beck. ———. 1995. Deutsche Gesellschaftsgeschichte. Vol. 3: Von der Deutschen Doppelrevolution bis zum Beginn des Ersten Weltkrieges, 1849–1914. München: Verlag C.H. Beck. ———. 2003. Deutsche Gesellschaftsgeschichte, Vol. 4: Vom Beginn des Ersten Weltkriegs bis zur Gründung der beiden deutschen Staaten, 1914–1949. München: Verlag C.H. Beck. ———. 2008. Deutsche Gesellschaftsgeschichte, Vol. 5: Bundesrepublik und DDR, 1949–1990. München: Verlag C.H. Beck.

10 The False Self Adrian Sutton

Our task is less that of thinking up valid theories than of finding working hypotheses that are of use in treatment. —Georg Groddeck (1917)1

Winnicott addressed himself to how the experiences of infancy, in particular

the mechanisms and structures set in motion by stress and trauma, contributed to subsequent life. His concepts of the True Self and False Self (Winnicott 1960a) are central constructs in his understanding. THE TRUE SELF Child as he was, [Oliver] was desperate with hunger, and reckless with misery. He rose from the table; and advancing to the master, basin and spoon in hand, said: somewhat alarmed at his own temerity: “Please, sir, I want some more.” The master was a fat, healthy man; but he turned very pale. He gazed in stupefied astonishment on the small rebel for some seconds, and then clung for support to the copper. The assistants were paralysed with wonder; the boys with fear. “What!” said the master at length, in a faint voice. “Please, sir,” replied Oliver, “I want some more.”

Charles Dickens (1839) sets the scene for Oliver Twist’s simple statement to the master of the workhouse as one of neglect and physical and emotional

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abuse within a framework of laws that were designed to protect the vulnerable but that better served the complacency and self-seeking of those administering the system. Oliver was impelled both by his own undeniable need, and as representative of his peer group’s shared need, shaped into a fear that they would be eaten by a much bigger and equally hungry boy if they did not act. Even terror of the workhouse master could not stop him. Not to have acted would possibly have been a fate worse than death. Somehow Oliver “found it in himself” to do what was necessary. Oliver’s wish for “more” was no expression of greed: not a wanting of something beyond a basic need. Dickens could perhaps have simply had Oliver say, “Please, sir, I want” using that other meaning of to want, “to lack.” Dickens had presaged this aspect of a “something” in Oliver that, despite the dangers, could and would create action for survival. It remained a matter of considerable doubt whether the child would survive to bear any name at all. . . . The fact is, that there was considerable difficulty in inducing Oliver to take upon himself the office of respiration. . . . Oliver and Nature fought out the point between them. The result was, that, after a few struggles, Oliver breathed, sneezed . . . setting up as loud a cry as could reasonably have been expected from a male infant who had not been possessed of that very useful appendage, a voice, for a much longer space of time than three minutes and a quarter.

Dickens paints a picture of what Groddeck ([1925] 1977, 197) came to call The It (Das Es)—“the vital force, the self, the organism” that “in accordance with its own infallible purpose creates speech, breathing, sleeping, work and joy and rest and love and grief” (Groddeck 1951, cited in Symington 1986). Winnicott also captured this in the “True Self,” which “comes from the aliveness of the body tissues and the working of body-functions, including the heart’s actions and breathing. . . . [It] is, at the beginning, essentially not reactive to external stimuli, but primary. . . . [It is] little more than the summation of sensori-motor aliveness” (Winnicott 1960a, 149). It is the necessary and sufficient minimum basis that makes a life possible and the agglomeration of processes that create the possibility of someone who can say “I am.” This psychosomatic entity has experiences that set in train a process from which the linking of experience and action can emerge. Neurological development will decide how well integrated that action is: at its most primitive, it will be what Anna Freud called “vegetative excitation” (Freud 1989), a whole-body response, uncoordinated and unrelated to self or other. The baby is hungry and cries: an ordinary process of development means “crying with hunger” becomes “crying because of hunger” and ultimately “crying for a feed.” Ordinary devoted care that is a close-enough match to the child’s needs



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and that brings relief from this hunger with sufficient promptness and reliability over time—a “good-enough” experience—results in repeated experiences of distress receding and satisfaction ensuing. This is the “Facilitating Environment” that makes possible the unfolding of the child’s “Maturational Processes” (Winnicott 1985). For Winnicott, the baby requires a sufficient experience of not knowing of her dependence on others, of not knowing that she does not know that there is a “me” and a “not-me.” “Sufficient experience” involves both an absolute period and periods during which the potential to know of dependence has emerged but without the infant having to be aware of this. This happens through the environment meeting the child in such a way that she is unchallenged enough by internal tensions consequent upon its provision. This formulation of a “True Self” before there is “an inner world of objects” (Winnicott 1960a, 149) differentiates his theories from those that argue against there being states of “un-object-relatedness” in the presence of some degree of mental organization. The “spontaneous gesture” is a key contributor toward the sense of self and others. An inner experience arises simultaneously with a movement that is responded to in a way that promotes a sense of personal coherence (integration). For the baby whose crying and accompanying movements arising from hunger are met by a feed, there can be both an experience of a sense of oneself as a being in need and of the event or process of need being satisfied through one’s own actions. In turn, this safely preserves an illusion of being able to create what is needed—an omnipotent state that needs to exist for long enough to enable the development of equipment to deal with the reality of not being omnipotent. This brings the future possibility that the constituent elements of “being fed”—sucking, pleasure in tasting, swallowing, relief from pain—can come to substitute for each other. These then act as mechanisms to ward off any threat of fundamental disruption; for example, where the comfort of a feed, rather than its substance, is needed, finger sucking can be sufficient. Necessity is the mother of invention and “conjuring up” fulfillment of need through hallucinatory processes precedes awareness of reliance on the outer world for what is needed. Neurological development means the existence of an outside world cannot simply remain “not-known.” But the illusion can be continued a little longer through the infant believing that she has created the real-world response that meets her need—the hungry baby creates the feed. But further development makes this position untenable to the point where “Mother is the invention of necessity”: it is “she” not “me” who creates the feed and provides fulfillment. This occurs in part through her appearances not precisely meeting the spontaneous gestures but occurring closely enough in

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association with them and clearly separate from what can now be experienced by the baby as her own creation. For the infant to thrive, this imprecision must be within a tolerable range such that her experience becomes a space where something can safely be expected to happen rather than a gap, a break in continuity. Winnicott stated: “There is no such thing as a baby. . . . Whenever one finds an infant one finds maternal care, and without maternal care there would be no infant” (Winnicott 1960b, 39). This is a lesson learned also by the baby. Successful progress through these processes depends upon a sufficient match between the baby’s particular needs, her inherent and emergent tolerance of states of arousal, and the care that is provided. Winnicott called this “good-enough” to capture the ways in which, above a minimum threshold, there is a range of responsiveness that will be at least sufficient, if not ideal. As described above, there comes a point when delay, which might previously have been experienced as not-good-enough care, becomes a promoter of development—that moment when the tension that would previously have been disruptive, to the point of being overwhelming, is where the baby finds a new ability in herself—an ability that is not dependent on omnipotent mechanisms but on a newly emerged ability in herself to tolerate imprecision. The “True Self” is central in developing an authentic sense of being alive in a world that provides not only satisfactions but also frustrations and suffering. No infant can experience an absolute, immediate, and perpetual “fit” to its experiences of need. A “perfect” fit would stifle development: the spontaneous gesture would never develop into true creativity, which derives from the possibilities of what can emerge from the inherent tensions of the meeting of the internal and external worlds. THE FALSE SELF Etiology

The False Self is “a defence against that which is unthinkable, the exploitation of the True Self” (Winnicott 1960a, 147), which “has one positive and very important function: to hide the True Self, which it does by compliance with environmental demands” (Winnicott 1960a, 146). “Exploitation” can be either simple “use” (utilization) or “abuse” (corruption). Nothing emerges without it having been contributed to by the True Self in contact with the entire environment: hence, defense mechanisms can only be manifestations of this “use” of the True Self. The central quality of “falseness” in the False Self arises when a catastrophically challenging degree of failure of provision



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evokes adaptations that misidentify or come to identify what is provided as if it were the provision that is needed. It may even become lived with as if it were desirable. Implications

Two distinct patterns may emerge consequent upon the emergence of the False Self: (1) one of “general irritability, and of feeding and other function disturbances which, however, disappear clinically, only to reappear in serious form at a later stage,” and (2) one in which “the infant gets seduced into a compliance, and a compliant False Self reacts to environmental demands and the infant seems to accept them. . . . [This] builds up a false set of relationships” (Winnicott 1960a, 146). So, from the True Self emerges an adaptation that hides it from both the outside world and from itself: this not only protects it but also uses its vitality to maintain this position. It is a “double bluff” on the self, a form of brainwashing carried out upon the Self. It exploits the potential present in the proximal zone of the individual’s development,2 the ability of the True Self to deny what the True Self cannot ultimately avoid identifying: it is placed in suspended animation, of quasi-non-existence. The False Self inevitably contributes to the shaping of what follows. Those providing “not-good-enough care” may not be subject to the stimuli that they could interpret as the baby needing something very different. In the UK, one question often asked of parents is “Is he a good baby?” which means “Does he fit in and not make too many demands on you?” Winnicott’s “compliant baby,” apparently provided with what is needed, may present false assurance that his needs are being met. In order to resume a healthier trajectory, he will need to become a “bad baby” and find or create parents who can know and meet the demands of the True Self. Good-enough care will be based on this new recognition and avoidance of regarding the child’s disturbance as willful, unwarranted, or exploitative manipulation seeking parental compliance.3 Without this, the False Self will become more substantial and consolidated but without proper foundations—it is a structure built on sand needing constant maintenance: for the baby this means reduced spontaneity and constraints on development. Manifestations and Effects

Winnicott produced a broad classification of the degree of False Self organization (Winnicott 1960a, 150–51).

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At One Extreme

The False Self goes beyond its defensive quality and becomes the entirety of emotional and relational life. Accommodating the “world-as-it-is” as the “world-as-it-should-be-for-me” leads to brittleness of structure and functioning. The ordinary “knocks” in life become shattering or life is lived to avoid any major challenges. The person is found, or finds himself, “wanting” in some quality, as though something is missing in his self. Less Extreme

The True Self finds expression through symptoms or signs of underlying turbulence or conflict identifiable through emotional experiences, bodily concerns, or behavior. In Winnicott’s terms, “the True Self is however acknowledged as a potential and is allowed a secret life.” The clinical signs may not trouble the person himself (and hence are not “symptoms”) but are manifest through challenges to those involved in his life, for example, the theft of something of no value to the person himself. The distinctive characteristic of this “antisocial tendency” (Winnicott 1956) is a sense of “I lack” translated into obtaining something and not simply or wholly a wish to have more (driven by greed) or to leave another with less (driven by envy or the aggressive wish to cause harm or suffering). It has its source in experiences that were not strong enough to instill robust Basic Trust (Erikson 1977, 222–26) and “represents the hopefulness in a deprived child who is otherwise hopeless, hapless and harmless; [it] means that there has developed in the child some hopefulness, hope that a way may be found across a gap. This gap is a break in the continuity of environmental provision, experienced at a stage of relative dependence” (Winnicott 1963, 103–4). Oliver Twist’s “Please sir, I want some more” was interpreted as an antisocial act indicative of him being morally corrupt and corrupting. But Dickens knew better, identifying Oliver’s True Self health. Move toward Health

Whereas in (1) and (2) the True Self is lost or hidden to the outside world and the self, in this intermediate position, the False Self is mobilized “to make it possible for the True Self to come into its own” (Winnicott 1960a, 143). “Coming into its own” is the opposite of “exploitation.” The False Self defense of self-brainwashing is exploitative. To “come into its own” means asserting that the environment must adapt and provide, and if it does not, “there must be reorganised a new defence against exploitation of the True Self, and if there be doubt then the clinical result is suicide” (Winnicott 1960a, 143).



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It may appear paradoxical that Winnicott presents “health” as being in the service of suicide, but he writes, “Suicide in this context is the destruction of the total self in avoidance of annihilation of the True Self . . . and it becomes the lot of the False Self to organise the suicide” (Winnicott 1960a, 143). There is a parting of the ways: in one direction is the route derived from a wholehearted belief that living a life of True Self exploitation is a fate worse than death; in the other, a route for further development through sublimation, mutuality, and expression of the True Self by social and cultural means. Still Further Toward Health

Sublimation may temper the extent to which a failure of integration of the True Self into the emerging sense of self has adverse effects (Winnicott 1960a, 150). Identificatory processes, as distinct from those arising from the child’s own inherent and emergent abilities, may come to play a significant part in bridging gaps. Personally enacting the carer’s good-enough actions can provide vicarious experiences of being cared for through providing care to others and identification with them. But incorporative processes involve “swallowing” one’s part objects as if they are whole, rather than achieving appreciation of the whole object through integration of its part object constituents. They can be the prelude to more egosyntonic forms of identification but will require reworking to achieve a more accurate perception of external reality and to construct a “True Environment” to complement the True Self. This provides a buffer against more substantial crystallization of a False Self and offers a modus vivendi for vicarious fulfillment of needs without fundamentally discordant and disruptive consequences. However, maintaining this position requires substantial ego resilience, and splitting into the good object and the failing object of infancy remain as a fault line in the overall ego-structure.4 The remnants will manifest through varying degrees of a sense of inauthenticity. Overreliance on them is an overcapitalization of the good to counter the bad and will be exposed when the gratifications and freedom for expression of the True Self that may arise from sublimation are insufficient to overcome the effects of a “True-Self-denied.” In Health

Because the True Self operates from a foundation of omnipotent fantasies, it ultimately has to be acknowledged, contained, and harnessed to allow engagement with the real world (see Kent 1976). Given that failures are inevitable and essential, a healthy outcome can arise when challenges faced by the emerging ego are within a range of tolerability and a gradual modification

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of omnipotent processes and abdication from omnipotent states occur. “Need unfulfilled” becomes “need not yet fulfilled” and then “but it soon will be.” The raw, primitive “beast” can be tamed, mollified, or at least contained without fueling its rage or simply caging it: its vitality can be harnessed without evoking an experience of exploitation. Mutuality and reciprocity become possible, and the parts can become greater than the whole with no sense of primary loss of self or of other. This is that form of False Self that is called “socialization.” THE TRUE AND FALSE SELF IN PRACTICE Winnicott emphasized the importance of identifying False Self mechanisms and the technical consequences for assessment and the process of analytic treatment. He particularly warned that the engaged, intellectually capable, and apparently insightful patient might actually have had to overcapitalize on their intellect to the detriment of other essential areas of experience. What, on the surface, appear as lively therapeutic interchanges may principally maintain the position of the True Self as, at best, hidden or, at worst, caged, alive but not living a life. Patients with more extreme forms of False Self require a particular form of therapeutic dependence and adaptation of technique. The analyst must not provide a “False Engagement,” since a patient’s False Self “can collaborate indefinitely with the analyst in the analysis of defenses, being, so to speak, on the analyst’s side in the game” (Winnicott 1960a, 152). Technique must be refined to contend with, and when possible articulate, the continual countercurrents of the wish to be known and the fear of being inauthentically known, of daring to be known and needing to be recognized as unknown. Winnicott illustrates this with his patient’s comment “The only time I felt hope was when you told me that you could see no hope, and you continued with the analysis.” Winnicott also identified the significance of False Self mechanisms in those seeking to be practitioners: “The organised False Self is associated with a rigidity of defences which prevents growth during the student period” (Winnicott 1960a, 144). The “organized False Self” can also be thought of as an “encapsulated False Self,” identifiable in the “Less Extreme” group. It may reside in the area of intellectual functioning or may be found in the patient’s physiology and anatomy, creating constellations that need to be distinguished from other “organic” and psychological causes (Sutton 2013, 155–56). Medically unexplained symptoms can be a manifestation of the True Self, which needs to be met respectfully in the arena of the body and its care, rather than expecting



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words to be either necessary or sufficient. Overemphasis on words may be counterproductive, particularly if patients have had unsuccessful “talking therapy” based on ideas of putting words to feelings without appreciating that words also serve to hide or mask feelings (see Sutton 2013, chaps. 7 and 8). The third grouping, “More toward health” is perhaps the most tantalizing in the way that it captures the paradoxes that inevitably arise when confronted with trying to integrate physical, mental, and existential health. Groddeck’s formulation of “Das It” can help us: “[This It] creates speech, breathing, sleeping, work and joy and rest and love and grief, always with correct judgement, always purposefully, and always with full success, and finally when he has lived long enough, it kills him” (Groddeck 1951, 40, cited in Symington 1986, 149). There is no simple dichotomy between being alive and being dead except to say that before being alive and in death, there is no It. Winnicott illustrates living unaliveness: “My patient . . . has come near to the end of a long analysis. She contains no true experiences, she has no past. She starts with 50 years of wasted life, but at last she feels real, and therefore she now wants to live” (Winnicott 1960a, 148). What makes life livable is the experience of authenticity of oneself in living. For some, this involves the idea of a “purpose,” perhaps even a “greater purpose” in living, but for others, there is a fate worse than death—living a life in which adaptation to a world can never be a good-enough experience. To be with someone who has reached this point of acceptance of death, and its corollary, suicide, can be challenging, perplexing, and disturbing. This individual is devoid of emotional conflict or distress and is oblivious to the experience of the other, insisting that it is a simple fact and there is no demand upon anyone to prevent this happening. The expression of suicidal thoughts, feelings, and wishes is a statement of the absolute belief that nothing will be of use: it is not “a cry for help” (Sutton 1998). This differs from situations where some degree of hope survives, and these consciously articulated or unconscious projective identificatory processes seek containment, holding, and a wish to mobilize the other’s resources. Further distinction must be made from circumstances where suicidality is expressed, but underlying sadistic processes seek to induce feelings of helplessness and lack of resources in others: secondary gain has filled that gap in True Self experience, and gratification provides purpose in living. This has its equivalent in the therapeutic process in what Balint termed “malignant regression” (Balint 1959, 1968). Identificatory processes can be powerful defenses, achieving a degree of equanimity and sustainability throughout life. But their utility relies on others playing their part. The compulsive carer needs those who will give back a sense of being relieved by the care that she or he is providing. Likewise,

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the teacher too driven by identification with his or her own teachers will be overreliant on a sense that the student is learning or has learned from him, rather than from him being with the pupil in a process of learning. In these situations, professional challenges become too personal. Winnicott’s conceptualization of health as compromise is observable as an organized “polite and mannered social attitude” (Winnicott 1960a, 143). To behave with healthy compromise means to not express all thoughts and feelings, which may resonate with conflicting processes arising from the True Self, without conscious or unconscious denial. For this person, the False Self can be a lubricant, not a fuel: a stark contrast to extreme False Self functioning, where superficially similar behavior is lubricant, fuel, and the vehicle requiring lubricating and fueling. Robust health goes beyond applying defensive solutions. It seeks and finds, or copes with not finding, reality-based explanations without being driven to attribute causation or blame to self or other, as in the paranoidschizoid and depressive positions. Symington (1986, 275–76) describes this as the “tragic position,” a “deeper abyss of non-meaning,” against which the paranoid-schizoid and depressive positions are defenses. While regressions may emerge as defenses against “non-meaning,” I would suggest the tragic position can ultimately provide relief from omnipotent states of mind, allowing more accurate and realistic observations of the world. It provides a platform on which to capitalize on the synergy of what Keats called “negative capability”5 and “negative culpability,” “[producing] a position of timely open-mindedness which allows data and information to be taken in without being acted upon precipitately” (Sutton 2013, 174). TRAUMA, TOTALITARIANISM, AND THE TRUE/FALSE SELF The False Self results from “trauma” in the psychoanalytic sense: “A psychic injury, especially one caused by emotional shock the memory of which may be either repressed and unresolved, or disturbingly persistent; a state or condition resulting from this” (Shorter Oxford English Dictionary [SOED] 2002). This chapter arises from a view that it is crucial “to understand the general effects of larger factors such as social upheavals and the development of totalitarian systems on the personal history and psyches of individuals over the years” (Huppertz, personal communication). I feel equipped only to offer some considerations for monitoring how we might attribute to totalitarianism (a) specific causation, (b) less direct but significant contributions to the emergence of clinical constellations, and (c) (perhaps, more justifiably) its use as an analogy helping us conceptualize wider interpersonal, social, and cultural structures and processes.



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Totalitarianism is authoritarian, since it claims to derive its authority from religious creeds, ethnic origins, national identity, or political analysis: it purports to have answers with no further questions. It provides a framework for its conception of the “greater good” as good for all those within its jurisdiction, reserving or exploiting an assumed right to have entry to all areas of their lives. Those supporting and promoting such a system will view it as optimizing opportunity and experience; those opposing it will see it as oppressive and repressive. In a totalitarian state, the former group will be provided with platforms and rewards for promoting their views while the latter will express themselves at their peril. The origin of the False Self could be conceptualized as an experience of totalitarianism. The means of production/provision, distribution, and reward are completely outside of the infant’s control unless he remains in a world of his own making. Experiences of the inevitable failures may find asylum in the land of the False Self and become reified in the literal totalitarian state, which is not responsive to individual and idiosyncratic needs. Survival in such a state will require compliance and the suppression of spontaneity. Oliver Twist only came to challenge those in authority when the threat of living a life unlived in Winnicott’s sense was “trumped” by the tension generated by the threat of being eaten if hunger did not find a voice. Totalitarian regimes may apply themselves directly to authoritarian infant care regimes. There may be forms of familial or cultural totalitarianism that seek to subjugate infants even in the absence of a political embodiment, in order to mold them to what is deemed desirable and avoid producing a “spoiled child”—that is, a child treated with “great or excessive consideration or kindness” (SOED 2002) whose character is deformed by “overindulgence or undue lenience” (SOED 2002)—so speak the proponents of “tough love” as a guiding principle in child care. This is the antithesis of Winnicott’s goodenough mothers, driven initially by primary maternal preoccupation (Winnicott 1956) to adapt and remain responsive to their baby’s emerging abilities and sense of individuality and person-ness. There are manifold influences around even the most determined potentially good-enough mothers. Some will support their attunement, and some will have to be resisted because of her attunement. In fact, there is no such thing as a mother and her baby; there is a mother and her baby and their environment. HUMAN RIGHTS AND WRONGS The True Self is a major participant in any Human Rights activity. It makes itself known and monitors the accuracy with which responsiveness to its

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signals meets the cause of those signals. But beyond this, it is not discriminating. It does not distinguish between those failures that are inhibiting or actively prohibiting. The mother who resists responding through a personal fear of spoiling her child is, at the earliest stage, indistinguishable from the mother who complies with those who view authentic and accurate responses as “spoiling.” The depressed mother, affectively flat and retarded in her psychomotor activity, may be similarly unable to respond.6 HUMAN RIGHTS AND THE TRUE SELF The United Nations Universal Declaration of Human Rights (1948) affirms the True Self’s presence: it exists equally in all and is worthy of respect and response. But that aspect of justice and equality that acknowledges individuality rather than sameness, enshrined in “From each according to his abilities, to each according to his needs!” (Marx 1875) is a compromise that the True Self has to come to terms with and own for itself. A mature understanding of rights requires more than statements about respecting autonomy: it must address the material and relational context. It must resonate with Winnicott’s “mother and baby” and appreciate that “there’s no such thing as a right, there’s a right and the resource and responsibility to respond.” This line of argument produces positions that, at first sight, may appear unacceptable. For example, “There are even occasional demands for a supposed . . . right to health,” which only becomes acceptable when one reads on: “a fantasy that overlooks the fact no human action can secure health for all, so that there can be no human obligation to do so, and hence no right to health” (O’Neill 2002, 9). Recently there was a media debate in the UK about people feeling offended by other people’s statements. The rhetoric included phrases such as “I have the right to feel offended.” To place experiencing an emotion as a personal conscious choice and therefore open to a debate about “rights” totally misunderstands the nature of emotional life: one either has feelings or one doesn’t. If one doesn’t, it is because nothing has caused that feeling or because an internal process has inhibited that feeling. Someone whose “right to feel offended” is denied is both victim and perpetrator of this breach. Neither is there a simple reverse argument. There can be no right to seek to cause offence, but there must be a right to reasonable expression even though somebody may experience (take) offense. Questioning the nature of rights is not to espouse an abdication of responsibility or exercise a form of tyranny by reasoning; it is a search for authenticity in understanding self and other. It acknowledges the True Self in its “pre-ruth” state (Winnicott [1954] 1982a, 265),7 from which a False Self



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may emerge. It does not differentiate between wish, need, and right, or self and other. The developmental shift from pre-ruth to ruthlessness produces a “right” in the True Self sense (the right thing arriving at the right time). There is a developmental achievement in moving from “a right unfulfilled is a right denied” through to “need unfulfilled is need denied” and ultimately to the tragic position that “a need unfulfilled may be a need unfulfillable” and recognizing that there are primary needs distinct from primary wishes. This realization may make life worth living despite unfulfillment. Failure to achieve this position or internal pressure toward regression along this developmental line may confound attempts to identify and accurately locate transgressions of human rights or, where there may be competing interests and rights, to make judgments. Fighting for a “cause” (SOED: “a movement which inspires the efforts of its supporters”) may become or derive from the original search for the source, the cause, of the False Self being created: the infant’s not-good-enough experiences and personal historical wrongs unconsciously become the drivers for action against contemporary wrongs, resolving neither. Challenging the social framework and its policies must not be purely an expression of the antisocial tendency derived from “the capacity to perceive that the cause of the disaster [in the infant’s experience] lies in an environmental failure” (Winnicott [1956] 1982c, 129), although it may provide a sublimatory route for True Self-expression. The True Self is not egocentric, since for the “It” there is no “Other”: it is “-centric” and not open to reasoning. Thus, clinicians in seeking to understand the interplay between individual psychodynamics and the social and political, the cultural and the religious, have to be open-minded. We must be ready to identify and locate the determining, maintaining, and perpetuating factors relevant to a sense of oppression and of “being done wrong to.” We must seek to understand the extent to which the determining contributions reside in the reality of external circumstances, the unalloyed expression of the True Self, or the resultant of the coexistence and interaction of both. And still we will need to ask ourselves if our search is merely another manifestation of False Self activity—intellectual understanding as another hiding place for the True Self. NOTES Although not referenced specifically in the text, Abrams (1996) The Language of Winnicott: A Dictionary of Winnicott’s Use of Words has been a companion in writing this chapter, and I would direct readers to this source in engaging with any of Winnicott’s writings.

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1. Cited in Lore Schacht, “Introduction,” in Georg Groddeck, The Meaning of Illness: Selected Psychoanalytic Writings (London: Maresfield Library, 1977), 19. 2.  To borrow and adapt a term of Vygotsky (1978). 3.  Elsewhere, Winnicott (1963) addresses the problems that ensue when a “moral stance” is taken to True Self expression that is misidentified as delinquent activity. 4.  The phrase “fault line” draws attentions to Balint’s formulation of “The Basic Fault” (1968) which has similarities to Winnicott’s propositions. 5.  See “Negative Capability,” Wikipedia, “the capacity of the greatest writers . . . to pursue a vision of artistic beauty even when it leads them into intellectual confusion and uncertainty.” 6.  See also O’Shaughnessy’s ([1964] 2003) useful concept of The Absent Object to explore the ramifications. 7.  See also Winnicott 1945 (154) for discussion of primitive ruthlessness.

REFERENCES Abrams, Jan. 1996. The Language of Winnicott: A Dictionary of Winnicott’s Use of Words. London: Karnac Books. Balint, Michael. 1959. Thrills and Regressions. New York: International Universities Press. ———. 1968. The Basic Fault: Therapeutic Aspects of Regression. London: Tavistock Publications. Dickens, Charles. (1839) 2008. Oliver Twist. The Gutenberg Project EBook [EBook #730] http://www.gutenberg.org/ebooks/730. Erikson, Erik. 1977. Childhood and Society. London: Triad Granada. Freud, Anna. 1989. “Mental Health and Illness in Terms of Internal Harmony and Disharmony.” In Development and Psychopathology: Studies in Psychoanalytic Psychiatry, edited by Clifford Yorke, Stanley Wiseberg, and Thomas Freeman. New Haven, CT: Yale University Press. Groddeck, Georg. (1925) 1977. “The Meaning of Illness.” In The Meaning of Illness: Selected Psychoanalytic Writings. London: Maresfield Library. ———. 1951. The Unknown Self. London: Vision Press. Kent, Jack. 1976. There’s No Such Thing as a Dragon. New York: Dragonfly Books. Marx, Karl. 1875. Critique of the Gotha Programme. Accessed November 2016. https://www.marxists.org/archive/marx/works/1875/gotha/ch01.htm O’Neill, Onora. 2002. Autonomy and Trust in Bioethics. Cambridge: Cambridge University Press. O’Shaughnessy, Edna. 2003. “The Absent Object.” In Key Papers from the Journal of Child Psychotherapy, edited by Paul Barrows. New York: Brunner-Routledge. Shorter Oxford English Dictionary. 2002. Sixth edition. Oxford: Oxford University Press. Sutton, Adrian. 1998. “Psychodynamics of Self Directed Destructive Behaviour in Adolescence.” Advances in Psychiatric Treatment 4: 31–38.



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———. 2013. “Becoming A Specialist in Not-Knowing.” In Paediatrics, Psychiatry and Psychoanalysis: Through Countertransference to Case Management. East Sussex: Routledge. Symington, N. 1986. The Analytic Experience: Lectures from the Tavistock. London: Free Association Books. United Nations. 1948. Universal Declaration of Human Rights. Accessed November 2016. http://www.un.org/en/universal-declaration-human-rights/. Vygotsky, Lev S. 1978. Mind and Society: The Development of Higher Psychological Processes Cambridge, MA: Harvard University Press. Winnicott, Donald. 1960a. “Ego Distortion in Terms of True and False Self.” In The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. London: Hogarth Press and the Institute of Psychoanalysis. ———. 1960b. “The Theory of the Parent-Infant Relationship.” In The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. London: Hogarth Press and the Institute of Psychoanalysis. ———. 1963. “Morals and Education.” In The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. London: Hogarth Press and the Institute of Psychoanalysis. ———. (1954) 1982a. “The Depressive Position in Normal Development.” In Through Paediatrics to Psychoanalysis. London: The Hogarth Press and the Institute of Psychoanalysis. ———. (1945) 1982b. “Primitive Emotional Development.” In Through Paediatrics to Psychoanalysis. London: The Hogarth Press and the Institute of Psychoanalysis. ———. (1956) 1982c. “Primary Maternal Preoccupation.” In Through Paediatrics to Psychoanalysis. London: The Hogarth Press and the Institute of Psychoanalysis. ———. (1956) 1984. “The Antisocial Tendency.” In Deprivation and Delinquency, edited by Clare Winnicott, Ray Shepherd, and Madeleine Davis. London: Tavistock Publications. ———. 1985. The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. London: Hogarth Press and the Institute of Psychoanalysis.

11 Totalitarian and Post-totalitarian Matrices Reflective Citizens Facing Social-Psychic Retreats Marina Mojovic´

Totalitarianism is never content to rule by external means, namely, through the state and a machinery of violence; thanks to its peculiar ideology and the role assigned to it in this apparatus of coercion, totalitarianism has discovered a means of dominating and terrorizing human beings from within. —Arendt (1951) We are dealing with the zero-level of subjectivity, with the formal conversion of the pure externality (its brutal destructive intrusion) into the pure internality of the “autistic” subject detached from external reality, disengaged, reduced to the persisting core deprived of its substance. . . . If one wants to get an idea of the elementary, zero-level, form of subjectivity, one has to look at autistic monsters. —Žižek (2008–2009)

TOTALITARIAN MATRICES

Totalitarianism as a psychosocial phenomenon involves in its essence con-

tinuous striving for the totality of rule over persons, groups, whole societies, and regions, and even wider, defeating people’s freedom of thoughts, feelings, and actions, even of fantasies, dreams, and creative imagination, submitting them all under one ideology without questioning. Art, science, everyday lives, and all communication are to be put under control by any means. Resistance is to be annihilated and punished, while unified, purified, and happily obedient people become idealized through all-encompassing 159

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propaganda. Many frightening phenomena occur in these paradigms. Human minds and communities can be invaded with terror, dissolving usual boundaries between the private and the public spaces, blurring the distinction between good and evil, truth and falsehood, reality and delusion—in short, abolishing the capacity for human judgment. Totalitarianism can be traced back throughout the history of humankind up to the present day, and, unfortunately, it will continue in the future. It was coined as a term linked to Mussolini’s party, which idealized a fascist utopia, and since then it has been widely used in social-political sciences, usually connected to a state system as a whole. In this chapter, it will be considered in its wider meaning, including a variety of human subsystems that possess these properties. Interestingly, the psychoanalytic movement was born and developed in the wake of and parallel with the so-called Age of Totalitarianism (Ffytche and Pick 2016), representing rather opposite paradigms. In trustful therapeutic relationships, it enables free associations and speech, opening up the mind to the chaotic and uncontrollable unconscious, thus keeping the flame of liberal and cosmopolitan ideals burning. Logically, struggles between these two kinds of paradigms, overtly and covertly, are continuously going on. Occasionally, the psychoanalytic field, similar to other liberal fields, is being defeated either in the decline/perishing of its activities, or in its submission/ collusion with dark totalitarianism forces. Examples of the abuse can be seen, for instance, where cooperation with the CIA for interrogation methods (Pick and Ffytche 2016) went on, or in the case of the reeducation of anti-regime prisoners in Tito’s Yugoslavia (Antić 2016). In recent years, these kinds of abuse are getting more publicity. Whether this means that the field is becoming more mature, enabling it to face its shadow side, or that the “enemies” are improving tools in turning publicity into instruments for denigration and destruction of the psychoanalytic fields, or perhaps both, might be better seen from “big picture” perspectives. Many scholars and practitioners have found it very helpful, in order to unpack these complex psychosocial dynamics, to turn to the group-analytic concept of the “group matrix”: the “hypothetical web of communication and relationship in a given group . . . the common shared ground which ultimately determines the meaning and significance of all events and upon which all communications and interpretations, verbal and non-verbal rest” (Foulkes 1964, 292), or the “network of all individual mental processes, the psychological medium in which they meet, communicate and interact” (Foulkes and Anthony 1965, 26). While the dynamic matrix relates to a certain group, “even a group of total strangers, being of the same species and more narrowly of the same culture, share a fundamental mental matrix (foundation matrix)” (Foulkes [1990] 2004, 228). This has been further developed



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within the modern theory of the “social unconscious” (Hopper and Weinberg 2011). The concept of the matrix lies thus at the core of the group-analytic project. It captures the deeply social nature of human beings: individuals and society cannot be separated, but represent different angles of observation in figure/ground terms. Foulkes’s friend, the sociologist Norbert Elias, became a significant influence in elaborating these conceptualizations (Dalal 1998). Studying people in dynamic interdependence over long-term processes, Elias was bridging the individual-centered and society-centered traditions in sociology—their micro/macro gap (Mennell 1992). Elias’s “figuration” concept frames the continuity of psychosocial movements in constant construction in asymmetrical balances of power. The dance metaphor is illustrative: “One should think of a mazurka, a minuet . . . or rock ’n’ roll . . . mobile figurations of interdependent people on the dance floor. . . . Like every other social figuration, a dance figuration is relatively independent of the specific individuals” (Elias [1939] 1994, 214). Capturing different communication levels over time, including contents, rhythms, and anything else involved in interdependence, these meaningful concepts enabled understanding the dynamic variations of different large group matrices. Their closeness with the contemporary, fast-evolving “psychoanalytic field theory” (Katz, Cassorla, and Civitarese 2017) also needs better understanding (Oklander 2017). Many related professional disciplines have also been evolving at the same time (systems-psychodynamic organizational consultancy, contemporary therapeutic community network, psychosocial studies, etc.). “GHOSTS” FROM THE TOTALITARIAN MATRICES: HAUNTING THROUGHOUT THE POST-TOTALITARIAN MATRICES Living and working in the highly traumatized Balkan region, running various psychodynamic groups for over three decades, I experienced continuous struggles of two opposite types of group processes: the totalitarian and anti-totalitarian—the latter usually pulling toward vicious circles. After the anti-Communist/anti-Milošević revolution in 2000 (when totalitarianism was officially overthrown), the endeavors to democratically improve the post-totalitarian matrices revealed dynamic oscillations among opposite paradigms in a variety of rhythms and clashes (Mojović 2007a, 2011). In this chapter I will consider some of the characteristics of the totalitarian and posttotalitarian matrices and the fluctuations within them. A new methodology of applied psychodynamic group work with the theme of citizenship, which I have called “Reflective Citizens” (Mojović 2007b, 2015, 2016) will be used as an example of both of ways of observing/facing as well as working

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through some of the significant, powerful, and relatively hidden phenomena conceptualized as “social-psychic retreats” (Mojović 2007b, 2011, 2015, 2016, 2017). These occur in both types of matrix. The consequences of totalitarianism can be long lasting, transmitted widely over many generations. In post-totalitarianism they continue to exist, but in more covert forms. Finding ways to overcome them is extremely difficult and complex and may lie on the “edges of the impossible” (Armstrong 2005; Mojović 2016). In spite of many devoted endeavors by professionals, liberal politicians, or citizen-activists, most often, they keep slipping out of spaces for comprehensive containment. Feral elusiveness, fast transformative mimicry into new forms, and mercilessness in terrorizing healthy human emotionality and vulnerability contribute in turning these complex processes into vicious death spirals. In spite of all the well-known malignancy they cause in peoples’ lives, it is very difficult to expose them to more mature ways of coping, and, generally, to turn these circles into less vicious or healthier life rhythms. It seems that their macabre dances can easily take the lead over those of hope, love, and peacefulness. Since the early twentieth century, the destructive effects of the World Wars, Nazism, Communism, and other endless social tragedies that have taken place over the last decades are widely spreading throughout our globalized world. They are like social-political tsunamis that can disrupt the relational matrices of families, organizations, and communities. Failed dependency may be related, alongside other factors, to the turbulences and collapses of boundaries, the uncontained anxieties, and many other difficult feelings from the terrorized selves/souls (or fragments of selves). These fragments continue their haunting like some “un-housed ghosts” over borders and generations. They dismantle our safety and make us all accountable (Mojović, 2015). BASIC ASSUMPTIONS IN TOTALITARIAN MATRICES: ILLUSTRATIONS FROM TITOISM Totalitarian processes are highly traumatizing for people and their communities in a range of ways: catastrophic and cumulative, visible and invisible, reparable and irreparable. Characteristically they evoke deep psychosocial regression, due to unbearable anxieties, despair, rage, hopelessness, helplessness, shame, guilt, and other extremely painful states. Primitive defenses are likely to come to the fore and overwhelm the social matrices, such as splitting, massive projections, projective identifications, denial of reality,



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self-imposed paralysis, and other mechanisms described in the Kleinian paranoid-schizoid spectrum. In groups, a massive lack of cohesion and the eruption of basic assumption (BA) processes, as described by Bion (1961), are the types of regression related to specific anxieties: dependency with passive compliance; fight/ flight reactions linked to attack and retreat; and pairing linked to manic defenses against depressive anxieties. Yugoslavia in the era of Titoism was a Communist regime that abused the people’s mature functions. They became dependent, and responsibility was delegated wholesale to the leader. Pairing was typically manifested in the bizarrely romanticized pair of Tito and the Communist Party, expected to solve all people’s problems. Fight/flight was obvious in the endless exploitation of the “Nazi-Partisans” fights or in so-called inside and outside enemies of the folk, as a continuous “threat” to the idyllic state. It was like living for many decades in an idealized bubble alienated from reality. Forced denial and suppression regarding the regime’s dark side had to be kept in silence (especially for young people) or punished, thus toxifying people throughout their matrices. Envious feelings toward the previous elite resulted in their being either exterminated or made into scapegoat objects. Forcing people to spy on and betray their fellows, their friends, or even their family members evoked despair, self-denigration, and self-hate. These unbearable and uncontained feelings would usually again be split off and projected onto scapegoats. Inducing projections of self-hatred, envy, and self-contempt into victims involved all the social hierarchies, accelerating and spinning toward total viciousness. Terrorizing processes, both internal and external, were endlessly reproduced in the striving for totality. Using the Slovenian social philosopher Slavoj Žižek’s expression (from the prologue of this chapter): experiencing oneself at a “zero-level of subjectivity” or total “autistic monstrosity” often ended in suicides or other destructive acts, serving to perpetuate the horror. For illustration of this point, I offer a family story from the 1946 General Meeting at the Medical Faculty in Belgrade, with over one thousand students present. The authorities announced that one student was not following the “party line” and would be expelled. All were questioned as to whether anybody was against this announcement. There was a long silence and then one student hand rose against the motion. His courage initiated strong sympathy from a female student, later to become his wife. However, envy from others for his courage made him soon become the victim of the large group’s aggression. He became the scapegoat and had to later leave the country. He then remembered many similar self-destructive actions on the part of ashamed colleagues.

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FAILED DEPENDENCY, ANNIHILATION ANXIETIES, AND THE FOURTH BASIC ASSUMPTION Violent penetration into the lives of ordinary people, with existential threats, torture, and killing of those in opposition to the dominant ideology evoked vast disappointments in “parental figures,” with resultant failed dependency, annihilation anxieties, and further defenses against them. This is linked to regression on lower levels of functioning than the “paranoid-schizoid,” described by Ogden (1989) as the “autistic-contiguous position,” which also needs to be recognized in order to achieve more comprehensive understanding. These ideas form the basis of the conceptualization of the fourth basic assumption of Incohesion: Aggregation/Massification, (BA) I:A/M, within Earl Hopper’s theory (2003, 2012). He conceptualized it using an alternative model of the mind offered by the Independent Psychoanalysts (Fairbairn, Balint, and Winnicott), suggesting that although it is important to study envy, it is more important to study helplessness and shame, which are associated with the fear of annihilation. Envy is seen to arise not from the putative death instinct but as a dynamic defense against the fear of annihilation directed toward spoiling the pleasure of people who are perceived as having the resources. Hopper’s theory bridges Bionian studies of group relations and Foulkesian group analysis, as well as psychoanalysis and sociology. Whereas the classical theory of three basic assumptions is in essence a “drive” theory, this new theory is essentially a “relational” theory. “Aggregation” and “Massification” refer to the processes through which the group becomes either an aggregate or a mass. Although a mass seems to be more cohesive than an aggregate, in fact these two bipolar forms of incohesion are equally incohesive (Hopper 2012). They are transitory and incapable of sustaining cooperative work. TOTALITARIANISM IS NEVER “TOTAL”: POST-TOTALITARIANISM IS NEVER “TOTALLY” WITHOUT AREAS OF TOTALITARIANISM The good news is that, in reality, reaching the “totality” is, of course, just an idealized illusion/delusion—an aspect of the totalitarian psychotic imagination. Bion (1957) made an important differentiation between “psychotic” and “non-psychotic” aspects of the personality, both of which can be found in a variety of degrees in all human beings. Those psychotic parts of the personality interact in all groups and communities, cocreating psychotic and nonpsychotic layers in group and social matrices. Even in extremely totalitarian



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matrices there can always be found non-totalitarian areas, and vice versa (Mojović 2007a). Just to remind ourselves, the cradle of psychoanalytically inspired group work, an initiation of these very democratic relational matrices, occurred in the Second World War, within the Northfield military hospital. In spite of current military conservatism, the originality and creativity of the founding figures of group work such as Bion, Foulkes, Main, Rickman, Bridger, Lyth, Sutherland, and de Mare, was temporarily so well housed in Northfield that it became the “first and the prototype of a self-reflecting institution” (Hinshelwood 2000), seemingly an impossible mission was made possible! Branches of group work later took separate developmental avenues, perhaps not cooperating as much as some of us might wish, especially, because their joined help is much needed in the frightening social-political situation of the contemporary world. Some irrational detachments and rivalries among those “sibling fields” might contain unrecognized remnants from the fields’ “conception traumas” with internalized “totalitarian objects” (Šebek 1996) and other traumatizing objects, taking the lead over the splits. However, the lived experiences of Northfield’s initial project are still an inspiration throughout the field of group work. In the Group Analytic Society-Belgrade, especially within its PsychoSocial Section, we tried to learn from this “myth of creation. . . . In the midst of war, it represented the triumph of hope and initiative” (Hinshelwood 2000, 7). This reflected on the fact that group analysis and its training in our country was also born in the wartime of Yugoslavia, during the 1990s (Mojović, Despotović, and Satarić 2014). Endeavors to create sanctuaries in opposition to the dominating culture of war or other terrors, and to bridge differences among sibling professional fields can in such circumstances act as an appeal to join hands for professional and humanistic survival. The conceptualization of “social-psychic retreats”—in itself bridging Kleinian, Foulkesian, and wider psycho-social fields, similarly to Hopper’s (BA) I:A/M theory, and the Reflective Citizens—also emerged as meaningful bridging endeavors. In liberal, democratic, and pluralistic matrices, there are always areas that could be regarded as totalitarian, but they are often hidden and difficult to grasp as such. Ex-Communist intelligence service officers can be found among many post-Communist police authorities or oligarchs with their powerful areas of influence. The Ku Klux Klan in the U.S. South survived throughout all “democratic” times. Such powerful residues of totalitarianism are often lodged in alternative psychosocial shapes, conceptualized as negative social-psychic retreats. On the other hand, within dominantly totalitarian matrices, we often encounter another version of these phenomena, supporting

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survival, conceptualized as the positive social-psychic retreats. These aim to oppose the terrorizing systems and have at their heart a longing for safety, in which anxieties, pain, and other “un-housed minds” (Scanlon and Adlam 2006) can temporarily take refuge and be embraced. The Reflective Citizens program was rooted in positive social-psychic retreats during Tito’s Communist Yugoslavia. After the anti-Communist/ anti-Milošević Revolution in 2000, reflective citizens’ activities were able to emerge from the “under-ground” to the “over-ground” (Mojović 2016). However, for a long time they were kept “low-profile,” relatively invisible to the wider public and media. In the last years, it became clear how much Reflective Citizens are facing and revealing the negative social-psychic retreats, being to a large degree actually residues of Communism and other social trauma. ILLUSTRATION FROM A LARGE GROUP AND THERAPEUTIC COMMUNITY DURING THE COMMUNIST REGIME IN YUGOSLAVIA The Psychiatric Clinic of the University Clinical Center in Belgrade, in which I was working for almost two decades as a psychiatrist and therapist on different wards, was among the leading Yugoslav psychiatric institutions. The clash between the totalitarian and liberal cultures was mirrored in the organizational and group dynamics between cultures of wards in which the pharmaco-therapeutic approach dominated and those with a psycho-dynamic psychotherapeutic culture. While working on wards of the first type, while at the same time being in psychoanalytic training, I myself experienced all sorts of persecution and scapegoat positions. In order to have a safe enough setting with my psychoanalytic patients, I was literally hiding in a small, forgotten room behind the ward toilets—if I was found mid-session, I was ordered to stop. In the later years, working in a Day Hospital with a very well-developed therapeutic community, thereby coconducting group-analytic large groups three times a week, I was able to learn much about sabotaging processes from other wards due to threatening changes that our psychodynamic culture represented. The special power of the large group in mirroring, among other things, organizational and wider social dynamics, expressing many aspects from the social unconscious, and even working through was internalized as a transformative learning experience for the future. Revealing it on a panel among international colleagues brought me new levels of insights about the complexity of the shifts from totalitarian toward post-totalitarian matrices (Mojović 2007a).



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Although most of the medical staff from the Clinical Center supported peace and democratic changes, most of us also regularly went to antiCommunist and peace demonstrations on a daily basis over very long periods. We saw that the same people were taken over by the old organizational cultures, which could only change very slowly over many years. An authoritarian style of decision making in teams resisted acknowledging the new, more liberal type of patients’ rights; the freedom and indeed obligation to expose corruption encountered among staff; or the examples of serious abuse of the psychiatric profession by the Communist regime when these were found in old “histories of disease.” All these were sabotaging phenomena that had been encrypted for many years in the matrices within which we were still working, imprisoning any vitality for real growth. THE THEORY OF THE “SOCIAL-PSYCHIC RETREATS” Psychic retreats (Britton 1998; Grotstein 2009; Steiner 1993) are internal pathological organizations involving highly structured and close-knit systems of defense and object relations. Formed initially out of desperation, these sabotaging, self-protecting, and self-organizing internal subsystems are actually sub-personalities that provide alternative shelters from human relationships and from reality in general. In their very essence lies a paradox: they both protect and imprison the vital parts of the self. Social-psychic retreats (Mojović 2007b, 2011) are similar phenomena to those of internal psychic retreats, and are unconsciously formed within groups, families, organizations, and societies. They are specific socialpsychic formations taking place below the surface of various social systems cocreated by recursive externalization and internalization processes. These are bidirectional, taking place from individuals and smaller systems toward larger systems, and vice versa. They involve highly structured systems of social defenses and object relations that create alternative shelters from many macro- and micro-social mainstreams. Transiently or permanently, they become properties of the dynamic and foundational matrices of social systems. The members of such social systems tend to be unconscious of them, as if they are unconscious of their personal psychic retreats. They covertly influence multiple arrangements and dynamics at work within social-political power relations. As with personal dynamics, they may veer toward more positive or more negative states of mind, either partial or total. In their negative versions they indirectly disseminate totalitarian patterns/styles over social discourses and practices, whereas positive versions may be protective against these factors.

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Returning to examples from the same clinic as above: At the therapeutic community ward, over some period of time, the defensive relational “wall” put up against the clinic as a whole became increasingly rigid. Although initially in the service of positive social-psychic retreats protecting democratic therapeutic-community values, at some point it actually turned into negative social-psychic retreats, thus dismantling growth potentials. Similarly, on some other wards, even after the democratic changes in the whole country, for a very long time, the old totalitarian cultures encapsulated the ruling ward establishment and terrorized parts of the staff who continued resisting the changes. Social-psychic retreats are indeed often the hidden destructive rulers behind chronic resistances to change and obstacles to various social healing processes. SERBIAN REFLECTIVE CITIZENS PROGRAM Psychosocial methodology combining sibling fields of group work such as group analysis in small and large groups, social dreaming, Listening Posts, group relation methods with intergroup events, reflection-and-review groups, Bridger’s double-task principles, as well as therapeutic-community principles, have been being developed in Serbia for a learning community/network of Reflective Citizens over the last twelve years. The Psycho-Social Section of the Group Analytic Society–Belgrade, in cooperation with the PsychoSocial-Art (nongovernmental organization) and Consulting-Art (organization for psychodynamic consultancy and education), organize seasonal workshops in many towns and villages throughout the region. Their roots lie in the tradition of living communities of the Balkan region that have suffered social traumas over centuries, and still surviving within positive social-psychic retreats. Throughout the Yugoslav Communist regime, liberating citizens’ activities were relatively hidden as in the avant-garde arts, which were persecuted or abused when their work was co-opted for the regime’s propaganda. Through the 1990s, the destruction of Yugoslavia through its civil wars, reenactments of atrocities, and camps from World War II and the Communist regime produced an overwhelming dismantling of the fields into basic assumption groups. The fragmented pieces of matrices often took bizarre shapes, epitomized in such phrases as “tramps of demons” rambling around, fusing with “gangs of ghosts,” and “disillusioned children of darkness” (Mojović 2012, 2015; Penna 2016)—all “homeless” and “un-housed minds” (Scanlon and Adlam 2006). The need thus emerged to offer our fellow citizens some containing space where they and we can, for a while, reflect, talk about, and bear to stay with such difficulties, which freely appear in dreams, fantasies, and narratives.



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We started on a small scale. We arranged a setting for citizens dialogue groups, some large groups that then evolved into small peer groups and again fed back into the larger group. People would come once, or more than once, stay over the whole workshop, or perhaps only for a while, and would usually invite other people for the next occasion. Some participants discovered their own motivation and abilities to make Reflective-Citizen branches in microenvironments, such as their gardens, terraces, schools, student centers, Red Cross rooms, local cultural centers, on river floats, even on shipwrecks. They got support in order to learn to co-organize and to co-convene. Later throughout the training they would become independent conveners of Reflective Citizen groups and support other interested people on similar journeys. Thus, we decided to continue learning jointly to navigate through the uncertainties inherent in these systems. Over time the Reflective Citizens network became both generative and generous. On the one hand, it is often very difficult to bear the depth of suffering, facing the ugliness of many collective defenses, responsibilities, endless losses, and humiliation. On the other hand, the richness of human exchange, resonances, and narratives that arise through the act of listening are indeed astonishing. New understanding of psychosocial complexities may emerge. Rooted in the founding paradigm of group analysis, such endeavors build on the heritage and values of the citizenship training (Foulkes [1948] 1983; Hopper 2000; de Mare and Schöllberger 2004). The meeting of citizens’ minds exists in a horizontal/lateral mode of communication, with no hierarchy of discourses. There is not one single correct “Truth.” The core values of humanism, peace, and democracy are taken seriously. Old and new, personal and collective stories, where layers of the foundation matrix and the Reflective Citizen matrices meet and engage, constantly moving and creating new perspectives, cocreate a lively space, attracting people to engage more actively. The concept of each workshop as “a temporal organization,” borrowed from the group-relations tradition and Bridger’s transitional approach (Amado and Ambrose 2001), is built into the regular structure. Learning from other network organizations and systems is also important. Over the years this develops into a learning network, and the community of Reflective Citizens is now called Reflective Citizens Learning Community. REFLECTIVE CITIZENS BORN IN POSITIVE SOCIAL-PSYCHIC RETREATS From the historical roots of the Reflective Citizens’ methodology, we can consider two major root-groups in positive social-psychic retreats:

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Northfield’s psychodynamic group work and the psychosocial gatherings of citizens in the extreme social trauma of totalitarianism. Leading on from our regional example of “applied Reflective Citizens,” Vera Kelava, a psychologist from Banja Luka and member of Group Analytic Society–Belgrade, founded and has run for twenty years a successful program for democratic leaders in high schools throughout Bosnia and Herzegovina. This initiative, embracing literarily all three hundred high schools, with over twenty-five thousand children participating, has been until recently kept relatively invisible, as a sort of positive social-psychic retreat. REFLECTIVE CITIZENS REVEALING AND TRANSFORMING: NEGATIVE SOCIAL-PSYCHIC RETREATS Born officially after the anti-Communist revolution in Serbia, Reflective Citizens groups continued the habit of living in relatively invisible social spaces, keeping attuned to current local psychosocial reality. In Kosovo, for example, in spite of the various ongoing dangers of extremism, a group of group-analytic trainees created their Cultural Retreat, as they call it, organizing Reflective Citizens and applied Reflective Citizens such as holding reflection groups after films, exhibitions, small musical concerts, and for 2017 even preparing the first “Adventures Therapy” groups in the region. Equipped with an understanding of the social-psychic retreats dynamics from the group-analytic training, they cope with complex anti-group (Nitsun 1996) forces, which continuously challenge their work. There are endless examples of how Reflective Citizens reveal and transform social-psychic retreats, making very significant contributions to the learning through the experience of containing and turning totalitarian matrices into democratic matrices. I will illustrate with a vignette from recent Reflective Citizens workshop in Banja Luka, which records the different contributions people made in the group: “I had two Labradors, mother and daughter—they went everywhere with me. Recently, I dreamed our town was being bombed yet again. I was in a sanctuary, realizing that food supplies had dried up: even children were starving. A thought emerged: “I must kill my Labradors to feed the children. I decided that I had to do it myself. How would I do it? I woke up in horror.” “We tend to deny that the terror totally penetrated into our most intimate feelings of attachment and love, forcing us to kill or make unbearable choices, sometimes between our children. Your soul either dies or you turn into a monster!” “I just try to be in a numbed state . . . and really can’t say



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anything more about it here.” “I am also scared, especially, that there may be a new war. The politicians are yet again behaving irresponsibly. . . . We saw how nationalistic forces can make a hell of our country! . . . We are now citizens, who have to make effort to change, for as long as it takes.” “I agree. In spite of all the democratic changes in this country, the fear in people is still so strong. And we can’t even talk about it. Almost nothing is really worked through. So many old problems are in the air, not daring to be voiced. I know that my parents were emotionally frozen when faced with terror, and still continue to behave in that way. When I invited them for these citizens’ talks, they only waved me off.” “I absolutely can’t imagine that something like this would ever be possible to happen in the village where I come from. It was quite normal that parents beat their children, and it still is! It would never be possible to create this kind of reflective space.” “Communist culture was in a way resting on similar patriarchal/authoritarian norms. Fear is in the bones, thus, to own our feelings as a person, having a voice, no, that did not exist. There was simply no idea about something like that in our parents’ generation.” “For me, the dream tells that sometimes we have to participate in decisions that may result in painful losses for generations to come.” “Now I remember Gershwin’s song ‘Summertime,’ with which we started the very first Reflective Citizens in this town. This was the black mother’s lullaby as she dreamed the future for her baby, trying to find a way out. Using this song was like protecting the newborn Reflective Citizens from conception trauma and providing them with hope for the future time.” A young handsome man said, “Until recently, I wouldn’t be able to imagine anything else either. I trusted Vera. My father and a few more relatives were killed in Srebrenica because they were Muslims. I saw in myself, then, that it is possible to overcome feelings of hate and revenge. We are responsible, and our duty is to be active, to find ways to do this kind of sharing emotions and thoughts, to take this further. We all can do this. It is possible; look how we talk here!” Another man: “And this long-lasting program for democratic leaders of our Vera, embracing literally all schools in this country moved so many of us. But why don’t the media speak about it!? And why don’t we even speak, saying it is possible to transform?” Many were moved, cried, admired the honesty and brevity of these contributions. We can have here a flavor of the emerging negative social-psychic retreats in the Banja Luka Reflective Citizens matrix, and how these may begin to dissolve the current and past systems. The merging of the different layers of totalitarian matrices (from authoritarian family cultures, Communism, wars, and contemporary postwar society) came to the fore in these conversations. Various psychosocial loci of totalitarianism, placed in different images, personify the various places where totalitarianism still hides, like some hidden

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rulers: we have village gossips, violent parenting habits, pseudo-democratic oligarchs, and other similar phenomena. These gather into gang-like figurations, and reveal one singular type of process: Totalitarian/tyrannical psychosocial systems put pressure on all to collude in silence, avoiding punishments from the cruel dictatorship (internal and external). These internal and external figures deaden the self, paralyzing the ego and imprisoning vital aspects of the individual. We reach almost zero-level subjectivity (like autistic monsters) as Žižek (2008–2009) maintains. However, in the analytic and holding environment of the Reflective Citizens-groups, the opposite types of processes also occurred. In the light of shared memories, dreams and reflections, with their mirroring and entanglements of similar aspects, enabled many hidden angles of social-psychic retreats and heir internal regimes to receive analytic focus more easily. Each supporting the other in transformative efforts is, indeed, often more effective in small groups and special workshops like Reflective Citizens. “Protective shields” raised to defend against overwhelming terror, like that used by Perseus in ancient Greek mythology when fighting the almighty ugly Medusa, are more easily provided in psychodynamic groups (Mojović 2007b). We need groups that provide a good holding environment in order both to overcome and to understand the complexity of these pathological systems. The appeal of traumatized youth in finding courage for democratic development was so touching that it pulled groups toward making further steps in the transformation of the Reflective Citizens matrix, thus offering a meaningful learning experience as well as sparks of hope and faith. Thus, in this Reflective Citizens group in Banja Luka, two democratic matrices were encountered and empowered. From Vera’s democratic leadership network and the Reflective Citizens matrices’ role in positive mirroring, strength was gained for furthering a joint vision of developing sibling matrices, in spite of totalitarian matrices around us and within us. ENDING THOUGHTS Hanna Arendt’s ideas about taking exile from the unbearable world of horrendous totalitarianism into “inner emigration” (1951) comes to mind, perhaps as a sibling concept with social-psychic retreats. Lecturing about “Humanity in Dark Times,” she emphasizes the ways people migrate: whether by the detaching from reality (being for her a default position), that is, actually turning away from life and following the lost/dead object (as in negative social-psychic retreats), or conversely, when exile is used in the service of



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searching for new ways for confronting and engaging with reality (as with positive social-psychic retreats). For Arendt, as for Anna Freud, “it was only possible to remain in the world, and to love it enough to want to make it worth living again” (Stonebridge 2016, 43). Learning about mature citizenship by humanizing and transforming hate into democratic dialogue can change the figuration, rhythms of absurdities, and negative power of much social destructiveness into more harmonious channels, even when all seems dehumanized. There is a crack in everything That’s how the light gets in . . . —Leonard Cohen

REFERENCES Amado, Gilles, and Anthony Ambrose, eds. 2001. Transitional Approach to Change. London: Karnac. Antić, Ana. 2016. “Therapeutic Violence: Psychoanalysis and the ‘Re-education’ of Political Prisoners in Cold War Yugoslavia and Eastern Europe.” In Psychoanalysis in the Age of Totalitarianism, edited by Matt Ffytche and Daniel Pick. London: Routledge. Arendt, Hanna. 1951. The Origins of Totalitarianism. New York: Schocken Books. Bion, Wilfred. 1961. Experiences in Groups and Other Papers. London: Tavistock. ———. (1957) 1967. “Differentiation of the Psychotic from the Non-psychotic Personalities.” In Second Thoughts. London: Heinemann. Britton, Ronald. 1998. Belief and Imagination. London: Routledge. Dalal, Farhard. 1998. Taking the Group Seriously: Towards a Post-Foulkesian Group Analytical Theory. London: Jessica Kinsley. de Mare, Patrick, and Robert Schöllberger. 2004. “A Case for the Mind.” Group Analysis 37 (3): 339–52. Elias, Norbert. (1939) 1994. The Civilizing Process. Oxford: Blackwell. Ffytche, Matt, and Daniel Pick, eds. 2016. Psychoanalysis in the Age of Totalitarianism. London: Routledge. Foulkes, S. H. 1964. Therapeutic Group Analysis. London: Karnac. ———. (1948) 1983. “Introduction to Group Analytic Psychotherapy.” Selected Papers: Psychoanalysis and Group Analysis. London: Karnac. ———. (1990) 2004. Selected Papers: Psychoanalysis and Group Analysis. London: Karnac. Foulkes, S. H., and James Anthony. 1965. Group Psychotherapy: The Psychoanalytic Approach. London: Karnac. Grotstein, James. 2009. But at the Same Time and on Another Level: Psychoanalytic Technique in the Kleinian/ Bionian Mode. Volume 1. London: Karnac.

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Hinshelwood, Robert. 2000. “Foreword.” In Bion, Rickman, Foulkes, and the Northfield Experiments, edited by Tom Harrison. London: Jessica Kingsley. Hopper, Earl. 2000. “From Objects and Subjects to Citizens: Group Analysis and the Study of Maturity.” Group Analysis 33 (1): 29–34. ———. 2003. Traumatic Experience in the Unconscious Life of Groups. London: Jessica Kingsley. ———, ed. 2012. Trauma and Organizations. London: Karnac. Hopper, Earl, and Haim Weinberg, eds. 2011. The Social Unconscious in Persons, Groups and Societies: Volume 1: Mainly Theory. London: Karnac. Katz, Montana, Roosevelt Cassorla, and Giseppe Civitarese, eds. 2017. Advances in Contemporary Psychoanalytic Field Theory. London: Routledge. Mennell, Stephen. 1992. Norbert Elias: An Introduction. Dublin: University College Dublin Press. Mojović, Marina. 2007a. “The Impact of the Post-totalitarian Social Context on the Group Matrix.” Group Analysis 40 (3): 394–403. ———. 2007b. “Psychic Retreats as Defences from the Ugliness of War Gorgons and the Power of the Analytic Group.” Presented at the IAGP conference, Barcelona. ———. 2011. “Manifestations of Psychic Retreats in Social Systems.” In Social Unconscious in Persons, Groups and Societies, edited by Earl Hopper and Haim Weinberg. London: Karnac. ———. 2012. “Untouchable Infant Gangs in Group-Analytic Matrices.” Presented at IIGA Conference, Gonen. ———. 2015. “Disrupted Matrices: Challenges and Changes.” Group Analysis 48 (4): 540–57. ———. 2016. “Serbian Reflective Citizens: Matrix Flourishing in the Leaking Containers.” Group Analysis 50 (5): 370–84. ———. 2017. “Untouchable Infant Gangs in Group and Social Matrices as Obstacles for Reconciliation.” In A Bridge over Troubled Waters: Conflicts and Reconciliation in Groups and Societies, edited by G. Ofer. London: Karnac. Mojović, Marina, Tija Despotović, and Jelica Satarić. 2014. “Conception Trauma of Group Analysis in Serbia.” Group Analysis 47 (2): 111–27. Nitsun, Moris. 1996. The Anti-Group: Destructive Forces in the Group and Their Creative Potential. London: Routledge. Ogden, Thomas. 1989. “On the Concept of an Autistic-Contiguous Position.” International Journal of Psychoanalysis 70: 127–40. Penna, Carla. 2016. “The Ghost Matrix.” Group Analysis 49 (1): 50–63. Pick, Daniel, and Matt Ffytche. 2016. “Introduction.” In Psychoanalysis in the Age of Totalitarianism, edited by Matt Ffytche and Daniel Pick. London: Routledge. Scanlon, Christopher, and John Adlam. 2006. “Housing ‘Un-housed Minds’: InterPersonality Disorder in the Organisation?” Housing, Care and Support 9 (3): 9–14. Šebek, Michal. 1996. “The Fate of the Totalitarian Object.” International Forum of Psychoanalysis 5: 289–94. Steiner, John. 1993. Psychic Retreats: Pathological Organizations in Psychotic, Neurotic and Borderline Patients. London: Routledge.



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Stonebridge, Lyndsey. 2016. “Inner Emigration on the Run with Hanna Arendt and Anna Freud.” In Psychoanalysis in the Age of Totalitarianism, edited by Matt Ffytche and Daniel Pick. London: Routledge. Žižek, Slavoj. 2008–2009. “Descartes and the Post-Traumatic Subject.” FilozofskiVestnik 29 (2): 9–29.

12 A Post-totalitarian Group A Collective False Self or Posttraumatic Growth? Helena Klímová

Group analysis is the discipline best suited to study the existence of the so-

cial unconscious. The discipline is developing and is in constant relationship with other related disciplines, including history and politics. As the highly recognized group analyst Earl Hopper says, “The study of the social unconscious is always both a political and religious and philosophical project” (Hopper 2011). As group analysts, we are citizens of more than one contemporary society. Our views may be modified (even unconsciously, we have to admit) according to our different places of birth and our upbringing. The discoveries concerning the social unconscious may be motivated by the life events of their authors (including this author). These discoveries may be considered as proofs of their authors’ honest efforts to understand reality, to find the truth, and to report this to others. I am a Central European. I consider my way of thinking, my view of reality, to be rooted in the history of this part of the world and to be motivated by my own experience, both of the Holocaust and of the Communist regime. I am a personal survivor of both of these totalitarian regimes. Thus my view of the world situation may be partial, but it belongs to the complexity of the whole as one independent and unique part. My country is the Czech Republic (Czechoslovakia from 1918 until 1992), which belongs to the European Union. Culturally, Central Europe has enriched the whole European heritage, in particular with literature that reflects a unique way of thinking. Let me look at the Czech case with the use of the theory of the social unconscious. According to Haim Weinberg, “the social unconscious is the coconstructed shared unconscious of members of a certain social system such as community, society, nation or culture. It includes shared anxieties, fantasies, defenses, myths, and memories. Its building bricks are made of chosen 177

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traumas and chosen glories” (Weinberg 2007, 307–22). According to Earl Hopper, “The concept of the social unconscious refers to the existence and constraints of social, cultural and communicational arrangements of which people are unaware; unaware, in so far as these arrangements are not perceived (not ‘known’), and if perceived, not acknowledged (‘denied’), and if acknowledged, not taken as problematic (‘given’), and if taken as problematic, not considered with an optimal degree of detachment and objectivity” (Hopper 2001). Trauma may be the moving force, or it may be the initiation or the motivation for various types of internal group development. TRAUMA MAY BECOME THE ORIGIN OF FALSE IDENTITY In the individual, the traumatic experience may initiate defensive attempts to ward it off. In this case, if trauma takes precedence over his own vital defensive forces, the individual may develop a false self: he gives up part of his own being, which has been cultivated in order to feel safe in life, and instead accepts something that is forced onto him by his oppressor. He gives up his independent self-conception and submits to the dominating concept of the persecuting authority. Thus the victim, in order to defend himself, identifies with the aggressor: he creates a false self (Laplanche and Pontalis 1973, 208–9). In our therapeutic practice, the most common examples occur with individual patients—mostly women—who as children had been abused or cruelly punished. Such a child victim, in order to safeguard her understanding of life, assumes the guilt herself rather than accuse the abusing adult (“I am a bad child, I misbehaved, and thus I am being punished quite rightly”). In the child’s simple mind the dominant adult should be stable, strong, and supported in his godlike position, so that the child can salvage meaning in the world. The meaning of the world for the budding fragile mind is the most cherished value, even prior to self-defense. This is the way an individual false self might have been initiated. When the originally abused child grows up, she quite rightly stops supporting the persecutor in his false self-righteousness. However, what is much more difficult and painful to work through, what often motivates the victimized person to ask for psychotherapy, is her own damaged self-concept. The former victim very rarely has a sense of self-esteem. More often, she persists with self-accusations and self-blaming, taking on herself all sorts of inappropriate guilts. In such a case the existence of guilt dominates her whole life and comes to permeate her relationship to others; there is no aspect of human existence that escapes this guilt.



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THE HEALING PROCESS OF OVERCOMING THE FALSE SELF PROCEEDS IN TWO STEPS First, the former victim is able to perceive external reality—that is, to admit the true image of the aggressor as oppressive, false, not to be trusted, not to be adored. She becomes able to liberate herself from the external dominance of the aggressor. The true image of the external world is discovered and accepted. Second, the former victim is searching for her inner freedom to re-create a sense of self-acceptance, self-esteem, and a life of peaceful inner wholeness. The second step of the healing process may be difficult to reach. The search for the true image of oneself is a long-term project. Such traumatization cannot always be healed in the span of one person’s life, and can be transmitted beyond that life, influencing the next generation. The survivors, who are often trying to forget about the original trauma, may not even mention it, so their children may be protected. However, the guilt can be ubiquitous, found behind every innocent human error, or even natural catastrophe. Human relations in the span of generations are thus marred by a constant fear of guilt, a constant effort to avoid self-accusations, or—God forbid—accusations of others. The phenomenon of identification with the aggressor means that the victim gives up creating her own truthful self-conception and self-esteem and, instead, accepts as her own self-image one that reflects the aggressor’s standpoint, interest, and intention. Thus, the victim is the one blamed, deprived of self-esteem and of self-acceptance. By internalizing these accusations as part of her self-image, the victim thus creates her false self. Thus the phenomenon of the false self is born. It is important to stress that even when the small child has been abused and unjustly punished, she may be longing for acceptance, or even for love, from the cruel adult. Until she reaches a certain degree of maturation, the false self involves this sort of illusion: the oppressor might be good and loving if only the bad child could be good enough. Taking on the burden of guilt, an inner duty to improve relations with the other, or others, this burdened mission may scar the lives not only of individual victims, but whole groups. Groups that historically were frequently victimized sometimes tend to produce reformers who, in the effort to improve the world, start by suppressing elsewhere some feature seen as characteristic of their own original group. Sometimes, in their missionary effort, they even deny or hate their own identity, even perhaps at a group level. Thus, the members’ collective self may also become false.

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THE PHENOMENON OF THE FALSE COLLECTIVE SELF: GROUPS LIVING UNDER TOTALITARIANISM The developmental pattern of the false collective self was comparable to that of the individual false self: •  The needs, quality, uniqueness and boundaries of the subject (here, of the group) were suppressed, not permitted; •  In their place other needs (here, in the form of ideology), were substituted, then identified with, supported, nourished by group members; •  Although the process was enforced, it was experienced as the genuine wish of the subject because the subject had identified with the aggressor. (Klímová 2011, 198)

What may be seen as strange, even unbelievable, is that these types of totalitarian patterns may start voluntarily (e.g., through elections: Germany in the thirties; Czechoslovakia in 1948). Nations have created their false collective selves and accepted the rules—which proved to be totalitarian—after having experienced severe traumata. They willingly behaved in this way in the hope of creating a “better world.” The illusion that the mighty oppressor would actually be a savior was nourished (just as the small abused child is longing to be accepted by her “good” abuser). There are more recent historical examples where totalitarian regimes in Europe came to power entirely legally, through their victory in democratic elections. Let me stay for a while with my own personal memory. It brings me back to the end of World War II, which was one of the mightiest events in the experience of the generation. Vignette 1

The end of World War II was a historical moment of the most important political change, involving the shift of the ruling system. However, human souls were very much attracted by the experience of the senses, too. This experience was like a revelation—previously unseen, unheard of, unsmelled, untouched; it was historically new. The victorious army appeared, and it arrived not in strict formations, not with men marching in immaculate uniforms in severe obedience to the leader’s hysterical voice, which had formerly been the norm. On the contrary, on small, freely galloping horses, groups of victorious newcomers appeared in the village, dressed in worn-out remnants of uniforms. They did not take over the school to occupy it as their base. These strange newcomers made their camp behind one of the village barns.



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The children of the village orphanage came running, having been attracted by the endearing horses: the small horses seemed so grateful for any gentle touch. To touch the animal’s living skin, to smell the horses’ good odor, seemed quite new to the children, and was a powerful experience. Later in the day, the horses’ masters sat in a circle on wooden blocks, on stones, on some rugs, and started to sing. The children were listening to something quite different from their Sunday church songs: these new songs were full of passion, wildness, and an unknown mighty musicality. The children, as well as other villagers, felt enchanted. Later these strange new songs started to fill the air through national radio broadcasting. The new musicality proved to be one of the most powerful sensual forces that moved people’s feelings and enriched their experiences of the world. The big change of system connected with the end of the war was thus very much perceived by the senses and lived through with strong emotions. This was the case not only for the village children but also for the majority, for the intelligentsia, and for the master poets, whose new creations were filling the pages of newspapers. On the first anniversary of the end of the war, the people of Prague were dancing in the streets. Thus people’s minds were influenced ritually; people were immersed in a huge overwhelming ritual experience. The elections followed in 1948 and the Communist Party won, stressing its connection with the Soviet Union as a liberating power. The Soviet Communist party was introduced as the source of strong matriarchal support and maternal emotions, as the embodiment of an archetype—a “Mother Party.” The warnings of those who were aware of the totalitarian danger were not listened to. This is how the totalitarian system started; and it lasted for decades. It started quite peacefully and legally, with the powerful support of irrational ritual experience. This immersive regression liberated the large group from the previous oppressor’s dominance and accused that group, quite rightly, of war crimes.

The group process could thus be compared to that of the formerly abused child on her way to maturation and liberation. First, she is able to discover the aggressive and oppressive nature of the aggressor and free herself from his outer dominance, and then she can reappraise her own self-image and develop full appreciation of the self. However, what may be hidden still are those very aspects of her inner disposition that had previously allowed her to suffer in order to survive, to adapt to the situation of violence and exploitation. This inner disposition may be lasting at an unconscious level as the basic motivation of her false self, affecting her low trust in her own capacity for

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independent life, and her unconscious expectations of a new good authority to appear as a savior. In short, while the original aggressor as a person might be discovered in his destructive nature and consequently unmasked and refused entry, the psychological form can remain, expecting to be fulfilled from another source: this is the structure of a dependent personality. Consciously, the previously victimized person wishes to be made complete in a better way, but unconsciously she may choose something not in accordance with her conscious wishes: she chooses a path where she is still able to suffer. Her frustration tolerance has been made very high, almost not functioning. She has been made able to bear and to survive a very destructive authority, a very destructive partnership. These unconscious psychological forms then prove powerful. While actual personal choices during a person’s life may repeatedly shift (as soon as the original victim recognizes, again, her customary faulty choice), the basic underlying psychological form remains, expecting to be fulfilled. Thus, conscious expectation may be continually disappointed. The initial liberation does not suddenly make a new person. Liberation can be reached only by gradual awareness, by making the whole situation conscious over time. Then the eternal question of who is guilty becomes senseless. The person can abandon her false self, her dependence on the (originally unrecognized) aggressive authority. She is then able to acquire the inner independence and self-esteem she has been seeking. She becomes whole, able to feel her true self and to act accordingly. Through the individual journey from the false self toward healing awareness, the possible journey of the group can also be perceived. There can be a collective journey from the original false collective self toward both inner freedom and outer liberation. As I have emphasized, the individual way is difficult and certainly by no means always successful. In the same way, the group journey from the collective false self toward inner freedom may be a task for generations. As postwar history developed, the one originally seen as a mighty savior— the Soviet Union—was later proved to be using aggressive means to maintain dominance and power. Together with the process of discovering the aggressive, oppressive part of the original savior, the citizens of Czechoslovakia started to understand something about their submissive role and their cooperation in the whole situation: the collective false self concept was ready to be discovered. Even when the term itself was still not found and formulated, its meaning began to be expressed and verbalized. From the outside, it may seem as if the Czechs and Slovaks were a sort of primitive tribe that could be easily manipulated through irrational means. But prewar Czechoslovakia had been one of the most industrial European coun-



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tries, with well-educated citizens and virtually no illiteracy. Czechoslovakia was known for its citizens’ ability both to create prosperous industries and to develop and keep democratic rules. Prewar Czechoslovakia was able to support many students from other countries and, later, was ready to provide a home for refugees from authoritarian regimes. In order to explain the paradox of the postwar elections that enabled totalitarianism to be installed, it is necessary to consider further the historical context. The almost blind way in which the citizens of Czechoslovakia after World War II mainly embraced the influence from the East has been explained, first, as a reaction to the previous fatal disappointment that was caused by the Munich pact of 1938. At that time, the Western allies of Czechoslovakia abandoned their previous promises and agreed that Czechoslovakia should give up a rather substantial part of its territory to Hitler’s Germany. The Western intention, namely to save the peace by sacrificing an independent country, did not, in any case, succeed, but the people of Czechoslovakia felt betrayed and deprived of their substantial trust in positive ideals. This is how historians usually explain the total submission of postwar Czechoslovakia to the Eastern influence. The social unconscious theory may however provide deeper insight. ON THE POWER OF “DEPOSITED IMAGES” One aspect of clinical observation that is especially relevant to understanding certain components of large-group identity is the transgenerational transmission of trauma. . . . There is a fluidity between a mother’s and child’s psychic borders. . . . The mother’s anxiety, unconscious fantasies, and perceptions and expectations of the external world, including those relating to her child, can pass into the child’s developing sense of self. . . . Psychic borders can be permeable in a relationship between a grown child and parent, or between two adult individuals when they relate to one another under drastically regressed or partly regressed states. (Volkan 2001, 85–87)

Thus Volkan coined the term “deposited image”: “The ‘deposited image’ then becomes like a psychological gene that influences the child’s identity . . . and manifests in ‘tasks’ the child is unconsciously impelled to perform, such as conducting the mourning that the mother cannot perform” (Volkan 2001). Volkan’s theory of deposited image has been supported by recent discoveries in biology, which indicate the possible material basis of those images: An international team [led] by Rachel Yehuda, professor at Mount Sinai hospital in New York, and for the molecular analyses Elisabeth Binder, director of

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the Max Planck Institute of Psychiatry in Munich, studied the genes of 32 Jewish individuals who had been held in concentration camps, experienced torture or had been forced into hiding during the Second World War. The researchers additionally examined the genes of the group’s children who are known to have an increased likelihood of stress disorders, and compared the results with Jewish families living outside Europe during the Holocaust. . . . “With ‘epigenetic’ we mean all processes that do not change its actual genetic code but alter its accessibility,” explains Elisabeth Binder. . . . The results suggest that “epigenetic inheritance,” where a person’s life experiences can affect the genes of their offspring, may play an important part in a child’s development. “The gene changes in the children did not appear to be mediated by adversity experienced during their own childhood but could only be attributed to Holocaust exposure in their parents,” said Rachel Yehuda. “Environmental influences such as stress, smoking or diet can affect the genes of our children. Early detection of such epigenetic markers may advance the development of preventive strategies to address the intergenerational affects of exposure to trauma.” (Niedl 2015)

While taking for granted the transmission of trauma in individuals, let us consider, too, the possibility of the transmission of trauma in groups. Apart from the term “deposited image,” Volkan has also coined the terms “chosen trauma” and “chosen glory”: One can observe processes at the group level that parallel those of individuals. . . . Within virtually every large group there exists a shared mental representation of a traumatic past event during which the large group suffered loss and/ or experienced helplessness, shame and humiliation in a conflict with another large group. Transgenerational transmission . . . is linked to the past generation’s inability to mourn losses of people, land or prestige, and indicates the large group’s failure to reverse narcissistic injury and humiliation. . . . Their injured self-images associated with the mental representations of the shared traumatic event are ‘deposited’ into the developing self-representation of children in the next generation. . . . With time, the chosen trauma changes function. The historical truth about the event is no longer important for the large group, but what is important is that through sharing the chosen trauma members of the group are linked together. (Volkan 2001, 87–88)

Through sharing the chosen trauma, members of the group are linked together. Here is the possible mechanism: the traumatic event has afflicted the whole large group and the experience is transmitted into families to be chewed and digested as bitter nourishment. The children grow up nourished by parents and grandparents who were not able to complete their mourning (as the trauma burst through the boundaries of individuals and a single generation). The experience of treating a subject as taboo, of sorrow without boundaries, of hopeless and helpless anger—all the usual companions of



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group trauma—are transmitted down the generations. At such times the exact historical context is overshadowed by the group’s vital need to find and establish meaning as a way of turning endless mourning into an acceptable structure for thinking. While, as the time goes by, the exact details of the traumatic story fade, the experienced energy—the anger, sorrow, and disappointment—is lasting. As we know from physics, energies are not destroyed. However, the energy is trying to find a way in which it can be used, to be transformed into some vital acceptable form or shape, which can then be expressed as meaning. The meaning is discovered and expressed by group creative forces and by culture: the group creates its own epics and poems. The epics of the group are designed to heal the traumatic wounds by retelling the basic traumatic event anew in a way in which meaning can be found and expressed. Meaning is key and is used to console, to heal, and to replace mourning. Poems, songs, dances—these are the ways in which the newly discovered and expressed meanings are celebrated. Thus the group traumatic event may start the process of group individuation, of the search for meaning, of realizing the necessity to create structure, roles, and boundaries—inner boundaries to mark the group identity and outer boundaries to avoid another possible trauma from the external world. As a result of the aforementioned processes, the feelings of group identity may be created and strengthened: thus the nation may be reborn. Let us consider the basic heroic epic richness of our culture: nations and cultures come to life after having survived traumatic events, after having created narrative richness that formulates meaning. The “deposited image” thus may be seen as a task to be solved, the task that is assigned, by the group, from generation to generation. The group creative forces are able to turn the trauma into an event by which the group meaning may be discovered and thus the group uniqueness established. Thus, the group is turned into a tribe or a nation with its own self-awareness and, probably, with a special self-imposed task or mission. The task may, however, be seen quite differently from the point of the group itself and from the perspective of its neighbors of other groups. In some cases, the difference may even turn into animosity. The difference exists here in the ways of viewing what is normal and what is deviant, for individuals as well as for groups. While individual irregularities and diseases can be described and stated relatively easily as soon as consensus among the scientists is achieved, with groups, the situation is different, more complicated, and more difficult. There may not be one single authority, as every historian belongs to his own group, and thus opinions sometimes may not be seen as independent. Thus, for example, the heroic group narrative may be

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perceived by the group’s neighbors as being the inevitable outcome of the chosen trauma. It is then that the broader term of “deposited image” seems more neutral and appropriate. The Czech “deposited image” has been painfully brought into awareness once more in the middle decades of the last century and may have been the experience of the repeated collective defeats. Its first/original appearance can be traced back centuries to its first imprinting.

Vignette 2

There has been in the Czech collective memory an imprinted image of the prosperous Czech kingdom in the fourteenth century. Prague University was founded as one of the first on the continent, and its master, Jan Hus, was gaining respect and admiration. His way of public teaching and preaching was based on a free way of thinking, on independent cognition and its truthful expression. Because of his search for truth, however, he was seen by the Catholic Church as a heretic. He was summoned to face the convention and was consequently burned alive in 1415. As a reaction to this, the armed uprising started. Later it developed into the Czech reformation movement, then reaching its spiritual maturation. A hundred years prior to the rest of Europe, the Reformation movement grew up in Bohemia, where the majority of Czechs belonged to some reformed denomination and in the relative freedom of worship and freedom of thinking. In the first quarter of the seventeenth century, the Habsburg monarchy seized power, ended Czech independence, and initiated the return of Catholicism by force. Many inhabitants left the country. People who stayed were subsequently forced for three hundred years to develop a variety of survival strategies. Some of these can be seen as signs of the false collective self. These three hundred years of subjugation were followed by the experience of World War I. Finally, state sovereignty was reached again and the independent Czechoslovak republic was founded in 1918.

This story may be seen as formative for the appearance in the group of the self-awareness of those who belong together. It began by the murder of the group hero by foreigners, which aroused decades of militant protest initiated by the hero’s followers. For two hundred years the rising group had striven for independence, and then for another three hundred years its members had to be subjugated to the will of the mighty aggressor. With major global trans-

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formations occurring after World War I, the hope for possible final independence arose again, and was marred again by the beginning of the World War II, starting, as it did, with the breach of faith in Munich, as I have recounted earlier. Thus, special turning points in group history can be seen as repeated trauma. The group yearned for the independent truthful way of life but was repeatedly defeated: by betrayal or by aggressive primitive forces from outside. This is what the Czech “deposited image” is about. The “deposited image” has been accompanied and followed by a rich variety of surviving strategies. Some of them belong to the concept of the false collective self; others may be seen as the signs of posttraumatic growth. All these survival strategies were brought to collective consciousness through culture, in the shape of tales and songs, and in the choice of heroes. The group has created various types of heroes. These heroes have represented special ways in which the group was using its creative forces to find meaning: to find what is good, what is wrong, and how to differentiate the two. As more beliefs arose, more strategies were evolved. This variety of beliefs, of viewpoints, of behavior, then marked some of the original cultural stereotypes or original heroes. Thus, throughout the last hundred years, the hero who had been seen to represent Czech culture, evolved into a new “deposited image.”

Vignette 3

The first example of a Czech hero that usually comes to the minds of those who are watching from outside the country is Švejk, “the good soldier” (from the novel by Jaroslav Hašek, 1921–1923). Actually, Švejk is everything but a soldier; he is lacking any sign of heroism and expresses direct opposition to any sign of order and structure. His fake and exaggerated obedience to military authorities is accompanied by inner disgrace and mockery; this attitude in itself reflects the rising awareness of the group’s false collective self—how to express this and still survive. Not all Czechs are admirers of this book, however. Not everybody identifies with it. Another hero of Czech culture appeared during the Communist regime and was immediately cordially welcomed by the audience and by readers: Jára Cimrman. Similarly to Švejk, he had been invented as a literary device (in 1966 by a group of authors), but he was presented as if he really existed as a living person. A collective game was started that suggested that we all are aware of his fake existence but we like to play with the idea that he was real. This game was accepted with enormous enthusiasm by the audience. The collective pleasure of the whole

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group came at the time when European nations were searching for their heroes. In 2002 the BBC had inspired the program named Greatest Britons. Czech TV was one of the many national TVs that bought the license to this program, and in 2005, the Czechs came up with their own response. The search for the greatest national hero was one taken up with the utmost pleasure by many Czechs and was continued in the game. The hero was named as Jára Cimrman: his name had reached the top of the ladder. Then the Czech TV bosses consulted with their British colleagues and consequently forbade the choice of fictitious heroes (even if the English audience, too, had named, King Arthur, another literary fiction, as one of their own heroes). After Jára Cimrman’s nomination was forbidden, a spontaneous petition appeared, signed by the Czech audience and demanding that Jara Cimrman’s character be allowed to be named the greatest Czech. Indeed he has in one sense really existed—if not in his own physical body then in the minds and hearts of so many people, starting with his creators. “Although the character was originally meant to be just a modest caricature of the Czech people, history, and culture he became an immensely popular protagonist of modern Czech folklore and an ersatz national hero. Cimrman is both the major character and the putative author of a great number of books, plays, and films. . . . He is presented as one of the greatest Czech playwrights, poets, composers, teachers, travelers, philosophers, inventors, detectives, mathematicians, amateur obstetricians, and sportsmen of the nineteenth and early twentieth centuries. Playing the game about his real existence is part of his characterization” (www.Jára Cimrman.cz). Jára Cimrman’s existence gradually outlived some of his original creators. Through the decades new authors and new actors joined and contributed to the original idea. New theatrical plays appeared allegedly written by Jára Cimrman and were introduced by playful scientific lectures. Meanwhile, some of the quotations became part of popular jargon; some sayings became characteristic especially in the language of the younger more informal generation. What was the reason of this strange collective phenomenon? What made the two characters—Švejk and Jára Cimrman—come to represent something special for the whole group? Both are seen as sui generis heroes. But what sort of heroes? Actually fake heroes. Both are invented, and both are deeply non-heroic. Švejk is presented as a simpleton and sometimes he is even proclaimed, by military authorities, to be an idiot. He is strong, however, in his



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survival strategies, and from his low position he is able to cheat the authorities, whom the reader can then see as the real stupid ones. This is the moment when readers feel attracted, when they can identify with the low and feeble one who is able to win over the mighty one. This type of hero has been rooted in the simple tales of European culture generally and repeatedly: the youngest of several sons (usually three sons are enough), the stupid Hans (Hloupý Honza), even the small David who later beats the big Goliath. Švejk seems to approach the archetype and as such he may be fulfilling some deep human need, the need to win over the strong but unjust authority. Jára Cimrman seems at first sight to be fulfilling a somewhat similar basic wish: that the genius of low origin is able to win over the hostile structures of power. But this basic idea is just the first level of Jára Cimrman’s tales. Immediately the audience rises to the second level, which offers a better perspective and the true possibility of realizing the funny side of all this effort: the ability to laugh at all those attempts to gain world fame and prestige. The so-called genius in fact is a mischief maker, but we can laugh with relief at this, as this hero has been created with the best sense of intelligent humor and self-acceptance. Both Švejk and Jára Cimrman, each one in his own particular way, have represented some special idea that made them strong and attractive in an unusual way. Both characters can be seen as representing the special attempts of how to find, in the specific historical situation of the group, the true meaning of masculinity, of heroism, of patriarchal virtues. The response was negative: we are not heroes. So, what made them so attractive for the group to choose them as protagonists? Both Švejk and Jára Cimrman revealed the liberating truth of the group. Švejk represented a non-heroic type, as in the world around him any heroism would be false, useless, or self-destructive. There was no place for heroism, as it cannot be attached to any positive ideal. The only good thing was simply to survive. So what can be found as appealing in such a finding? There was one clear advantage: such finding was free of pretense, free of the false collective self, and thus was felt as liberating. Cimrman was the more recent “hero” of group culture, presented as one of the great Czech playwrights, poets, composers, teachers, travelers, philosophers, inventors, detectives, mathematicians, amateur obstetricians, and sportsmen of the nineteenth and early twentieth centuries. From the beginning his character was conceived as a gentle, sophisticated mockery of all ambitions, even in the sphere of intellect: as if there was no place for any group hero. The only reward for creating such a non-heroic character as the group hero was the relief connected with self-acceptance in truth. But can this identification of the group, first with Švejk and later with Cimrman, be seen as the final result of the group process? The group can be

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recognized and understood through its literary heroes, which are accepted as representing some basic characteristics proper to the group itself. While the unfinished mourning of the collective injury—that is, the transgenerational transmission of trauma, may be compared to the group neurosis, group culture is both the moving force and the outcome of the healing process. Culture is the power by which the group is able to renew its life. Culture is the way of both using and giving birth to the group spirit itself. Thus, the truth discovered through literary heroes helps to recreate the inner truth, the healing force of the group. Group analysts are interested too, not only in the stories and their meanings for adults, but also in what is usually overlooked but may signify something important: the culture of mother talk and of the art and literature designed for children. While the Czech culture for adults gave birth to those two characters well suited for group-analytic attention (Švejk and Cimrman), what was designed as the culture for children also seems to deserve this attention. Throughout the last century, two playful characters appeared that intended to offer leading examples to children: these were Ferda Mravenec and, more recently, Krteček, both introduced as cartoons, with Krteček also appearing later in short films. Ferda the Ant organized other inhabitants of his anthill for sporting activities, for any cooperation in group work, for common goals. He demonstrated a fine intellect and a readiness for any job. He could mend broken things, he was kind to various insect-beings, was gifted with a high IQ, and had the ability to work and to have a good time with others. He inhabited the time of the middle of the last century. After the middle of the last century Krteček (Little Mole) was introduced. Krteček usually appeared in the company of the Little Mouse Girl and other animal friends. They were created not as caricatures to be laughed at, nor as cute sweet pretenders. Instead, they were symbolic images of cooperating and developing a loving human family. Krteček was the one who cared for others and helped them when necessary, with humor and creativity. Neither Ferda the Ant nor Krteček were fighters or heroes. Actually, in their stories there is no physical fighting, mockery of any enemy, or cruelty, even when both animal heroes are bravely standing for truthful animal relations and are ready to defend the right thing. This was probably the reason why they won such sincere admiration within families and why their cartoons and films were admired abroad. (Unfortunately these two nice creatures were not allowed to stay at home. Last time Ferda the Ant was seen, he was playing a role in a foreign film. Krteček in recent years [as soon as his author passed away] was sold to China, to accompany the tales of the big Chinese panda. It is not easy to avoid thinking about the symbolic meaning of these two endings.)



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However, an interesting finding comes to one’s mind when comparing with other heroes of European culture. With all those four literary heroes, two for adults, two for children, an important pattern is missing in their stories, either having been played down or being absent entirely. What is missing is the drama-triangle that usually accompanies any tale as its ground plan. The drama triangle is a triad consisting of three roles: Persecutor, Victim, and Savior. From the earliest human beginnings this triad used to appear as the basic pattern of any dramatic plot. This triad stepped up from the collective unconscious as a way of organizing group energy and the power of instincts, namely of aggression, in order to find meaning and to save the group as a whole. The drama triangle is inscribed as a pattern into all dramatic tales, starting with the myth of the first humans, through folk tales, Shakespearian drama, and crime stories—with the typical triad of murderer, victim, detective—to Harry Potter. All these stories use their thrilling plots and interesting situations to alert human minds to the notion of separating evil from good and recognizing the right solution, for the sake of the survival of the human group. Many human groups have derived their right to exist from some basic primordial story, from the special founding myth with the drama triangle inscribed at its roots. But contrary to drama and literature, interpretation of a real-life situation according to this triangle would be seen as a neurotic pattern. The drama triangle can be seen as a special case of archetypal typology, which—like the other archetypes—is to be eternally sought for, but never reached in reality. The drama triangle is based on the presumption of guilt. But in reality, therapists try to avoid any superfluous guilt feelings and accusations, what can be seen as the eternal wandering of guilt: we see this as the possible foundation of neurosis. (Even in everyday prayers one of the most important pleas is for the redemption of guilt and for the mutual ability to forgive.) From this point of view it seems interesting indeed that those two heroes— Švejk and Cimrman—seem to exist somehow apart from any real tough drama triangle. The Persecutor may exist somewhere, but any fear, fight, or hatred is overcome by the main frame of mind, which is life-saving laughter. Ferda the Ant and Krteček, the two main characters of the children’s tales, seem to demonstrate similar life conditions: their little stories are made of humor and good states of mind with happy endings; their world is easy to organize. Last but not least: similarly to the four protagonists of group culture, the national anthem, too was chosen, more than a century ago, by the majority. And what a strange song it is, unlike other anthems. It does not mention any fight, any enemy’s blood drying and blackening on our roads, it does not worship any person or any state organization. The words of the national anthem praise the water running over the meadows, the forests murmuring over the rocks, the flowers growing in the gardens. It is as if the culture that resolved

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from the original group trauma did not mention any drama triangle. There is no mention of the cruel enemy-Persecutor, there is no victimization, there is no need for a Savior. The world can be inhabited and life is worth living. The reality principle is the leading force. There is one more exceptional feature in Czech culture and history: since the beginning of the state that was created at the end of the World War I, the Czechs have become the major non-believers among the Europeans. Thus the whole way of thinking is influenced differently. There are no group idols seen as saints, or saintly, and other idols are easily mocked. At the beginning of this chapter the experience of the repeated collective defeats was considered to have been the possible basis for the group’s deposited image. Group traumatic events may also have started the alternative process of group individuation. The energy awakened by the group traumatic event may turn into the search for meaning. The search for meaning is expressed by repeated attempts to create a hero who would be able to express, through his story, the most important message of, and for, the group. In the Czech case, the message may be to leave the realm of heroes and victims, the realm of the sacred and the damned, the realm of group regression, and to find support in sober reality with its helpful relieving mirror of humor. The task then appears to be, for every living contemporary generation, to search for the truth, to distinguish between right and wrong in every life situation, every time anew, and in full consciousness. REFERENCES Hopper, Earl. 2001. “The Social Unconscious: Theoretical Considerations.” Group Analysis 34 (1): 9–27. ———. 2011. “Foreword.” In The Social Unconscious in Persons, Groups and Societies, Vol. 1, edited by Earl Hopper and Haim Weinberg. London: Karnac Books. Klímova, Helena. 2011. “The False We/The False Collective Self.” In The Social Unconscious in Persons, Groups and Societies, Vol. 1, edited by Earl Hopper and Haim Weinberg. London: Karnac Books. Laplanche, Jean, and Jean-Bertrand Pontalis. 1973. The Language of PsychoAnalysis. London: The Hogarth Press and The Institute of Psycho-Analysis. Niedl, Anna. 2015. “Holocaust Survivors Pass on Trauma to their Children’s Genes.” Max-Planck Gesellschaft, https://www.mpg.de/9375728/holocaust-trauma-epi genetics. Volkan, Vamik. 2001. “Transgenerational Transmission and Chosen Traumas: An Aspect of Large Group Identity.” Group Analysis 34 (1): 85–87. Weinberg, Haim. 2007. “So What Is This Social Unconscious Anyway?” Group Analysis 40 (3): 307–22.

IV CLINICAL MATERIAL Bernd Huppertz

Eight cases with case histories and a brief summary of treatment of trau-

matized patients are described by me from my private psychiatric/psychotherapeutic practice in the former GDR. I begin by offering a series of brief summaries of the patients and their personal histories. Subsequent chapters provide more detailed accounts of the patients and their treatment. Impressions of Trauma Just dead When it was clear that I was dead, Just dead, Suddenly everything was clear. I ascertained it While eating, Looking out on the empty street, And stuffing shrimps with Judas ears into me. Suddenly everything was clear Just like that, just dead. A Lake of Tears A lake of tears my soul, The time and all the losses, the loved and dear, A deep sea of tears, All the years, my life, Fears, fights and escape, So many disruptions, All my life, Fragments of the past! 193

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Painful Mourning Painful mourning, Like raw flesh, Always diffuse pain, Every thought, always this pain, Away, still there is this wound, Blood, scab, tattered, raw flesh, No secure protecting limit there, Away, No again, no repetition, Just dead. —Anonymous

13 Case History Summaries

THE CASE OF MR. Q

This is the case history of a man in his mid-twenties who was a science

student. He came into treatment complaining of lack of concentration due to cycles of depression that prevented him from studying. In addition, he was also preoccupied by his inability to find a partner. His maternal family history revealed a great deal of traumatic experience. This rural family, coming from an Eastern country, had experienced violence and terror and witnessed political as well as community violence. Expulsion had resulted in displacement with resulting separation and loss; homelessness and subsequent migration had taken place against a background of arson and murder. The paternal history was unclear but was also marked by war and migration. The parents’ intercultural marriage had resulted in a cultural mix where both sides had the experience of prolonged trauma. He said his mother looked after him only when she felt he had not had enough to eat. The first word she had taught him in her mother tongue was “keep your distance.” She seemed to have cared little for his needs and indicated that this was in fact his father’s responsibility. His father had been different, having a rather warmer personality; he had read to his son and sung songs to him, although he had also been somewhat fussy and pedantic. Thus, Mr. Q felt a lack of his mother’s emotional presence in his childhood and he had, as a result, felt alone. Both parents seemed to have had low emotional expectations and capacities, and it seems that his mother, in particular, had suffered because of the results of intergenerational family trauma. The consequence was that neither his authoritarian mother nor his pedantic and rather restricted father could engender feelings of warmth for their son, who suffered a sense of insecure attachment as a result. He 195

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was trapped and unable to free himself of these generational problems, with parents who failed to give him enough of a sense of identity and emotional stability. The constant maternal rejection haunted him; one might term this emotional abuse. Subsequently, the loss of a girlfriend in an accident added further trauma to what was already ingrained. As a child, Mr. Q had sensed himself always to be a loner, a dreamy boy who had trouble concentrating. He suffered from an overwhelming lack of self-confidence, feared to assert himself in any way, and was plagued by intense fears about his attachment figures, which were stirred up even more by any threatened separation and loss. During his treatment, it became clear to me that he needed to have concrete proofs of love and had a tendency to be massively injured by anything he perceived to be an emotional slight. As the treatment unfolded over time he became increasingly able to acknowledge and accept a sense of real understanding and support from me. THE CASE OF MRS. U Mrs. U was seventy years old when she came into treatment because of repeated acute depressive problems. Throughout her life, Mrs. U had experienced the darker sides of German history, both in the past and more recently. When she was a child during the war, she had witnessed actual violence and had experienced the outcomes of political power struggles: eviction and flight, homelessness, and the threat of violence and death. In the end, she became a refugee. Mrs. U spoke about all of these chilling experiences in a somewhat detached and distant way, as if they were part of normal life. The family history showed intergenerational trauma stretching back over many years. Mrs. U could trace her family history back to the twelfth century, when the family had immigrated from the Rhine-Moselle valley to a country to the east. They had lived there in a tribal situation, where marriage outside the clan had not been encouraged. Finally, after the end of the First World War, the children of the family had been able to become citizens of the country in which they had been born. Mrs. U’s paternal grandparents had been involved in making agricultural products in the east. Her father, also an agricultural producer, and his younger brother, had both been conscripted and subsequently killed in the Second World War. Her maternal grandparents had been similarly involved in terms of work in the east, and had died there. Mrs. U’s mother was their third child and she had arrived as an immigrant to Germany in the late 1980s. Mrs. U’s parents had married in the east at the beginning of the 1930s and Mrs. U, the second of five children, had been an unplanned child. Her parents had very much hoped for a boy; their previous girl had



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died in infancy from dysentery the year before. Childhood had been a Spartan time, Mrs. U recalled. Her mother had been a strict woman who often beat her children. In 1944, as the war came ever closer, Mrs. U, then ten years old, fled with her mother and siblings toward the east, with the idea of entering another country by that route. Meanwhile, her father was fighting with the Germans in the war. It was a terrifying flight, and the family had ended up being driven in a cattle truck. Finally, they arrived at Christmastime at the place where Mrs. U still lives today. Things hardly improved at all after the war ended; in fact, life did not get better until the end of the 1950s. Mrs. U had always needed to toe the line in order to avoid conflict or rejection. She talked about how both during and after the war she had constantly feared the loss of parental love. The strict treatment meted out by her mother had resulted in the internalization of a strict superego figure. The outcome of this strict childhood had cultivated in Mrs. U a rigid obstinacy. She seemed to be extremely controlled and controlling and to have restricted thoughts and feelings. It was difficult for her to freely associate. She preferred to talk in a concrete way about concrete events, and she displayed a clinging dependence. At the heart of her personality there lay a sense of deep mistrust and unbending rigidity. THE CASE OF MR. R Mr. R began treatment with me following a traumatic cancer diagnosis, surgery, and chemotherapy. A university-educated man in his mid-fifties, he suffered from irritability and lack of energy. He had chronic insomnia and suffered both from an inability to concentrate and short-term memory problems. His life had featured frequent separations, which had been very hard for him to bear. Many individuals in his family had lived in eastern countries; both the First and Second World Wars had been the cause of frequent changes of both citizenship and nationality for them. The resultant migrations and upheavals pointed to the evidence of severe intergenerational traumata. Mr. R’s illness had robbed him of any feelings of independence and self-sufficiency. He was his father’s sixth child and his mother’s second child. He was the last child living with his parents, so had thought of himself as an only child despite all these siblings. He had been illegitimate, conceived when his father was still in a previous marriage. When the divorce finally went through, Mr. R was happy to receive his father’s name after his parents married, as previously he had taken his mother’s name. Thus, as with the issue of national identity, there had been changes that had impacted on Mr. R’s sense of self within his family setting. Mr. R had felt himself to be somewhat of an outsider at school because he had changed schools frequently, losing friends along the

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way. His father used to beat him with his trouser belt, and Mr. R used to dissociate rather than cry out. Thus his father, although a role model, was a severe and overbearing one. Mr. R had been loved as long as he toed the line. If he didn’t, then his father became rigid and dogmatic. The marriage became more and more difficult, and a crisis point was reached. The parents moved twice and then finally divorced, and Mr. R was forced to testify in court that the marriage had indeed broken down, much against his most ardent desire, in line with his mother’s, that his parents would be reunited. So there was a background history that must have contributed a great deal to Mr. R’s states of depression. He himself had had a girlfriend whom he loved dearly and they eventually married and had four sons. Then his wife had an affair, and so this marriage too resulted in divorce. This was a very bad time for Mr. R. There had been conflict at work over his contract, and he had left the firm to become a self-employed tax consultant. Following all these losses he did find a new partner, but after the cancer diagnosis he had reacted with acute depressive symptoms. He was thrown into states of confusion and fear: all his plans were overturned. He was clearly a sensitive man, who was easily injured. Any threat of separation or loss threw him into panic, and he had a very low tolerance of frustration when his own demands were thwarted. He had suffered emotional deprivation from the start, raised by two parents who he felt had both been wanting in terms of what they had offered him. He complained repeatedly of all the various separations that had occurred in his life: how he had felt (and had been) permanently on the move as a child and had suffered later losses both at work and in his private life. If any confrontation threatened, he would simply retreat into a fantasy world. THE CASE OF MRS. O Mrs. O was a woman in her sixties when she came into treatment, suffering from the aftermath of an acute trauma. After one of many episodes of domestic violence her husband had threatened to burn the house down with her inside it. She managed to escape through the window and now lived in a much smaller flat in a run-down area. This had, of course, been a massive life change for her, and she had referred herself because of feelings of acute depression. She said things had been bad between her and her husband for about fifteen years. She felt timid and irritable and was full of complaints. Flashbacks of various traumatic events occurred, and she tended to avoid any situation that might provoke them. She tired easily and found it hard to remember things and to concentrate. She was sensitive to any upset and had trouble sleeping at night. The darker sides of German history had been



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reflected in her family too, both those in the recent past and further back over time. During the Second World War, she had seen much violence as a result of political power struggles and had become a refugee following eviction and separation, homelessness, and headlong flight. She spoke about these events full of death and destruction in a detached way, as if they had been quite normal. But she became upset when she spoke of the more recent traumas. Both sets of grandparents had lived in the east, where her parents had met and married in 1936. She had warm feelings both about her parents and her early childhood. She had been a premature baby, but life had continued normally until the family had to escape from the eastern area while her father was at war. She and her mother and sisters were continually on the move, fleeing the front where the Red Army was steadily advancing with its trains, carriages and tanks. She recalled seeing countless dead bodies on their flight. Her father was eventually captured by the Russians and the rest of the family were taken care of in reception camps. Finally they were settled in a small village in East Germany. Following their original flight from the east, life had been full of emotional as well as physical deprivation. At the end of the fifties, Mrs. O did an apprenticeship as an industrial worker and met and married her husband. In that same year, her only daughter was born. Mrs. O said her husband always had to be the one “in the right,” and wanted to have total control over his wife. Tensions increased over time, and her husband became ever more brutally aggressive, impulsive, and belligerent. Mrs. O’s way of dealing with any confrontations was to withdraw from them. In her general dealings with other people, she appeared correct, responsible, and conventional. She had lived alone in her small tenement flat since her husband’s final attack. THE CASE OF MRS. P Mrs. P, a woman in her thirties who had a girlish appearance despite her rather sporty and “boyish” dress, came to me because of feelings of depression. There had been early attachment issues in her life, and later her mother had actually become psychologically ill. According to Mrs. P, her mother had never given her a simple hug. Nothing was done together as a family; no stories were told or games played except at Christmas, and all her mother did was work. She had simply given her daughter orders: “Do this, do that.” Perhaps inevitably, the development of attachment bonds was disturbed. These events sounded shocking, and I thought this would be classified as emotional abuse. Mrs. P would burst out crying without warning, she said, and was plagued by thoughts about her sick mother. She had suffered from depressive symptoms over the years and had drunk a lot in order to cope with her

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insomnia, her anxiety, and her feeling of chronic tiredness. She was a loner who found it hard to socialize, and sometimes she would have an outburst of screaming. Her mother had herself suffered huge anxiety and periods of recurrent mental illness and had never shown her any loving feelings. She was felt by Mrs. P to be hard and domineering. She felt beaten down by her mother’s harsh and negative words. Her mother had never considered her daughter’s needs but simply “trained her with words,” as Mrs. P said. She had been a “daddy’s girl” because her father, while also being a strict man, had had a much milder temperament. She was much more keen to talk about her father than her mother. Mrs. P had been an unplanned child, but born within marriage. She had few friends and recalled sitting in a hedge alone in one corner of a field with some food and a glass of milk, reading a catalog. She did an apprenticeship as an industrial worker, which was a common training for East German women at that time. The conflicts with her mother had escalated over the years, and Mrs. P’s first experience of depression began during one of these periods of family conflict. Mrs. P suffered from very low self-esteem, unsurprisingly since she had suffered such early emotional deprivation. She feared any kind of aggression and remained in total emotional thrall to her mother, who never, even in the early days before her illness, Mrs. P thought, offered her daughter any shred of love or respect. Nevertheless, Mrs. P continued to nourish the hope that finally her mother would recognize her daughter’s true worth and show her some love. She often idealized her mother, but this would then be swiftly followed by denigration. The depressive-anxious symptoms improved; however, any threatened or actual conflicts around separation and loss exacerbated the internal situation. She began to have panic attacks. She was aware of these deficits herself at some deep level and also of her own attitude of clinging dependence. Mrs. P often appeared as controlling and inflexible with an obsessive need for perfection as a defense against her underlying insecurity. She was prone to making inappropriate and impulsive remarks, or acting in an impulsive way, particularly at work. Then she would collapse into litanies of self-accusation and the old seesaw of rigidity and collapse would begin. This resulted in states of helpless exhaustion. THE CASE OF MRS. M Mrs. M was a youthful-looking twenty-seven-year-old when she began treatment with me. She had come because of long-standing depressive troubles and had subsequently developed phobic symptoms following several deaths of those close to her, which she experienced as being traumatic. In fairly quick succession, she lost her grandfather, her mother-in-law, an aunt and



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an uncle, her stepfather’s daughter, and her own best friend, whom she said had been like a mother to her. Mrs. M had always been terrified of death and could not come to terms with this succession of losses. Her feelings threatened to overwhelm her; she became nervous and irritable, full of sad brooding thoughts. She feared darkness and being alone. Mrs. M said she knew little or nothing about the backgrounds of either of her sets of grandparents. Her own parents had divorced when she herself, the youngest of three children, had been only a year old, so she knew nothing about her own father either. She simply knew that “something had not been right” with her father, but this was never spoken about. Her mother had been a strict woman who “educated” her children with frequent physical abuse. Mrs. M had also suffered emotional and verbal abuse from her mother, who felt that her daughter could never do anything right or be independent, all adding up to a picture of a disturbed and traumatic life. Her mother, too, had been overstrained and taxed by the burden of having to look after three children alone after their father left. In the end, a neighboring couple had in effect taken over the parental role for Mrs. M: finally, she had found a mother substitute, only to have her then too. However, the man who subsequently married her mother turned out to be quite understanding: he had been, she said, the only one who understood her. She described her childhood as having been “fairly unpleasant,” which seemed like an understatement. But in spite of describing such events, such as her mother “training her out” of defiance as a toddler by hitting her, she spoke about all these shocking things in a rather distant way. At times, she seemed to have identified with her abuser. She was very hard on herself, just in the way others had been to her in the past. She described herself as being lively but oversensitive at home, with a tendency to be stubborn and aggressive. She was very fearful of loss and rejection and feared that her depressive illness would drive her long-term companion away. Thus, she avoided all hint of conflict in order not to trigger the situation she so feared. During the treatment, her depressive and phobic symptoms began to lessen and then disappeared. Then it was time to deal with her own rather inflexible psychic structure: Mrs. M always needed to be “in the right.” Out of the blue, or so it seemed, she became pregnant (she already had a five-year-old son). At that point she married her long-term companion and found pretexts to attend her sessions more and more rarely. The treatment thus ended after three and a half years. THE CASE OF MRS. N I met Mrs. N, a married middle-aged woman, in a psychiatric emergency meeting, when she was suicidal. Mrs. N’s family showed signs of intergen-

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erational traumata. Her maternal grandfather had committed suicide in the mid-1990s and her paternal grandfather had been killed years before in the Second World War. Mrs. N was an unplanned surprise for her parents, being born during their first year of marriage. While the birth was much wanted, what they had hoped for was a son and they were disappointed with the birth of a daughter. This was an early disadvantage for Mrs. N, and her “not being a boy” had an effect both on her rather weak father and her dominant mother, creating from the beginning a trauma of attachment for Mrs. N herself. She reported that her mother always worked hard and sometimes hit her daughter, while her father mainly ignored and rejected her, occasionally giving her painful slaps too. Apparently, his view of his daughter was, “She’ll never amount to much.” He often said she just got worse with the passing years, and he called her a fool. He could do nothing for his daughter, Mrs. N said, but he worshipped his sister’s son. While her father seemed both emotionally and verbally abusive, Mrs. N spoke about these things in a rather remote way, as if they were perfectly normal. Family life had been dominated by the parents’ quarrels. As a young child, she obeyed her parents unquestioningly, but then when adolescence began, her defiance finally erupted. By then she felt both parents largely ignored her in any case. The depressive symptoms first erupted following what was actually a fairly minor row with her parents. At this time her feeling of being continually under stress worsened, both because of the general level of family conflict and because her father was progressively becoming ill after a diagnosis of cancer. Mrs. N then became the caretaker of dependent parents. From the beginning of her treatment, Mrs. N’s timidity and emotional dependence became increasingly evident. This apparently passive and withdrawn woman had feared from the start of her life the withdrawal of parental love and approval. This had resulted in the internalization of an excessively severe superego. Her greatest fear was that of failure: if she let herself go and let others down it would be a catastrophe. She feared ever saying no to anyone, thinking that nobody would love her if she stood up for herself. Thus, she just withdrew to avoid conflict, and as an adult, she still seemed like a little girl controlled by two tyrannical parents. As an adult, Mrs. N became a neat, dependable, and thrifty woman. She demanded absolute perfection of herself; lacked any real spontaneity; and often appeared fragmented, anxious, and lost. Her behavior, which was both fearful and demanding, seemed to recapitulate something that had its origins in her childhood, where she felt that unquestioning love had been exacted while none was returned. She was still dominated especially by her mother, on whom she continued to lavish both this unquestioning love as well as fearful dependency.



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When her parents’ demands escalated with her father’s advancing illnesses, domestic conflicts that had remained latent until that point started to erupt. Her mother too became more and more demanding as her husband’s condition worsened. Mrs. N felt she could do no more, but she still drove herself on. On the day of the reported row with her mother, she said that her father had looked so vengeful and angry that she had wanted to hang herself, as she had become what she called ‘crazily sensitive’ because of the family tensions. She could see that while she lavished such care on others she did not care for herself. She received little help in this regard from her husband. THE CASE OF MRS. B Mrs. B, a powerfully built woman in her late forties, began treatment with me after suffering from previous depressive phases and extreme mood swings. She was a social worker and felt exhausted both by her job and by frequent rows within her family. She seemed at first sight relatively undisturbed. She reported that her beloved maternal grandmother had been badly treated by her husband. He had died some time before and had come from a background of intergenerational trauma. Mrs. B portrayed her parents as having been quite strict, with her mother as the dominant figure within the marriage. Mrs. B was a much-wanted first and only child. She recalled a childhood of relative freedom and could not recall any difficulty with her parents or opposition to them. While she had to eat every single thing on her plate, she did so without complaint. Nevertheless, she thought that underneath an apparently happy exterior she had been rather moody and sometimes felt rather alone. But she did not seem to attribute this to any sense of deprivation or emotional abuse from her domineering mother. She would get bored on the weekends when she went with her parents to their country house, and felt acutely lonely. While she admired the robustness and resilience of her parents, she felt ambivalent about them because of their lack of empathy and strictness, especially on the part of her mother. There were no confrontations, however, as she always damped down any strong feelings. She met her husband while working at her first job in a social institution. Following a period of childlessness, they adopted two children and she became a full-time mother. Her husband then began an affair with a younger work colleague. Mrs. B was shocked and totally unprepared when her husband suddenly left the family home to live with this woman. But she seemed to be able to access little anger over the event. Her elder daughter had dearly wanted to live with her father but was forced to stay with Mrs. B. This

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became the cause of rising tension and battles over the years. Once again, Mrs. B seemed to be capitulating to a situation of emotional abuse. Through patient work over time, however, she became more able to separate her own rightful needs from those that were more unrealistic, to accept her own angry feelings, and to move toward a more realistic picture of the world, both at home and at work.

14 The Case of Mr. Q

I began treating this young man in his twenties a few years ago and the treatment lasted for over three years. Mr. Q was a slim, tall, and rather delicate person, with a serious face. He was well groomed and athletic in appearance. At our first meeting, his movements seemed tense and nervous. He was eager for therapy and well motivated. Mr. Q had referred himself because of depression and difficulties in studying. He said to me when we first met, “I’ve been studying for seven years, and I’m still not at the end of it. I’m so very tired. I lack motivation. If I get down to work at all, half the day’s already gone. I study on occasions with a fellow student and that sometimes works better, but I’ll be glad to finish with it all. I’ve also got problems finding a partner. I know quite a few women, and I’m quite close to one in particular, but I don’t know—it’s all so difficult!” He said he had suffered from cycles of depression earlier, but now with the end of his studies in sight, things had got much worse. He couldn’t concentrate, was very affected by anything stressful, had no staying power, was moody, and found it hard to sleep. He tended to eat a lot as compensation when he felt low, got overwhelmingly tired, and had a stutter. As a child, he recalled, he had been somewhat of a loner, a dreamy boy who had always had difficulties concentrating, found it hard to get down to work, and was always late for things. Besides chickenpox and mumps, he could recall having frequent bouts of tonsillitis in childhood. He had received no previous psychotherapy treatment. He told me that his maternal grandparents lived in the East and that his grandmother was the child of a rural family in an Eastern country. Her family had been expelled to another country in the 1920s, where his maternal grandmother had been born as the younger of two sisters. Later the family had been allowed to return to their own country after 205

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World War II. His maternal grandfather also had roots in the East, his father having been massacred and the estate where he worked deliberately destroyed by fire. After this Mr. Q’s grandfather had spent some years in an abbey and had been first a teacher and then an economist. When he moved farther east he met his wife and they married in the 1950s. Mr. Q’s mother had been their eldest child, born before their marriage. They then had a younger daughter, but left her to be looked after by relatives when they moved again to an area where the grandfather worked as a leading administrator in the region. After the birth of another daughter, they had a son. It was noteworthy that in the family there was a tendency to find work in the academic and educational sphere. Mr. Q did not know much about his paternal grandparents and indeed had no personal experience of them, since the grandfather had died before his birth and the grandmother very soon afterward. Apparently, his grandmother had been a housewife, and his grandfather had worked as a foreman. During the Second World War they had lived and worked in the occupied areas in Czechoslovakia and then had returned to the West afterward. He told me this couple had had five children and their youngest child, their only son, had been Mr. Q’s father. Of the four daughters, one had already died and one was in a nursing home with a chronic illness. Mr. Q’s father had first used his laboring skills in the building business. Subsequently, he followed his wish to study and became an engineer. He met his future wife when he was transferred to the East to work. Mr. Q was conceived before they were married. They moved yet again, and his mother worked as a civil servant while her husband continued in his previous line of work. Then they had another son, who was also still a student and single. Mr. Q experienced his mother as an authoritarian woman and his father as a rather fussy, pedantic man. When he looked back, he thought his childhood had been uncomplicated, and it seemed to him that it went by very quickly. As a small child he had not eaten enough, but this led to his getting more attention and care from his mother at such times. The first word in the native language of his mother that she taught him was one that meant “keep your distance.” She cared little for his needs and often pointed out that his father should be responsible for these. She sometimes said in an offending and humiliating manner that the father had problems and was too shy. Yet he had always got on with his tasks, had warmth, had sung songs and read aloud from books to his son. Although Mr. Q had been conceived by accident, he was a much-wanted child. As far as he knew, the pregnancy and delivery had been normal, and he was an active infant who had been cared for by his mother. He could not recall ever being actively oppositional. He had contact with other children his



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own age and had never asked how babies were made or why they were different sexes. He thought he had been a moderately assertive child, although occasionally he had felt like an outsider. He was able to play both on his own and with others and felt he had been given adequate attention by his family, although he had no sense of there having been tenderness between the parents. Mr. Q had always enjoyed looking after his younger brother and could recall no sibling conflicts. They had a large enough house; first he shared a room with his brother and later he had his own space. He was allowed quite a lot of freedom as a child and liked loud, active, messy play. He could remember a photo of himself as a little boy sitting on his parents’ doorstep, muddy from head to foot after he had been playing in puddles. While he didn’t get regular pocket money as a child, he remembered being given toys, but only on a few occasions. He liked kindergarten well enough and got on with some of the adults and children, and then he really enjoyed later going to primary school. He was an average child, he thought, quite independent but a little shy. He was not a rebellious boy and was concerned to be “good.” Later, he made more friends and enjoyed bike rides and collecting stickers. He emerged out of latency with a developing interest in sailing and gliding and occasional jogging. He had had a friend who later, some years ago, died in an accident, maybe through her own fault. He also enjoyed photography, especially taking pictures of cloudscapes. He went to the disco with his friends, kissed a girl for the first time when he was fourteen, and then had two or three friends who were girls, but no special girlfriend. After school, he began to study science, lived in shared digs with other students at the university where he had now been for five years, and still had no steady girlfriend. As I understood it from Mr. Q, his depressive symptoms emerged most recently following a combination of family conflicts, both large and small scale, and a tiny slight by a female friend. TREATMENT What was clear from the beginning of Mr. Q’s therapy was that he had an overwhelming lack of self-confidence and a fear of asserting himself. He was extremely anxious about his attachment figures and had an intense fear of separation and loss. He told me how he retreated into a world of daydreams, losing himself in fantasies in order to avoid his anxieties. Mr. Q told me during his therapy about how he had felt extremely deprived emotionally during his first years of life. Yet he had a way of normalizing this and seemed to have no sense of a right to protest about or grieve for what trauma and neglect

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he might have suffered. He had been afraid that he might lose his parents altogether and became inhibited and fearful, dominated by a powerful superego, partly formed from the strict upbringing they imposed on him. He talked of what a conformist he had been, how worried he was about his inability to work and to graduate from his studies. He lamented his lack of ability to get down to anything and to concentrate. His lack of any spontaneity and his wish to prevaricate and procrastinate became increasingly evident. Frequently, he hesitated before speaking. Sometimes it seemed he was simply refusing to open up. There were long silences; he seemed to avoid using the time to think about his difficulties, and he talked very little about the real issues around his lack of motivation for work. He told me many times what an independent person he was. He told me that he already ran a successful business venture with a fellow student and that if all else failed he could make a living that way. He had a very early memory of going through his parents’ bedroom one morning as a young child. His mother had become extremely angry with him, and he had hidden under a kitchen chair while she hurled soft balls at him, shouting and scaring him. He had his own particular view of most things, was generally highly critical, but had a very polite and correct way of expressing himself. He employed his thinking in abstract, work-related ways and seemed to be coolly detached from anything more subjective and rooted in feeling. Mr. Q seemed extremely uncertain about any issues to do with the opposite sex and about relationships. He talked of different relationships with women students, but there were always problems. He wished for intimacy but feared it as well. He bemoaned his lack of intimate relationships and the absence of emotional contact in his life. He felt at a distance from other people, out of contact with them, and he had a friend who was rather similar to himself in that respect. Mr. Q did have a girlfriend at that point, but she was rather withdrawn, and in any case, he feared contact because he might then be let down. “I don’t want to be disappointed again,” he said. Again and again, he brought up different facets of these problematic relationships with girls. Mr. Q constantly ruminated over what this girl had meant when she said a particular thing, or what that girl might have intended when she did a particular thing. But in reality, these seemed to have been rather superficial contacts. Further description of these various conflicts made it very clear how anxious and uncertain Mr. Q felt, both in relation to these girls and to me during the therapy. He wanted security, but he felt helpless, continually beset by conflicts. It reminded him of a line in a film he’d heard: “Friends: if they phone, I’m nervous; if they don’t phone, I’m disappointed.” Over and over, Mr. Q brought up these relationship problems. He said he had had some



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sexual contacts but not of a lasting nature. But he was still on the lookout for something secure and intimate, a close relationship. He was scared of being alone, scared too of asserting his needs, and seemed entangled in internal conflicts. He wanted so much at an unconscious level, expected so much, and then was disappointed over and over again. He seemed to have little in the way of creative imagination. He remembered as a child dreaming about being a fisherman and then later of being in the “A Team,” employed to fight against evil. Later, he had had sexual fantasies but couldn’t describe any of his dreams and recurrent reveries. Well yes, he thought he did dream, but he didn’t know what his dreams were about. The one thing he wanted more than anything else was a relationship that functioned in a normal way. Mr. Q’s lack of insight into himself also limited his view of others and his capacity to relate to anyone. Even when he did start to reflect about something, too often the reflection swiftly turned into a theoretical discourse, which had to do with “facts” rather than feelings. During the therapy, there was improvement, but this was very gradual. He would start each session outlining his problems in a coolly distant and rational way, with no spontaneous expression of feeling at all. It seemed that his perfectionism was a way of protecting himself from any hint of criticism. He seemed in his life and in his work neat, correct, and responsible, but also rigid and controlling. When this defense broke down in the sessions, he then seemed to lack any spirit, to be helpless, rudderless, and fixed rigidly to concrete reality. Occasionally he seemed more actively to be searching for affirmation both from himself and his objects. Things got better as we gradually worked on his terror of asserting himself, his fears of separation and loss, and his repressed anger. He became more committed and attached to his therapy and was able to use it to develop a more coherent sense of his needs and of the ways in which they could be fulfilled. What remained painfully clear was his need for concrete proofs of affection and his tendency to be massively injured by what he perceived to be emotional slights. TRANSFERENCE AND COUNTERTRANSFERENCE From the beginning, it was evident that huge demands were being made on me: I should help him, and quickly, and he would cling to me until I did this. As things unfolded, he became more able to accept a sense of real understanding and support from me. But because of his fear of being dependent on an object that would, he thought, inevitably let him down, he would quickly withdraw and become aloof and rather hostile. I felt this interplay too in

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my countertransference, when feelings of responsiveness would then be replaced by the kind of detached stance that Mr. Q himself employed in order to avoid real contact. As he went over and over the recurrent difficulties he experienced in relationships, I would often find myself becoming tense and impatient. This has reduced somewhat.

15 The Case of Mrs. U

Mrs. U’s two-and-a-half-year treatment began at the beginning of 2005. This

seventy-year-old woman seemed self-confident, if a little tense, when we first met. Her white hair was cut short, and she was simply dressed. She had referred herself for treatment because of acute depressive problems. At first, she was looking for medication rather than psychotherapy treatment. “Pills have helped me to sleep better, and that’s what I need for the depression too,” she said. She duly received the medication, but then stopped it a short time after treatment began. Over time, Mrs. U was able to open up and tell me that her depression had erupted at the time that her grandson had wanted to leave his parents’ home. She thought he was still much too young and that it wouldn’t be the right thing for him to do. She had also previously become depressed when her mother died, and this had continued for some months. Then it had happened again when the company for which she worked after the political changes, “the fall of the wall,” got into economic difficulties. The customers were assured that orders would be fulfilled but the company then became insolvent and bankruptcy followed, and so she had become unemployed. Then one of her grandsons started to smoke marijuana, which caused her further anxiety and depression. It was then that she decided to come for treatment. Her depressive symptoms included chronic lack of energy, feelings of withdrawal, unmanageable circling thoughts, lack of capacity to concentrate on anything, and insomnia. She told me that as a child she had been defiant, had told untruths, had a passion for sweets, and had frequent headaches. She had suffered the usual childhood illnesses, with repeated bouts of tonsillitis. She had not had any therapy previously. I will give quite a detailed account

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of her family history because her illness seemed to stem from many difficult early events. The family history could be traced back to the twelfth century, when the family had immigrated from the Rhine-Moselle valley to a country to the east at the behest of the current ruling monarch. It was a tribal situation, and marriage outside the group had not been encouraged. It was only following the First World War that the children of the family finally became citizens of this country where they had been born. Her paternal grandparents produced agricultural products in the East and had four children. Mrs. U’s father had been their firstborn son, who had grown up to be an agricultural producer himself. He had been conscripted and subsequently killed in the Second World War, as had his younger brother. His younger sister was deported to a Russian labor camp during the war and then later moved to Austria. He also had a much younger sister, who had been a civil servant. She was now a widow and had no children of her own. Mrs. U’s maternal grandparents had also produced agricultural products in the East and had five children. These grandparents were both now long dead, and had died in the East. Mrs. U’s mother was their third child and had arrived as an immigrant to Germany in the late 1980s. One of her mother’s sisters now lived in West Germany and the other had died in the 1950s of tuberculosis. Mrs. U’s parents had married in the East at the beginning of the 1930s, and Mrs. U was the second of their five children. Born two years after her parents were married, she was an unplanned child. Her parents hoped she would be a boy: a year previously, a girl child had died in infancy from dysentery. Of her three younger sisters, the eldest, who had been widowed and then remarried, had been a baker, and the next youngest had died of complications following heart surgery. Her youngest sister, a nurse by occupation, was now widowed and had one son, who had been born one of twins, but the other twin had died. Mrs. U had only very sparse memories of her father, but she thought he had been a hard worker. She had experienced her mother as a rather severe woman. She herself was industrious and hard on herself. She had brought up her children strictly and had often chastised them physically. Nevertheless, Mrs. U recalled her childhood as being a good one, as long as she obeyed the rules: she had always been required to help at home when she came back from school. Mrs. U knew she had been a result of an unplanned pregnancy, and she thought her mother had been under a lot of stress at the time. Both parents, as already indicated, had hoped for a boy. Delivery had been normal, and she had been breast fed for a year, walking when she was just over a year old. Toilet training began when she was about eight months old, and Mrs. U could recall no toddler tantrums. She would eat everything on her plate, and she had been quite a quiet child. Family recognition had been dependent on



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results, but she felt she had nevertheless been noticed within the family, as well as when she played with her peers, where she would often thrust herself forward into the center of a group. She loved playing, either alone or with other children. She couldn’t recall any evidence of tender feelings between her mother and father. She had slept in their bedroom until she was ten years old with her two other sisters, but had had no idea about sex or procreativity. She could recall no particular sibling conflicts and felt that they had all gotten along well. In fact, she had enjoyed taking care of her younger siblings in their rather crowded family home, which they shared with their grandparents. It was quite a Spartan life: she could recall being given no pocket money. She had always to share her toys with her sisters and had to clear up after herself at all times. When she was six, Mrs. U was sent to school, where she did quite well and enjoyed lessons, which she learned easily. As the war got physically closer, in 1944, Mrs. U, then ten years old, fled with her family—her mother and siblings (her father was fighting with the Germans in the war)—with the idea of entering another country by the eastern border. This plan failed, and the family ended up being driven by the retreating German armed forces through two other Eastern European countries in a cattle truck with other people for over six weeks. Many people died in this arduous and terrifying journey toward an unknown destination, especially toddlers and old people. Finally, they celebrated Christmas 1944 near the German border. The next part of the odyssey was on foot, with just a cart, through parts of East Germany. They were permanently under attack from low-flying planes, and the roads were lined with the dead and the wounded. While they were undertaking this terrible journey, the war ended. At Christmas 1945, they finally arrived with just one small suitcase at the place where Mrs. U still lives today. They lived on a diet of cabbage and potatoes and even baked cakes from potato skins. Mrs. U remembered that as a schoolgirl she was also allocated two slices of bread, sometimes with some plum jam or sugar beet syrup donated by a local farmer. At that time, medical supplies were almost nonexistent, and there was never enough milk. Mrs. U’s mother had to cart stones in a small truck, and she used to saw wood by hand, which was then used to make floorboards. They all collected firewood in the nearby forest. Mrs. U finished school in the sixth grade, having missed two years’ education because of the war. After the war, things were still hard, not much better at all in fact, and improvements only came at the beginning of the 1950s. It was easier if you were employed by a company because at least you were given lunch. When she left school Mrs. U worked for a time on a farm, but it was a long way from home and she was very homesick. Therefore, she returned and did housework nearer to her family home. When she was seventeen, she began work

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in industry, where she got lunch as well as training. She read a lot, but didn’t have much opportunity for going out and dancing or socializing. She was scared of committing herself emotionally, but then she met a young plumber who was a neighbor of theirs, fell in love, and got married in the mid-1950s. She portrayed her husband as a hardworking and honest man, who had been a laborer in a particular part of the Eastern area. Their eldest son was born a couple of years after the marriage. He was now married with five children, lived in another Eastern area, and worked as a craftsman. The second son was now divorced and had one daughter. Mrs. U’s daughter had been born quite a few years later; she had three children and worked as a clerk. Mrs. U had remained at home looking after her children for fifteen years, then she had gone back to work in an office. Mrs. U’s depression had resurfaced when she discovered her grandson’s marijuana smoking. There was a huge amount of conflict within the family about this, which upset her a great deal. She needed concrete proofs of her family’s affection, was fearful of any threatened loss or separation, and felt easily overwhelmed by feelings of frustration and fears of rejection. TREATMENT The strong feelings of guilt, emotional dependency, and passive withdrawal became evident early on in Mrs. U’s treatment. She felt she always had to toe the line in order to avoid conflict or rejection. She discussed the terribly hard times she had experienced as a child, during and after the war and how she had feared loss of parental love. The strict treatment meted out by her mother had resulted in the internalization of a strict superego figure. She told me how much she had feared making any kind of mistake and how she had always been over-compliant in order to please her mother. She talked also of the current difficulties with her grandsons: had she done something wrong in bringing up her own children? She feared she had failed and felt devastated by this thought. She also felt very sad that she had apparently been unable to preserve what she called “the rural reverence for the parents” into the current generation. She acknowledged that she could be rigid and obstinate and that this had been the outcome of such a strict childhood. She realized that things were different now, one could no longer take such a narrow view, but she struggled with it. She discussed her tremendous fears of doing “the wrong thing.” She also feared any kind of loss or separation and felt extremely hesitant of ever asserting her own wishes in terms of relating with her family. This conventional woman stressed her own reliability and conscientiousness and talked



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in a sincere but rather arid way about her efforts to do what was appropriate in any given situation. She talked little about emotional issues. Her marriage seemed solid, even rather ossified. What came across was her indecisiveness, her uncertainty, and her way of avoiding difficulties by retreating. Her internal world seemed sparse and bare. As a child, she had dreamed of having a good job and wearing a white coat. Then, as a young adult, she had become an assistant. After the war, alongside everyone else who had suffered so many privations, she dreamed of huge meals: it seems as if the whole of life centered around food. Sometimes she also dreamed of having beautiful clothes to wear. She rarely, however, remembered her dreams, but those that she did recall were frightening. In such dreams, she would have to take a train journey without being fully dressed, and she would hide behind boxes on the platform. Usually, however, Mrs. U’s rather featureless internal world was not peopled with lively relationships, and she found it difficult to relate to others. Frequently in our work, she seemed extremely controlled and controlling, and like her feelings, her thought was restricted. Free association was difficult for her, and she preferred to talk concretely about concrete events. TRANSFERENCE AND COUNTERTRANSFERENCE From the beginning, Mrs. U’s transference to me was one of clinging dependence, with the expectation that help would be immediate. Later, over and over again, the mistrust and the rigidity at the heart of her personality became evident. Sometimes she seemed painfully shy, fearful that someone would come too close, so she tended to avoid contact with people. In the sessions, too, she would return to periods of withdrawal if ever she felt I had offended or misunderstood her. After some considerable time, she became more able to relax and receive real help and support. Although I felt some compassion and sorrow for her, she often wished to draw me into power struggles about the right and the wrong way to think about things. While she appeared dependent, there were flashes of outright mistrust with resultant distance and coolness. Clearly, Mrs. U’s past and more recent traumatic history meant that she needed considerable help. However when her husband suddenly became ill, Mrs. U abruptly stopped her treatment with me. Despite the reality of her external situation at this point, I suspect it was also due to her profound mistrust, which gained the upper hand and affected this decision to terminate the therapy.

16 The Case of Mr. R

Mr. R’s two-and-a-half-year treatment with me began in 2005. This man in

his mid-fifties seemed tired to the point of exhaustion when I first met him. He was a well-dressed man, carrying a briefcase and a bottle of water from which he drank from time to time. Quite a short man, with short dark hair and sideburns that framed his oval face, he was, despite his evident tiredness, eager to have treatment. The reason for the referral was that he had become acutely depressed after an operation for cancer. “I really don’t know much more at the moment except that they say the operation was successful, I am undergoing chemotherapy, and the outcome is hopeful. That’s it, really.” He described the symptoms of his acute depression: irritability, lack of energy, lack of ability to concentrate, short-term memory problems, and chronic insomnia. He also said there had been frequent separations in his life, which he felt had been very hard for him. He was worried now, as the illness seemed to have robbed him of his feelings of independence and self-sufficiency. Mr. R recalled he had had the usual childhood illnesses, including repeated tonsillitis. He had received no previous psychotherapy treatment. I will describe Mr. R’s family history in some detail. He was much preoccupied with it himself and how it had resulted in frequent changes of citizenship and nationality in the family. There seemed to be considerable evidence for the existence of intergenerational traumata. His paternal grandfather, born in the second half of the nineteenth century, was a blacksmith by trade: a German with citizenship in an Eastern country, he had actually grown up in Czechoslovakia (CSSR). He had married a local girl of roughly his own age from the town where he had grown up, and since they had had nine children, she had spent her time looking after them. Both these grandparents had died in the 1920s. Mr. R’s father 217

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was their youngest child, who, at the age of eighteen, had moved to a large city in East Germany as a commercial employee. He was in an internment camp during the First World War, subsequently losing his original citizenship and gaining citizenship of CSSR. In 1920, he had married his first wife, an educated German woman, who had gained CSSR citizenship through the marriage. There had been four children from this marriage (Mr. R’s halfsiblings). One son died in infancy, one was killed in the Second World War, a third son had recently died of cancer, and a remaining half-sister of Mr. R, a professional person, was still alive but unmarried. The whole family became German citizens via the father, in 1925. At the beginning of the Second World War, Mr. R’s father had gone to work in the East and, finally, it was there that he was arrested. While living in the city, he had met his future second wife, a village girl with no education. They had an illegitimate daughter who died during the war as a young baby. After his escape at the end of the war, Mr. R’s father went back to the same city in Germany where his first wife still lived. He lived there together with the girlfriend he had met in the war. Eventually he married her after a protracted five-year divorce. Mr. R, who had been born illegitimately, was then reputed to have said, “Oh, now I can be called R too!” He had an early memory of sitting on the leather armrest of his father’s chair, and his father was taking notice of him. He said, “I can’t recall ever being so close to him again.” He also remembered that he would never cry when his father beat him with his trouser belt. One could speculate that this physical abuse may have led to a tendency to dissociate. On the whole, Mr. R had thought of his father as a role model, but a rather severe and overbearing one. Mr. R received love as long as he toed the line; otherwise, his father would become rigid and dogmatic in his demands. Mr. R had a younger brother who was born after his parents married. His brother currently worked in an office and had two children. Mr. R couldn’t recall any particular conflict between him and his brother as children; in fact, he had enjoyed looking after him. He recalled that in primary school he used to play truant and then get a severe thrashing. He also recalled having fun being together with similar-aged children and exploring the area. His father became ill and the family then moved into a country village in order to help his condition. A few years later, the mother wanted to move to the coast, complaining of the “terrible sanitary facilities” in the village where they lived. After much conflict, his parents’ marriage ended in divorce in the early sixties when he was in his teens. These painful changes and losses may well have contributed to Mr. R’s capacity to fall into states of depression. A few years later, Mr. R’s father died of heart failure. Mr. R’s mother lived in an old people’s home. He recalled that his mother had been an affectionate,



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somewhat lackadaisical person, but he remembered warmth and shelter in his family life, at least up until the quarrels started when he was about nine. He could not recall signs of tenderness between his parents. He thought his father had not been a tender man. Mr. R was his father’s sixth child and his mother’s second child. He had an assortment of siblings and half siblings: six in all. He thought that he had been a wanted child and that pregnancy and delivery had presented no particular problems. He was breastfed until he was nine months old and his mother took care of him until he was about a year old. He was reported to be a “good baby”: but he had no information about such things as language development, toilet training, or oppositional behavior. He thought, however, that any “naughtiness” would have resulted in severe scolding and punishment. He ate everything that was put in front of him, had playmates of a similar age, but could not recall having asked any questions about how babies were made or about sexual differences. He recalled how he had been rather an outsider as a child and only got noticed at home if he performed well at something. He loved imaginative play, either alone or with other children. Their living quarters were quite cramped: Mr. R shared a room with his brother, but had his own corner within it. He recalled being able to be noisy and get dirty, and that his mother would help him clean himself up afterward. He did get pocket money, but had to account for it, and recalled only getting presents on days like his birthday. He went to school when he was six and was a model pupil. Generally, he made himself scarce at home and tried not to draw attention to himself. Since they moved house so much, he had to make frequent school changes and so had no long-term friends, becoming rather a loner. He loved riding his bike and would go into the forest where the Russian troops’ camps were. The troops were kind to him (they were considered the country’s protectors). He also liked films, the theater, and reading. He was a member of a bee-keeping society at school and also of a puppet show society. But increasingly his parents’ marriage was in crisis. Again and again, Mr. R recalled a scene where his father, on returning home from a trip one day, had simply bypassed his wife’s outstretched welcoming arms with no comment. When things in the household got really bad, the father obtained lodgings for Mr. R as a teenager with an eighty-year-old widow of a bank employee. He had to sleep in a corridor. Yet in this way he was able to live in the city during the week and only go home at weekends. When he was sixteen, his father asked him to testify in the divorce proceedings that the marriage was indeed broken. He did so, but against his most urgent desire (and his mothers’), which was that his parents would reunite. This wish was never fulfilled.

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Although there was a majority of girls in Mr. R’s secondary school, he did not form a relationship with any of them. Sex could only be performed under the condition of being in love, he thought. Even though he longed for a girlfriend, he rejected a particular girl who wanted to have a sexual relationship with him. Then suddenly, Mr. R did fall in love, with a girl in his singing group. And that was it. After a bout of heavy drinking, he had the courage to have his first sexual contact, and he was surprised that it had all happened so easily. He left school in the mid-sixties and subsequently studied at the university to be a civil servant. This became his career, and he worked in several different departments. A few years before we met, he had been in conflict over his contract and had then left in order to become a self-employed taxconsultant. He finally married his beloved girlfriend, and they had four sons, all of whom were still living, but all still unmarried. However, his wife had had an affair at the end of the 1990s and that was the reason why they had divorced in 2003. This was a very bad time for Mr. R and he felt full of doubt and uncertainty about life and himself. After a time of self-employment, he found a new partner, a warm-hearted woman two years younger than himself, who was also a civil servant. After his cancer diagnosis he reacted with acute depressive symptoms. This had upset all his plans and had thrown him into a state of confusion and fear. TREATMENT Mr. R’s lack of self-confidence, timorousness, and fear of rejection were evident in the therapy from the beginning. He talked about how hard his early years had been, “when all I really wanted was to be held and cherished.” What he sought was emotional security and feelings of warmth. He was clearly very easily injured, feared any experience where separation or loss might threaten him, and had an extremely low tolerance for frustration and any denial of his demands. Yet in spite of this frustration, he was not able to assert himself, and thus remained passively dependent. Mr. R talked of his early years and the emotional deprivation he suffered, with parents who were both felt by him to be wanting. His mother, he felt, had been both unpredictable and unreliable, and his father had been strict, leading Mr. R to internalize a very severe superego. This suppressed his rightful wishes and they thus became enormous and overwhelming, but nevertheless unexpressed. All of this had been stirred up after his cancer diagnosis, which threw him into great uncertainty. He knew that for years he had pushed himself to impress others and had been disappointed when this had not been sufficiently acknowledged. He complained repeatedly of the various frequent



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and significant separations in his life: how he had been permanently moved about as a child and had later suffered further losses both in his work and in his private life. He went over and over the details of his family history and felt he had no way to work its shortcomings through, in order to move on to a better sense of himself. About his actual illness he said very little, but he often seemed weak and lacking in any kind of spirit. During the therapy he discussed his perfectionist tendencies and, in line with his own demands, how he felt the world to be a demanding place. He feared his own anger and selfassertion. He couldn’t stand up for himself and say no to anything. In order to avoid any confrontation, he simply retreated into a fantasy world. This too seemed to be an area of some restriction. Even as a young man he told me how he had been in constant fear that his father would die. He thought of his life as a long street of stretched-out time in which there were occasional twists and turns, but altogether rather featureless. Sometimes he would fantasize about how he could get girls to fall in love with him. He could not recall any particular recurring dreams, or even any dreams at all. It all seemed barren, restricted, and without joy. However, gradually in the course of treatment these depressive feelings diminished to a great extent, and that was particularly so when he allowed himself to accept that he actually had a good prognosis in terms of the cancer treatment. He became quite successful at looking after himself and his needs. When he needed something, he had more courage to ask for it. Gradually he came to understand, in a more realistic way, his life and the decisions he had made. He thought that maybe previously he had missed something crucial in terms of his own capacities to influence events. These new feelings emerged as he discussed the various aspects of his own and his family’s history and development in a variety of places and situations. He began to mourn over what he saw as so many missed opportunities: “I seem to have missed the boat on many occasions,” he said. Spontaneity was hard for Mr. R: he was reliably present for his treatment, but with the tendency to be rather rigid. His communication was rather polished, and he had a factual style. Yet there was something lifeless at the heart of his interactions. He was very willing to help his sons and his mother, but he persisted in feeling guilty about them. There was nothing specific he could accuse himself of, but nevertheless he could not let go of his deep-seated feeling that he could have done more. He was a rational, conventionally controlled, and over-serious man, although he had a well-developed sense of irony. Over time, things changed, however, and he began to take more interest in his life, developing various outside activities and becoming freer emotionally. He started to go on long bicycle trips with his long-term female companion, exploring various cities. Mainly he had an ambition to visit

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New York. But he abandoned that idea because he had problems finding cheap accommodation there. He told sentimental and nostalgic stories about his student days—“my years in the East.” For him, this “country in the East” represented something about becoming freer, more able to feel his emotions and recognize differences. He had begun to experience more friendship and warmth with other people in the East. He remembered however that as he became more and more aware of the political problems of the East during a second stay in the 1980s, he felt its poverty and its conflicts, and he was powerfully drawn to go back home to the West. Eventually he formed a plan to research his family history, and he set out with an old friend for a weekend trip to the town in the East where his family had lived. He visited old family houses, looked up church records, and continued this subsequently by email. He grew in confidence, and his plans had more focus and perspective. TRANSFERENCE AND COUNTERTRANSFERENCE From the start, Mr. R was possessed of an intense wish and hope that I would be able to help him. He became quickly attached in a rather panicky way, and it was only later that he was able to relax and really experience a feeling of being helped and supported. From the beginning, I felt a sympathy for this lonely and anxious man; from time to time, however, there would be struggles between us in the work, with a feeling projected from Mr. R of the need to be “in the right.” Occasionally, I would find myself becoming bored because he continued sometimes to perseverate in a very concrete way over the details of his family history. After the depressive symptoms were diminished, the search for his identity and the working through of his losses stood in the foreground. Gradually he gained increasing integration.

17 The Case of Mrs. O

I saw Mrs. O for over two years. Despite her sixty-six years, she still seemed youthful and appeared simply groomed with short gray hair and an oval face. There was, however, something uncoordinated in the way she moved. She was eager and motivated for treatment and had referred herself because of her acute depression. “I can’t go on any more,” she said when we first met. “My husband tried to kill me and I went to the neighbors’ for help. Then I called the police, managed to retrieve some of my possessions, and now I live here in this city in a small tenement flat. My life has changed so much. I’m still on good terms with my daughter, but money is tight and maintenance has still got to be sorted out. Now it’s all going on in court. I’ve got a lawyer, and I’m just so very sad. It’s hard for me to motivate myself, and I would never have thought I’d have to be doing this at my age.” She said things had been bad between her and her husband for about fifteen years. She now felt timid, irritable, and full of complaints. She had flashbacks about various traumatic events and tended to avoid any situation that might provoke them. She got easily tired and found it hard to concentrate and remember things. She was very sensitive to any upset and couldn’t sleep at night. As a child, she used to suck her thumb and was terrified of the dark. She was scared of airplanes and snakes, and couldn’t bear to watch surgical operations on the television. She remembered having the usual childhood illnesses but nothing else of importance. She had had no previous psychotherapy treatment. She could not remember much about her maternal grandparents. They had lived before the war in an Eastern country and had remained there afterward. Mrs. O’s mother was the elder of two daughters: her younger sister, married with four children, 223

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had also remained in this Eastern country. Apparently, this aunt’s husband was an alcoholic and had a history of being violent to his family. Her paternal grandparents had had a rather large business in the East, where they had brought up four children. Mrs. O’s father had been their youngest child, and she knew nothing about his brothers and one sister. After the war, they all had moved to the West and she had no further contact with them. Mrs. O’s parents had lived and married in 1936 in this Eastern country. Her mother, whom she had loved and respected, had died a few years before we met. Her father, a craftsman by trade, had died in the early eighties. Mrs. O missed him a lot and had very warm feelings and memories of both parents and of her childhood. But then, while her father was away during the war, she had had to escape with her mother and her sisters and they made their way west to East Germany. Mrs. O’s birth had been premature, and she did not know at present much about her early life, except that her mother had taken care of her. She could not remember whether she had a defiant stage or asked any questions about sex differences and where children come from. She had functioned well in a group and in her family as well, even though she felt she had only been recognized when she had done well at something. She played with others but also liked to play imaginative games on her own, and what she loved most of all was gardening and flowers. She recalled that her parents had been tender and loving toward one another as well as to her. As to sexual matters, she had remained largely ignorant, perhaps because it seemed as if it had to be a taboo area in the family. Mrs. O had two siblings: an older sister, who had married and had three children; and a younger brother, who was also married and had a family. She could not recall significant sibling conflicts and felt they had been happy together. If anything, she had sometimes worried about them and their wellbeing. They lived in cramped conditions, with only three rooms for the five of them. She had always shared a room with her sister but had her own wardrobe and small personal space in their room. She had very much enjoyed noisy, active games and making a mess, but she had to be careful not to upset any lodgers they might have at any time. She always tidied up after herself but was given no pocket money. She thought that she had been cheerful at home, didn’t draw attention to herself, and had an open temperament. While she had been able to look after herself, she felt she had always been motivated to be “a good girl.” In 1944, when she was six, the family had had to escape from the Eastern area where they lived. She had set off with her mother and two sisters, first of all in a bus, where she had hidden behind the luggage. Again and again, they had to move on, escaping the front where the Red Army was advancing with



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trains, carriages, and tanks. She recalled seeing many dead bodies as they escaped. Of course, for her mother this was an extremely hard time, feeling the Russians always behind them. Often she was forced to hide and leave the children on their own for considerable periods. In the end, when the Russians had captured her father, they were looked after in reception camps. After the war, there had been a family taboo on discussing any of these events. Finally, in 1945, they were accommodated in a small village: all the family had to live in one room. They lived mainly on potatoes, which they had to beg for from local farmers. Their possessions had all gone, and they were permanently hungry. They had to go into the woods to find fuel for the fire, and once their mother was caught and narrowly escaped being flogged for this offense by a farmer. The following year, their father, who became ill following his captivity, returned to join them. He found work locally but only came home at weekends. Gradually things got better. His job provided a food allocation, which her mother could then sell. But there were constant checks by the Russians, who monitored everything they did. One day, the woman whose house they lived in was suddenly snatched by the Russians while she was still in her slippers, and they never saw her again. However, they still had a room, and Mrs. O went to dances with her friends on the weekends and, in spite of all the hardships, she still retained her love of gardening and flowers. When she became an adolescent, she started to be interested in boys. After leaving school, she did an apprenticeship as an industrial worker, a job she did very successfully until she retired. She met her husband, who had come from a small farm and was also an industrial worker, soon after she began work. They had gone out dancing and to see films and had got married at the end of the fifties. That same year, her only daughter was born, who also grew up to be a craftsperson. She was married and had a son of her own. Mrs. O portrayed her daughter as being an open and loving individual who had managed her life successfully: “She knows what she wants and she gets it.” Even though this daughter was afraid of her father, the husband of Mrs. O, he was forced to respect her. Since the husband’s attempted attack, Mrs. O had lived alone in a small tenement flat in the town. It was after these events, and Mrs. O’s move to the town, that the depressive symptoms had erupted. TREATMENT I could see from the beginning of the therapy how Mrs. O’s main problem was her lack of self-confidence, her fear of being “pushy,” and her inability to assert herself. She was extremely anxious about any threatened separation

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and loss, and during the treatment, she discussed the emotional deprivations of her childhood following their escape from the East and how much the family atmosphere had changed at that point. It was then that she became fearful, and had been concerned to adapt her behavior in order not to lose the love of her mother and father. She also talked about her propensity to overdo things and her lack of self-esteem. She seemed often very hard on herself and hung on to small details in a perseverate way. It became clear just how intense the conflict had become between her and her husband. They had frequent arguments, often over minute and trivial differences, and the power struggles between them had escalated. Her husband always wanted to be in the right and to have control over his wife. Mrs. O felt persistently injured, suffering from what she felt to be a total lack of empathy and from her husband’s demanding and exacting behavior. He certainly was not the loving and devoted man she had dreamed of. After he retired, he went even more frequently to pubs, where he drank or played cards. Long-standing tensions only increased, and her husband became more brutally aggressive, impulsive, and belligerent. On their final evening together, he had erupted into a fury and threatened Mrs. O, so she had locked herself in the bathroom. It was at that point he threatened to kill her. Mrs. O ran next door to alert the neighbors and then called the police. After this incident, she got her own flat, which she had to furnish all by herself, since the family furniture remained in the old house, and rented a small garden space, all of which cost a lot of money. Maintenance was a constant concern: she really hadn’t thought she would have to be doing this at her time in life. Then, of course, all the legal matters would take a long time to sort out. Over and over again, she talked of who should be doing what and how things should get done. She would think about this for hours, looking at the situation from all possible perspectives. She didn’t like being the underdog and thought that if she was too flexible, it would be like giving in. She later told me that her husband had already met up with an old girlfriend who lived nearby and rekindled their relationship. Mrs. O always attended her sessions regularly. During treatment, Mrs. O often seemed to lack any kind of spontaneity and to be rigid and inflexible. She was defensively perfectionist and also discussed her inability to set boundaries and ask for anything for herself. She was a thrifty person who could economize well, but she was also ambitious and wanted to get more out of her life. She tended to deal with confrontations by retreating, and in her general contact with others, she appeared correct, responsible, and conventional. Her imaginative activity was rather restricted. All she could recall in terms of hopes and dreams was that she had always wanted her own house and garden. She often dreamed of her father’s death, seeing him laid out in



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his coffin. In the light of all this, it was no surprise that she led a restricted life and thought other people were just like her. But gradually, she began to find new friends through her gardening activities and as the judicial tribunal started to sort out some of the confusion around financial matters, her depression lightened, but only very slowly. Once we had begun to think about separations and loss, Mrs. O was able to revisit her traumatic experience with more insight. She often felt helpless and at somebody’s mercy, and this occurred in different guises and with various incidents. Slowly, her attitude of grievance began shifting, but she frequently went back over previous events, especially around court dates, when the issue of maintenance was in her mind. Gradually she developed more of a sense of being able to have a fulfilling leisure time and that it was fine for her to have needs of her own. She began to feel more independent, although her low tolerance of frustration remained evident, and she remained fearful about loss of love. TRANSFERENCE AND COUNTERTRANSFERENCE Clinging to me from the beginning, Mrs. O had intense expectations about receiving instant help. As her mistrust evaporated, at first only in flashes, she became more able to accept understanding and real support without expecting a magical solution to her problems. She engendered in me feelings of compassion, even though she tried many times to pull me into power struggles about who was “right” and who was “wrong.” Nevertheless, I felt deep respect for this strict but engaged woman and for her dry sense of humor in her frustrating fight with the conditions and facts. Over time, her complaints began to diminish, and she felt a little better. But it was hard for her to feel she could ever get full satisfaction from her activities. After two years of onceper-week treatment she went on to come on a monthly basis.

18 The Case of Mrs. P

Mrs. P, a woman in her late thirties, came to me for treatment beginning in

January 2000, and it lasted for five years. She was a tall, rather cautious, and somewhat girlish woman in spite of her sporty and boyish way of dressing. Mrs. P walked in a jerky way. She seemed strained and had been referred from her GP because of her feelings of depression. In the initial consultations, she lamented, “I can’t manage this anymore, I cry a lot, I just burst out crying without warning, and I’m worried too about my sick mother. Everything causes trouble and makes me feel so upset. How am I going to keep working with all this going on?” She revealed she had suffered from these depressive symptoms over the years and that she drank a lot to counteract her angry moods, her insomnia, her anxiety, and her chronic tiredness. It emerged that she had always been a loner, found it hard to socialize, and had periodic screaming fits. In the assessment sessions, Mrs. P recounted many details of her early history. She had experienced her mother, who had for decades suffered great anxiety and had a history of a recurrent psychological illness in later life, as being harsh and domineering. Her father was strict, but in a milder way, and Mrs. P described herself as “daddy’s girl.” She preferred to discuss everything with her father. Mrs. P was a legitimate, but unplanned child. She was said to be a quiet baby. She said her parents had had a good relationship and that she had slept in their bedroom until she was six or seven. She had a brother fourteen years older than herself, who also tended to overuse alcohol. Her grandparents were all now dead, and Mrs. P described her childhood as “mixed, but pleasant.” Her parents and grandparents were country people and had worked long hours. She had a picture in her mind of her mother binding sheaves of hay

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while her father was working in the field, and while she spent the whole afternoon in a corner by the hedge surrounding the field, equipped with a catalog to look at, a drink of milk, and some food. She said that she tried in vain to be the center of her parents’ attention. She was never allowed to get dirty and was taught to be tidy at all times. She didn’t get pocket money, but was given presents on special occasions. She had few friends. This friendless state gradually improved, however, and at the age of fourteen she was allowed to go with a girlfriend to an afternoon disco. Her parents told her to “hook a man,” but warned that she must not get pregnant. Gradually she went out more and more, but after her father became ill, he tried to keep her at home and to ban her from going out with friends to the cinema. At the age of fifteen she had her first kiss, and at the age of seventeen her first boyfriend, her subsequent husband. After her final school qualification she did an apprenticeship as an industrial worker, a common training for a woman in East Germany. But when the factory where she worked eventually closed after the fall of the wall, she became unemployed. She described her husband, an electrician, as a know-it-all who was in fact a very slow worker. They had no children and lived in Mrs. P’s mother’s house. Her mother’s psychological illnesses had led to many conflicts over the years, and Mrs. P’s first experiences of depression began during one of these periods of family conflict, a period when there had also been uncertainty at work. At this point her mother wounded her terribly by calling her a “clumsy village oaf.” THE TREATMENT The treatment revealed very swiftly Mrs. P’s great lack of confidence and her emotional dependence on a mother who had never, even before her illness, she felt, offered her the love and respect that she needed. She continued to nourish the hope that her mother would finally recognize her worth and turn her emotional attention to her daughter. Her mother had always kept her distance and never hugged her. Nor did they ever do things together. She was never told stories, and the only games were played at Christmas. The one subject of conversation was work, never feelings. It was as if Mrs. P’s feelings did not exist, she said. She received only negative comments and said she had been “trained by words.” During the therapy, we discussed her early emotional deprivation and her fear of aggression, which might further alienate her from her strict parents. We also discussed her conforming behavior, her lack of self-confidence, and her continued fear of her own aggression. Often she idealized her mother, but this would be swiftly followed by devaluation. Repeatedly during the therapy,



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Mrs. P became anxious about failing to meet her mother’s requirements; at other moments she feared a return of her mother’s illness. Often she appeared despairing, somewhat hopeless, full of self-complaints, tired, and without drive in a largely colorless world. Her imagination seemed as limited as her social life. During her childhood, she had often dreamed of riding out to fight with the Musketeers. Later she fantasized about her dream man, or herself as an omniscient super-wife. She feared being alone, and loneliness. She found it hard to say no to excessive demands and was also internally excessively demanding of others, only to suffer inevitable disappointment. She wanted approval and love from those in her environment and was keen to help those she perceived as weaker than herself. She was in a perpetual state of fear about being beaten by rivals and of not ever being good enough. In our session she would often burst into tears, “I can’t manage anymore, I can’t go on. . . . Everyone thinks I’m so strong, but I’m not at all.” In the transference, she was full of anxiety about separations and presented herself as anxiously clinging as a defense against this. She desperately asked for my help. During the therapy the depressive-anxious symptoms improved, but only very gradually. Any threatened or actual conflicts around separation and loss, especially those to do with her and her husband’s work, exacerbated the internal situation. At one point, she did actually fall on black ice and fracture her arm. At the time, this seemed to be connected with the loss of a job. Her husband’s unclear future prospects (he might have to move away to find a job) and conflict with her psychologically ill mother exacerbated a fraught situation. Increased disagreements with her husband, whom she experienced as weak and passive, became evident. Mrs. P wanted a husband she could lean on, she said, not one who seemed to hide behind her. She was looking for security. She began to have panic attacks. Mrs. P wished for children, but feared she would not be an adequate mother because of her own experiences. At the beginning of sessions she often related in a very concrete way a list of “objective things” that had happened in the time since we had last met. When she then “by chance” recalled hurtful situations, suddenly her emotions would break through. How should she manage this? She would cry and moan for some time. I suggested that this pain seemed to lie so close to the surface, repressed but available at times, and she was in some sense constantly aware of it. She would ask me again and again, what should she feel, what should she do, how should she handle the situation? She continually asked me these kinds of questions. This barrage of requests always triggered a countertransference response of anger in me. I would find myself thinking that other people might have some idea about how to feel, or how to handle it, but not Mrs. P. Why? She was aware of these deficits herself at some deep level, but they were largely repressed. She had some idea that the difficulties were

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related to her attitude toward her mother and that both of them indeed had deficits. We talked many times about this, but then the realizations would again get lost. During the course of treatment, there was usually little evidence of spontaneity, although Mrs. P occasionally erupted impulsively. Mrs. P often appeared as controlling and inflexible, with an obsessive need for perfection as a defense against her underlying insecurity. She told me that this was the way she ran her home. She desperately wanted the admiration and approval of others, but underlying an air of apparent self-confidence, she was fearful of exposure, and this turned her life into a question of fearful survival. She was prone to make inappropriate and impulsive remarks or act in an impulsive way, particularly at work, and then she would collapse into litanies of self-accusation. This would be reflected in the sessions, where rigidity could give way to flashes of instability, and her “battle stations” presentation would collapse into submission. TRANSFERENCE AND COUNTERTRANSFERENCE As I have indicated, the initial transference was marked by a clinging dependence. Gradually Mrs. P’s unrealistic expectation of instant help gave way to more understanding, but the old seesaw of rigidity and collapse always threatened this. This was reflected in my countertransference, where feelings of empathy could be often very swiftly attacked by the impact of these seemingly instantaneous alternations between omnipotence and collapse into helpless exhaustion. I often felt worn down by the inevitable litany of grievances. There was clearly much more work to be done on her character structure.

19 The Case of Mrs. M

Mrs.

M’s treatment of over three and a half years began in 1998. This youthful-looking twenty-seven-year-old woman was casually dressed when we first met, with mid-length blond hair and a tense expression. She was eager to have therapy and had been referred by her general practitioner because of long-standing depressive troubles. “I’m always so scared,” she lamented when we first met. “I don’t know how I can go on. So many people have died recently: my grandpa, my mother-in-law, an aunt and an uncle, my stepfather’s daughter, and my best friend. And that was the worst one, because she’d been like a mother to me. I just can’t come to terms with all these losses. I just can’t process it. I’m scared to leave the house and go out on my own. I can’t go shopping: it’s awful.” Mrs. M said she had always been terrified of death, but since so many people now really had died, the fears had become overwhelming. She relied totally on her long-term partner, without whom she could not venture out of doors or drive her car. It was all she could do to carry on looking after her sons. She was nervous, irritable, full of sadness, and could not stop her brooding thoughts, such that she was unable to work or to sleep. She feared darkness and being alone. She also blushed frequently and had developed a trembling of the hands. Mrs. M knew nothing about either of her sets of grandparents or her father, as she was the youngest of her mother’s three children and the couple had divorced when Mrs. M was a year old. Her mother had always told her that there was “something not right” with her father. But nobody talked about it. It was completely hidden away. Mrs. M felt that her mother, now a pensioner, had always been a strict woman who had brought up and educated her children by hitting them frequently. Her mother had never believed, said Mrs. M, in her daughter’s capacity to do anything independently. After the 233

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divorce, her mother had been left with the three children on her own. Her son, who had been born before her marriage, was now an electrician. The other daughter, still unmarried and suffering from epilepsy, worked as a hairdresser and still lived with their mother. When she was young, Mrs. M had spent a lot of time being looked after by a neighboring couple, and they had in effect taken over the role of parents. This couple already had a son, but they longed for a daughter: they treated Mrs. M indulgently and allowed her to do things that had never been permitted at home. When the wife had died two years previously of cancer, the husband had met up again with a former girlfriend and moved away. For several years, Mrs. M’s mother had had no long-term companion, until she finally met someone whom she then married when Mrs. M was nine years old. This man had a son and daughter from his former marriage with a very dominant woman. This stepfather was the only one who understood Mrs. M. She thought she might also have had a half brother because her birth father had a second marriage. But she was not sure. In sum, Mrs. M’s verdict on her childhood was that it had been “fairly unpleasant.” She knew that she had been an unwanted child but that pregnancy and birth had apparently proceeded without problems. She was breastfed, but only for a short time, less than three months, she thought. She couldn’t tell me much more about her early childhood, but thought that her mother had looked after her along with the other two children during her first year of life. Her general development had been fine, or so she remembered. She had started to walk soon after she was a year old, and had been toilet trained a few months after that. According to Mrs. M, when she had reached the defiant toddler stage, her mother had reacted by hitting her frequently. Mrs. M had found it easy to be the center of any group of children, and pushed herself forward into the role, as she did at home as well. She loved playing imaginative games and getting dirty, and she reveled in solitary play too. She had slept in her parents’ bedroom until the split and then remained in her mother’s bedroom until she was two or three. She could not recall displays of affection between her parents, and felt that neither was she herself one for showing her feelings openly. When she was a child, she had had no idea about sexual matters. She had felt very much “the baby” of the family and was jealous of her older siblings. She shared a room with her sister and things were very cramped and overcrowded. While she was allowed a certain amount of free messy play, she had to be extremely observant of the needs of her siblings. She was given no pocket money, and only occasionally had toys that had to be shared with her sister. She enjoyed kindergarten and made good contacts both with adults and children while she was there, “performing well,” as she described it. She went to school at seven and became a very “good” schoolgirl. She was lively



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but oversensitive at home, with a tendency toward stubbornness and aggressive behavior. In her teens, she soon became “buddies” with boys, and from the age of thirteen went to the disco fairly regularly. She also loved swimming. She had her first kiss when she was fifteen and then met her present husband a year later. When she left school after the tenth grade, she became a manual laborer, which had been a common job for women in the former GDR. She had done this up until the last few years, when she had become unemployed. At the start of the treatment, Mrs. M had a three-year-old son together with her longterm companion. The acute depressive symptoms broke out after the death of a close friend and other fatalities in the family. Mrs. M then developed an overwhelming existential feeling about the ever-present closeness of death. TREATMENT Mrs. M’s early experience of a mother who “educated her with smacks” was evident early on in her treatment with me. She was clearly very fearful of loss, and of showing any aggression that might precipitate this. In actuality, her single mother had been very stressed with work and her family, and Mrs. M talked of how she had tried in vain to find a way of becoming close to her mother when she was a child. Finally, when being looked after by the couple next door, she had found a mother-substitute. Her total dependence on her long-term companion was also evident. Without him, she could not leave the house or do any household shopping. Mrs. M discussed all this with me: how needy she was and fearful of rejection. Very rarely did she talk of her long-term companion as a real and valued person. She was just scared he might leave her and she would then be truly alone. It became clear that the depression had arisen because of this fear and her avoidance of any sort of conflict in order not to trigger potential situations of separation and loss. She told me she had always feared death and that as a child she had once cut herself accidently but very seriously with a knife, resulting in a huge loss of blood. She had been so afraid. Her mother had simply said, “Oh well, now you’ll die!” She would not forget these words and they seemed to be always in her mind. Mrs. M discussed her passivity, her over-stressing of herself and her almost total inability to ask anything of anybody else. At an unconscious level, she expected a great deal and was continually let down. She often had quarrels with her long-term companion and wanted to be the boss in most things to do with their day-to-day affairs. She talked in a concrete way about these

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disputes—it seemed that being in the right was more important to her than having a lively and flexible relationship. She often seemed very restricted in the way she thought about things. She just said, “No, that’s unacceptable, that’s impossible, and that’s it!” No argument or discussion was possible. In this way, she kept rigid control and there was no other perspective possible except her own. She seemed to have come to identify with her emotional abuser and to be as hard on herself and others as she had been to her. Mrs. M had a rather sad and flat internal world. She thought that any kind of imaginative life was irrelevant: it was the real world that mattered, not thoughts and feelings in the mind. Nevertheless, she had had a fantasy as a young adult of climbing a red mountain in Australia. She had two recurrent dreams. In the first, she dreamed of an old house, surrounded by a huge grassy area. From the front, it looked run down, but at the back it was beautiful. In the dream, she lived there with her long-term companion and her son. They couldn’t return to her old house where they had lived before because everything was moldy there, but they always wanted to move back. In the second dream, she flew in an airplane without any fear to Australia, although she had previously always been fearful of flying. Mrs. M saw herself and others in a restricted, one-dimensional fashion, and she related to other people in a constrained and awkward way. In the therapy, she was seldom spontaneous, though she attended regularly. She was evidently a reliable, thrifty, and neat person, but lacking in any kind of flexibility in her dealings with herself or with other people. Sometimes she appeared stubborn, over-controlled, and avoidant. At other times, she seemed weak, dependent, and shy. Occasionally one could detect her yearning for admiration and for the ability to experience a wider range of feelings, but mainly she showed herself as full of doubts and fears. She was clearly loving and caring to her son, but the feelings of anxiety and fear shown at the beginning of our work remained in the forefront for a long time. Her depression began to lift. Once she had been able to process her difficulties in expressing her needs and her existential fears, then she was able to start thinking about her future and to have some hope and a little more confidence. Gradually, she began to feel less attacked and less chronically fearful of separations and she began driving again, and going out to the shops. She was glad to be able to leave the house once more, do things with her son outside in the garden, and drive longer and longer distances, first accompanied, and then on her own. But she was still unable to manage the necessary transactions on a shopping trip. More and more, she was able to accept her anger and acknowledge her needs. It was clear how vulnerable she was, how sensitive to anything she perceived as an insult, or something that might precipitate a separation. She also found it very hard to accept any kind of frustration.



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TRANSFERENCE AND COUNTERTRANSFERENCE From the beginning of treatment, the transference to me was one of complete clinging dependence, accompanied by the idea that I would be able to help her immediately. Gradually, she relaxed and was able to accept more understanding and support. However, her trust in me broke down very easily. Often she seemed inwardly focused on complete mistrust: her own private and unchangeable perception of reality. At these moments, she wanted always to have the last word. If she was in the right, her world was safe. My own feelings in the countertransference were of compassion, but Mrs. M’s constant need to be “in the right,” sometimes in a faintly erotic but distant way, played a part in the dynamic between us. Over time, her depressive and phobic symptoms began to disappear. Then we had to work on her psychic structure and her need “to be in the right” again became very important. Out of the blue, or so it seemed, she became pregnant. At that point, she married her long-term companion and found pretexts to attend her sessions more and more rarely. The treatment ended after three and a half years.

20 The Case of Mrs. N

Mrs. N’s four-year treatment with me began in 2003. I had previously met

her in a psychiatric emergency situation. Mrs. N, a middle-aged woman, was well groomed when we first met, still quite youthful in appearance, and well motivated for treatment. She seemed, however, tired and tense and immediately broke out “I’m at the end of my tether, I can’t go on!” In tears, she talked of meeting me during the previous month. “I nearly killed myself then, because of a fight with my mother. I wanted to hang myself in the cellar. Where does one get these awful ideas, I wonder? My father has had cancer for nearly two years now; he is lying in his bed at home and needing my full-time care. But I just can’t seem to do anything right for my parents—I’m stressed out at work, stressed out at home. There’s nothing I can do about it, and I end up feeling perpetually guilty. My father has been so ill he can’t talk, and then I became scared my mother wouldn’t talk to me either!” Mrs. N complained of constant worrying and irritability, a profound lack of energy, and an inability to concentrate or remember even quite simple things. She couldn’t sleep anymore, and she couldn’t take any further stress. When I asked about childhood illnesses, she couldn’t remember anything beyond the fact that she had had chickenpox. She had had no previous psychotherapy treatment. Both sets of grandparents were country people. On the maternal side, her grandmother had been a housewife, while her grandfather had been a carpenter who had killed himself in 1996 when Mrs. N’s mother was fiftyeight and she herself was forty. They had had three children, and Mrs. N’s mother had been the middle child. On the paternal side, there was rather scant knowledge. Her paternal grandfather had been killed in the Second World War and her grandmother had worked in a butcher’s shop. They too had had

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three children, and Mrs. N’s father was their youngest child. Mrs. N’s parents had met at school, and Mrs. N had been born in the year they married, an unplanned but nevertheless much wanted only child, although they had very much wished for a son. Her father was a craftsman and her mother a clerk. Now both parents were pensioners, and the father had been diagnosed with cancer eighteen months previously. Mrs. N felt she had always suffered from the disadvantage of not being the boy that her parents had hoped for. In childhood, she had experienced her mother as domineering and her father as largely capitulating to his overbearing wife. Family life had been dominated by quarrelling between the parents, as Mrs. N recalled it. Mrs. N’s birth had apparently been normal, but she had been breastfed only for a short while, with her mother and grandmother sharing the care of the baby. Her mother was mostly at work, and she was ignored by her father. Members of the family often slapped her. Her father was continually saying that she would never be able to do this or that. He spoke about her changing for the worse and said she was a “simpleton.” He never played with her or took her out. He saw the son of his sister as a hero. There seems to have been serious emotional abuse and neglect and probably dissociation as a result, and my patient spoke about some of these disturbing facts in a distant way, as if they were normal. However, she did seem to have received some care and attention from her grandfather. She couldn’t recall being defiant when she was a small child, and she did what her parents told her, but her defiance erupted when she became an adolescent. By then, she felt her parents largely ignored her and her behavior. She had got on well with other children, but had also played happily on her own. She couldn’t recall any displays of affection between her parents, and she herself had had no questions, no ideas in her mind, about the difference between the sexes or where children came from. They lived in quite a large house, and Mrs. N had her own room. She always cleared up after playing and couldn’t recall being given pocket money. She liked going to kindergarten and then to school, and she had been an average pupil. She found learning relatively easy, and after school, she had trained to be a nurse. She had friends of both sexes at school, and first kissed a boy who was in her class. She loved going to the disco to chat and listen to music, and she had a best friend to whom she talked about men and about school. She met her husband when she was eighteen—a technician who was a year older than she was. They had two sons. The oldest was born before they were married. The older son worked as a civil servant, while the younger was still studying. Both sons were unmarried. After training as a civil servant, Mrs. N did subsequent training in the public sector, and then after the political changes, “the



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reunification,” she worked in the private sector. She and her husband owned their duplex, which they shared with her parents. The depressive symptoms first erupted in an acute way following a minor row with her parents. But this was at a time when she felt continually under strain from work, family conflict generally, and also the care of her progressively ailing father. TREATMENT Mrs. N’s timidity and emotional dependence became evident in the treatment from the beginning. She seemed passive, withdrawn, and helpless. She continually pushed herself and then felt let down when people did not appear to appreciate her efforts. She was hugely afraid of separation and loss and experienced herself as living in a demanding environment where, despite her best and continual efforts, she experienced no reward and her struggle went largely unnoticed. Her fear of self-assertion was evident, as was her great fear of loss of love. She talked about her early years: how she had constantly feared the loss of parental love and approval and she had developed, as a result, an extremely strict superego. Since her father’s illness, she had had sole care of him. Nearly two years had gone by with Mrs. N laboring under the triple load and strain of her nursing work, looking after the household, and caring for her terminally ill father. Her mother did very little for him. Just like her mother, she felt he was constantly demanding of her. He had spoken less and less, and now when he did speak, latent domestic conflicts erupted. She really felt she couldn’t do any more, but she still drove herself on. But after all, she said, she wasn’t a doctor and couldn’t take responsibility for this final illness. On the day of the reported row with her mother, her father had looked so vengeful and angry that she had wanted to hang herself, so crazily sensitive had she become through all this tension. She realized she didn’t take care of herself while caring for others, and thought she had probably been depressed for quite some time. She felt sensitive, vulnerable, and terribly easily hurt. During the therapy, what emerged was Mrs. N’s desire to be perfect in every respect. Her biggest fear was failure: letting herself and others down. She feared ever saying no to anyone, as she feared that nobody would love her if she stood up for herself. Even after some treatment, she still considered her parents’ behavior when she was a child as absolutely normal. She talked a lot about the family’s current huge garden, as big as two soccer fields. This had been her father’s retirement project, and he had enlisted the whole

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family to join in looking after what was in effect almost a small park. As he was now sick, all the rest of the family had to keep it up. Unfortunately, it took so much time to care for it that no one had time to sit and relax there, as had been the original intention. Mrs. N’s way of avoiding conflict was to retreat. She had no sense of self-esteem, lacked confidence, and appeared full of overbearing scruples. Repeatedly she talked about how she felt she hadn’t done enough, or she had done things less well than she should have done. She thought if anyone found out about her failings in this respect, they would turn away from her. Again and again, Mrs. N broke down in tears as she considered the imminent death of her father. It was hard for her to accept, and her fragile and sensitive self could easily be undermined by her own internal accusations. Her mother too was becoming more and more demanding as her husband’s illness progressed. She came daily to Mrs. N’s apartment, ate with them most of the time, and demanded that the upkeep of the garden continue in honor of her father’s wishes. Mrs. N’s depression only improved slowly, because real external-world stresses increased as her father deteriorated. But she was in any case only too prone to giving in, accepting any demands made on her, and this made her fall into depressions, which did, however, gradually begin to lift in increasingly shorter periods of time. Mrs. N’s capacity to think often appeared sparse and restricted. She complained about a lack of joy in her life and she often seemed weak, lifeless, and exhausted. She was able to discuss her lack of capacity to be firm with others and could see how, particularly with reference to her mother, she had remained the little girl with two tyrannical parents. Despite some awareness of this, she continued to be overstressed and remained almost unable to set any boundaries herself: she carried on giving in and felt let down when no one thanked her. She was clearly very concerned about her husband and her sons in a loving way, but spoke little about this in the therapy. She would appear at times anxious, fragmented in her thinking, and lost. Her feelings cycled up and down and seemed beyond her control. Mrs. N was a neat, dependable and thrifty woman, but her difficulties showed in her demand for self-perfection and her lack of real spontaneity. She had difficulty recalling her thoughts and feelings and reported no dreams. Her insights into others and herself remained rather limited. Repeatedly, I became aware of how her demanding and fearful behavior recapitulated something that had originated in her childhood in her family of origin. She was easily hurt, and her demands for unquestioning love remained evident and very close to the surface. Although she continued to fear separation, Mrs. N slowly began to change, to accept that she had justifiable needs of her own, and to find ways to fulfill them.



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TRANSFERENCE AND COUNTERTRANSFERENCE At the beginning, Mrs. N’s anxious dependency was evident in our work. Once this had somewhat relaxed, she could begin to accept real help and support, though this was often threatened by outbursts of fear and resultant instability. At the beginning, she projected into me these fears of rejection, and I felt pushed almost to act them out by rejecting her. By working on them, I was able to reach states of empathy for this woman’s state of mind. Her competitiveness with me was touched at times with erotic feeling; at one level, she engaged me in a seductive way, fiddling with her blouse, revealing her cleavage, and crossing her legs in a flirtatious way. It seemed as if she was trying to gain my attention as she had, without success, tried to gain that of her father. Sometimes her complete helplessness would induce in me a state of frustration and impotence and, as I have said, at one level she remained fixed at the level of a small child, helplessly dependent especially on a domineering mother figure. Further work is needed in order to help her to grow up from being a “daughter” to being an adult woman and mother.

21 The Case of Mrs. B

Mrs.

B came into treatment with me in the year 2000 and we worked together for over five years. Born in the mid-fifties, Mrs. B was quite a powerfully built woman with short dark hair and an open expression. She was simply dressed when we first met, but I had the impression of someone rather restricted in movement. She was, however, keen to have help for her depression. She explained in our first session, “Things have got much more difficult lately: I’ve got problems with my daughter, and I’m getting to the end of my tether. My job’s no fun anymore. I used to love it, and I still do now from time to time, but often I just feel sad and hopeless.” She let me know about previous depressive phases. She worked as a social worker and felt increasingly exhausted by the job, and she had frequent tiffs with family members. She said she had always been someone who got easily agitated and out of sorts. She slept badly, was increasingly unpunctual, and disliked her work more and more. Generally, she just felt exhausted, suffering from headache attacks. Currently she was experiencing extreme mood swings. She found herself brooding and irritable, having many sleepless nights, with subsequent energy and concentration problems. She had had repeated tonsillitis as a child, but there was nothing else remarkable in her history. She had had no previous psychotherapy treatment. Both sets of grandparents had come from industrial small-town backgrounds. Mrs. B’s beloved maternal grandmother died soon after Mrs. B came into treatment with me. Mrs. B had always been the apple of her grandmother’s eye. Her maternal grandmother’s husband had died many years before, and Mrs. B recalled that he had treated his wife badly. Mrs. B’s mother had been the elder of two daughters, the younger of whom was married to a former member of the administration. This had been an issue for the whole 245

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family because they had not been allowed by the East German government to have contact with the West. Her paternal grandparents, both born around the turn of the twentieth century, had been robust people. Mrs. B thought that her grandmother had been quite restless and talkative, while her laborer grandfather had been a more relaxed character. Her paternal grandparents had three children, and Mrs. B’s father had been the youngest of these. Mrs. B’s parents had met in the mid-1950s. Both now in their seventies, Mrs. B portrayed them as having been quite strict when she was a child, with her mother being the dominant partner. They had worked hard but in a somewhat joyless way. They had moved to the country in order to build their own house, and Mrs. B felt she had, despite her parents’ strictness, quite a pleasant childhood. Mrs. B had been a much-wanted first and only child. After a short period of breastfeeding, she had apparently been looked after by both her mother and maternal grandmother. She had had a childhood, she felt, of relative freedom, and she could recall no times of difficulty or opposition to her parents; for instance, she remembered that she always had to eat every single thing on her plate, and did so without complaint. She had felt very comfortable in groups and had much enjoyed painting and handicrafts. She had slept in her parents’ room until she was three or four and had disliked kindergarten but enjoyed school later. She thought, however, that she had always been moody underneath her generally happy exterior. She had always loved swimming, and took it up as a serious hobby. When she wasn’t occupied by taking part in competitions, she went away on the weekends with her parents to their country house, but she got somewhat bored on her own there, as she felt too alone. By her mid-teens, she had quite a large group of both female and male friends, and then after her graduation she had started her studies to become a social worker. Away from home, she felt a need to make up for her lost time and expanded her social life even more. Then she embarked on her career, in which she did very well and became a significant figure in her profession. Her first job was in a social institution. There she met her future husband, also a social worker. They married at the beginning of the eighties, and since their marriage remained childless, they adopted two young children. They continued to work in the social institution, and then Mrs. B became a fulltime mother. A couple of years after the adoption, however, Mrs. B’s husband had an affair with a younger worker in the institution. She seemed to have been very unprepared, “indeed shocked,” when her husband left her for someone else. She seemed to have little access to feelings of anger and outrage; it is possible that the strictness of her upbringing may have inhibited these feelings and produced a degree of emotional abuse. Divorce ensued, and at that time the elder child, a daughter, wanted to go with her father. She was forced, however, to stay with the mother, which was the cause of increasing



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tension and battles over the years. Mrs. B and her two children lived in an apartment together with a tomcat for company. Her depression ensued after escalating conflicts, both with her daughter, who demanded money, and with a coworker, who made unwarranted demands on her at work. TREATMENT It was evident in the treatment that Mrs. B lacked self-esteem, had a great fear of asserting herself, and tended to try to fit in with others in order to maintain their affection. She talked about her early years and how much she had feared that she might lose her rather strict parents’ love if she did not adapt to their demands. She felt deeply ambivalent about her parents: she admired their robustness and resilience, but felt critical of their lack of empathy, especially that of her mother. Saying no, she felt, had never been an option, so she had always tried mightily to do whatever she was asked and then felt let down when approval was not forthcoming. She soon began to discuss how let down she had felt by her former husband and by her adoptive daughter. The tensions had escalated over the years. Her daughter had run up phone bills of hundreds of pounds and then expected her mother to pay them. Mrs. B would pay the debt, explain that she would not do so in the future, and then the very same problem would arise again. There was an exhausting cycle of confrontation, ultimatum, and eventual collapse into agreement. She seemed to be submitting to emotional abuse all over again. In addition, Mrs. B worked with someone who did not pull his weight at work. Mrs. B was outraged about this, but could not bring herself to confront the other worker’s behavior. During the therapy, Mrs. B talked about her tendency to overdo things and to demand a lot of herself in an inappropriate way. She experienced the world as lacking color and joy. Often she felt that she had to accept this state of affairs, and felt lacking in energy, solitary, and unhappy. Confrontation was avoided by retreat and a passive damping-down of any strong feeling. While she was concerned to try hard for her clients, this too was becoming something she experienced as increasingly problematic. She still tried to do her best for those who needed her help and worked with empathy and warmth, but she often overtaxed herself and became exhausted. At an unconscious level, Mrs. B made huge demands on herself and on the people in her environment. Her inevitable disappointments led her to retreat more and more into her domestic isolation. As already mentioned, she pushed unpleasant thoughts to the back of her mind, very rarely confronted anyone, and remained enormously anxious about any form of self-assertion. It was only gradually as we worked together that she managed to think about herself and her own

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interests and started to take little breaks and holidays, as well as further vocational training. Often she showed almost no spontaneity, and she appeared very rigid and inelastic. She was a perfectionist and felt consumed with guilt, being unable to tolerate any imperfection in herself. Things were always her fault, she felt, and she blamed herself endlessly. She kept a tight rein on her domestic affairs, and wanted to be 100 percent efficient. She had a mind full of “oughts”—one ought to do this, one must do that. These thoughts were in marked contrast to her often complete lack of capacity to decide anything at all. In her fantasy life, Mrs. B seemed to be equally held in check. As a small child, she had dreamed of having a sibling and of being a princess. As she grew older, the dreams turned to wishes for the latest jeans and other Western products. She fantasized about a better life for herself, and her favorite films, in which she was the star, included Lassie and Flipper: she longed for a pet and a home in the country. She also loved TV magic shows and wanted to be able to do all the tricks. She had no memory of recurrent dreams of any other kind. Her insight into herself and into others was restricted. As we continued with the work, what became clear was how much the depression was related to feelings of helplessness whenever she was faced with any sort of conflict and with the impossibility of reconciling her desires with reality. When she felt out of her depth and emotionally wounded by others, she retreated. It was only very gradually during the course of her therapy that she came to have a better sense of herself and her own capacities, both at home and at work. Her situation improved a great deal when her daughter left home at eighteen to live with a friend. But Mrs. B still felt caught up in worry about this daughter and her inability to manage her finances. And she still carried on overexerting herself at work with resultant depressive collapse in a seemingly never-ending cycle. She talked to me about her acute fear of separation and loss in any situation. These were core issues in our work and needed to be discussed repeatedly. She needed concrete proofs that she was loved and found it hard to tolerate any sort of frustration. Nevertheless, through patient work, she became more able to separate her rightful needs from the unrealistic ones, to accept her own anger, and to move toward a more realistic picture, both at home and at work. TRANSFERENCE AND COUNTERTRANSFERENCE From the beginning, I was aware of Mrs. B’s simultaneously hopeless and unrealistic expectations of me. Issues of mistrust continually came up, and Mrs. B could only gradually relinquish her desire to be in control and begin to accept understanding, help, and support. However, intense feelings of inse-



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curity still made themselves evident at times. I felt sorry for her, though I too could feel myself drawn into arguments that sometimes were charged with both aggression and eroticization. At other times, I had difficulties managing my feelings of impatience and boredom, as Mrs. B rather monotonously recited seemingly endless lists with factual considerations and reflections that had little relevance for her real difficulties.

V TRAUMA TREATMENT GROUNDED IN PSYCHODYNAMICPSYCHOANALYTIC APPROACHES

There are many ideas and conceptualizations concerning the treatment of

trauma that tend to come under the umbrella either of a one or of a two-person psychology. Each of the following chapters (by Anna Balas, Mariângela Mendes de Almeida, Adrian Sutton, Joseph Fernando, Sverre Varvin, Koichi Togashi and Amanda Kottler, Adrienne Harris, and Orit Badouk Epstein) gives descriptions of possible treatment methods and interventions as well as general rules that govern the approach under discussion. Divergences and differences are seen to remain both in terms of the intensity and type of trauma and of the interventions practiced. Differences also occur as to whether the trauma is an individual or a collective issue. Furthermore, the age of the patient or patients in question can be seen to determine certain aspects of the treatment. Trauma can take on multifarious forms, not always easily classifiable. Treatments can be full of difficult impasses and astonishing moments. Most forms of trauma seem treatable under this vast umbrella, as creative therapists in different areas demonstrate. The question of which forms of trauma remain resistant to treatment remains, as yet, unclear.

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22 Challenges of Treatment with Traumatized Individuals from a Modern Freudian Perspective Anna Balas

There is no trauma outside the individual’s omnipotence. —Winnicott 1960, 585

This chapter opens with a definition of trauma, as I understand it, to help

me discuss some central therapeutic challenges to the treatment of this varied group of patients. My guidelines in treatment are to maintain neutrality while being as flexible as needed, to pay attention to my own emotional reactions, and to prevent a patient’s undue regression while reestablishing basic trust. To prevent undue regression, the analyst needs to remain alert to the secondary gain of a patient in “the sick role.” One must respect the complexity of traumatic states, understand repetition compulsion, and be able to live with the uncertainty of not knowing what happened exactly. This uncertainty is due to the patient’s mistrustful withholding of information or to not remembering because of repression or dissociative states. I also describe pressure on the analyst, through the patient’s seductiveness and/or paranoid projections, to depart from neutrality. This pressure can be the patient’s way of dealing with the intensity of his needs toward the analyst. Another seminal theme in traumatized individuals is distortion of the perception of reality due to omnipotent beliefs, also closely connected to the psychology of “the exception” (Freud [1906] 1974c, 113). Finally, after discussing the importance of secrets and the problem of false memories, I give a brief example of transmission of trauma. I conclude by outlining the personal qualities necessary for working with such challenging patients. The conclusion offers occasional surprisingly positive outcomes, as some individuals reorganize their coping style and are able to heal. 253

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CONTEXT Ours is a vast and complex topic, as trauma is ubiquitous and all people have their strengths and weaknesses. Everyone suffers from trauma following the loss of the fantasy of infantile omnipotence at the hands of external reality. Therefore, we therapists must not divide and think of “us,” the healthy, versus “them,” the pitiable damaged ones. Also, we need to recognize temptations in order to avoid assigning responsibility: to the extent that traumatic experiences impinge from without, theoretically they exempt the victim from responsibility. Yet, our work revolves around the realm of personal responsibility and of taking charge of one’s life and suffering, to whatever extent possible. Unless a patient has ulterior motives, such as material compensation, seeking help shows signs of strength and resilience achieved by reaching out. We analysts need to begin with respect for the adaptation the person has made to individual circumstances. It has possibly worked in some measure. In fact, the most severely traumatized people are less likely to seek help. Patients with a history of significant trauma tend to present with an uneven mixture of strengths and vulnerabilities. It is best to anticipate that they may not fit classic diagnostic categories. What we know is that we are likely to find a deep undercurrent of pessimism, even under the guise of being well functioning (“false self” [Winnicott 1975], “basic fault” [Balint 1968], “fixation” [Greenacre 1960]). These patients are likely to show features of overt or hidden despair, of a compromised capacity for basic trust. DEFINITIONS OF TRAUMA A shorthand history of the concept of trauma includes some basic ideas: trauma means the breach of the “stimulus barrier” (Freud [1920] 1974a), namely that external events are overwhelming the ego. The patient finds himself in a state where there is a correspondence between the external event and an unconscious or preconscious fantasy akin to that event (Furst 1967). This correspondence becomes the trigger for unleashing a traumatic state, confirming one’s fantasies of omnipotence and the power of magical thinking (Winnicott 1960). The traumatic process consists not just of the event itself (Oliner 2012), but the aftermath, the sequence of internal reactions it sets off in the individual subjected to the noxious event(s). The interweaving of the traumatic events with the characteristic anxieties corresponding to the



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specific developmental stage in the life of the child can worsen the symptoms. I am referring here to the developmental hierarchy of anxieties as first delineated by Freud in Inhibitions, Symptoms and Anxiety ([1926] 1974b). These individual anxieties in developmental sequence are: danger of feeling overwhelmed by physical helplessness, danger of loss of the object, danger of castration, and fear of the superego. These vulnerabilities are characteristically stage specific. When a noxious event chronologically corresponds with a stage-specific anxiety, it can trigger more severe reactions, such as a panicky reaction to a hernia repair at age two and a half or three, when a child has a heightened worry about castration and/or threats to bodily integrity, for example. Laub and Auerhan (1993) delineate a hierarchy of defensive reactions to massive trauma, depending on the severity of the psychic insult to the organism. They address the connection between reality testing and trauma: How compromised does the perception of the self or of external reality become in the case of severe traumatic experiences? For instance, one may use paranoid distortions to exonerate oneself or loved ones, projecting the aggression outside the self. We also need to consider different types of traumas (Furst 1967), such as those triggered by ill treatment, neglect, or physical or psychic illness. We may analyze superego distortions as resulting from trauma, as well as endangered basic trust (Balint 1968; Ferenczi [1933] 1994; Lemma and Levy 2004). How do I work differently with patients who present with histories of severe trauma? My work is a direct result of my theoretical knowledge of traumatic states. It requires more flexibility and more availability during times of regression. Yet maintaining neutrality is paramount. I guard against having a preconceived agenda, not hurrying with quick formulations. One needs to respect the complexity of the patient’s long-standing adaptations and the multiple purposes of those ways of coping. Vulnerability makes these patients very sensitive to hypocrisy, just as children are perceptive to falseness (Ferenczi 1994). Such sensitivity presents a major challenge for the analyst: one gets pulled into an affectively charged world, where it is harder to think clearly and to maintain objectivity. There is pressure to become the rescuer. Often the analyst is the first to hear details of the traumatic events—a privilege and a heavy responsibility. One could inadvertently re-traumatize the patient or provide relief. The analyst needs to be cautious about rapid relief because it is hard to judge what that relief is based on. If the relief is based primarily on an intense idealization of the analyst, it is then in danger of sudden collapse once that idealization is thwarted.

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AVOIDING THE SECONDARY GAIN OF THE SICK ROLE AND DISCOURAGING UNDUE REGRESSION What follows is an example of trying not to coddle too much even if the patient demands it (Freud [1920] 1974, 133). A longtime patient who had a history of traumatic sexual molestation by a stranger suffered symptoms of PTSD for many years. These were characterized by sensitivity to physical intrusion and verbal disparagement. His boss was a man who was typically known to be disparaging and physically intrusive. At one point, my patient started to have severe anxiety attacks in relation to his boss’s behavior and wanted me to write him a note to stay out from work on grounds of disability. He became very angry with me when I expressed hesitation and suggested that we explore the options carefully. I pointed out the gravity of such a decision and wanted to be sure that he was not undermining himself, just after having received a sizable raise from the same boss. I also indicated that if he was taking time away from work on grounds of disability we needed to make an intensive treatment plan commensurate with the severity of his condition. I was introducing external reality factors that challenged his attempt at omnipotent control. He took a few days off from work to think it over and decided to not take leave. The decision to stay on in the job protected him overall. Instead, he found a better solution when he was no longer in panic mode. In the interim we increased the frequency of his therapy and added new medications recommended by an expert in pharmacology. By my resisting intimidation and introducing reality factors, his cooperation we accomplished and thus he avoided jeopardizing his life situation. COMPLEXITY OF TRAUMATIC EVENTS The analyst needs to be open and not prejudge causality, as the circumstances can be fairly complex. For instance, an eighteen-year-old college student presented with acute depression following the death of her grandmother. The following traumatic events emerged in reverse chronological order: she reported that she had lost her young mother to cancer two years before; a year before that, when her mother was already ill, a group of boys had tried to molest the patient in broad daylight at a playground; she narrowly escaped by running away, but it had been a dangerous and frightening experience for her. Later I learned that she had recurrent nightmares about her brother trying to drown her, a brother who throughout her childhood had tormented her mercilessly, with no protection from her parents. Going back further in time, we discovered that she had fallen down a flight of stairs at the age of four and lost her



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front teeth, thus needing to have false milk teeth. It was not clear whether her brother might have pushed her. Here is an example of layers of trauma, layers of suffering, some of them self-induced (I return to this issue when I discuss repetition compulsion below). Therefore, it is important to keep an open mind about the causes of trauma. This particular patient did not want me to be too soft or sympathetic, nor did she want me to be protective about her life choices at the time of treatment. This is an example of how important it is to take the cues from the patient on what approach they need. This patient did not want to be coddled. Having hardened herself with all of her suffering over the years, she wanted the analyst to tolerate her suffering and not to be overly soft or sympathetic: she thought that would be a sign of weakness. Prior to her work with me she had seen a school counselor and a therapist, both of whom burst out crying and told the patient about their own troubles (as she reported it). This had left the young woman mistrustful of seeking help from adults. REPETITION COMPULSION It is a known feature of traumatized individuals, first described by Freud in Beyond the Pleasure Principle (Freud [1920] 1974a, 31–32), to account for recurrent dreams that could not be accounted for by the principle of dreams as wish fulfillments. Freud thought that re-creating a traumatic situation either in a dream or in action could be understood as an attempt at mastery by turning passive into active and sometimes identifying with the aggressor, sometimes keeping the role of the victim. The young bereaved woman described above found a boyfriend who enjoyed physically tormenting her in a manner similar to her brother. By careful observation, he determined which types of hurt and intrusion she minded the most, such as being pinched for example, and he inflicted these minor tortures on her as part of their love life. She was enraged at him for disrespecting her warnings, yet she could not resist him and, for a while, subjecting herself to such treatment. Only gradually through our work did she gather the strength to break off that relationship. Addressing the element of sexual excitement was especially challenging. EXAMPLE OF FALSE MEMORY After working with a patient for a while, one gains an understanding of whether there was an atmosphere of genuine deprivation, overstimulation, or abuse in the household. The overall climate of childhood is easier to glean than specific memories and details, which are often not easy to verify.

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For example, after I had worked for many years with an elderly man, he confessed that an experience of molestation by a fatherly figure, previously described as having occurred when he was three years old, had never happened. A major accomplishment of our work together was that he confessed this fabrication to me. Nevertheless, I was surprised, having worked with him for years discussing this technicolor memory as a supposedly true event. Together we discovered that his father’s neglect and lack of interest in the patient’s life was profoundly painful. The myth of the seduction by another father figure had served to protect him from the pain of the parental deprivation and to avoid his profound anger at the father. Also, he felt that this story of molestation better explained his severe symptoms of impotence and overeating with which he had struggled for many years. Thus, the false memory worked as an organizer and a justification for his unhappiness. It took much additional work to accept that his suffering was authentic and all the more painful because it came from a close family member in the form of painful deprivation. DISSOCIATIVE STATES I worked for many years with an older man who had gone through frightening experiences as a young child during wartime with his family. When hiding with his family in France, he was instructed to say “Je ne sais pas” to any questions asked by the gendarme. He and his brother were taught to practice this phrase over and over again, as French was not their native tongue. All his life as an adult, when he encountered a frightening or upsetting situation, this patient would suddenly blank out and disassociate, entering a state of “je ne sais pas”—of not knowing anything. He found himself with a blank mind. Over time, he developed a method of making up cover stories to conceal his deficiency of having lost the thread of conversation. This adaptation presented an obstacle in his relationship with his family and an obstacle to friendships. He would suddenly go blank and emotionally tune out and then sound jarringly disconnected to those who knew him well. In our work together, we discovered that this happened just as he was starting to feel either frightened or very angry. Instead of experiencing those threatening emotions, he would go blank. Over the years, he became better able to recognize and tolerate his anger and therefore he disassociated less. Because the patient so feared his own anger that he had trouble acknowledging it, I had to connect the missing affect to his flight into a dissociative state.



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SEDUCTIVENESS TOWARD THE ANALYST I had a young woman patient who had been seduced as a child by a nanny in a foreign country. The nanny danced with naked breasts in front of the patient and her sister when they were little girls and enticed them to suck on her nipples. This patient used seduction to achieve a stronger sense of self. She had managed to seduce her former therapist to reveal some of her private gynecological information. She then turned her seductiveness on me. Early in our work, this young woman started off by flattering me: “I bet you are an older sister, you are so poised and sure of yourself.” The ploy was intended to get me to reveal things about myself and to thus be vulnerable, putting her in a position of knowledge. Given prior warnings, I was especially alert to challenges regarding boundaries and threats to my privacy, even with a seemingly innocuous question. This woman needed attention at all costs, including outright deception. I learned from her that in high school she had painted her skin yellow to feign jaundice as a way to stay home and gain sympathy. Less interested in achieving a genuine sense of self than gaining attention, shortly thereafter, this patient left her treatment without paying for it, a sign that she was not taking responsibility for coming to terms with the underlying trauma. As intense negative affect states are revived, the analyst can become an object of fear or be suddenly perceived as the victimizer: the patient may blame the analyst and flee in a paranoid reaction. The playing field may look like the realm of the torturer and the tortured. TWO EXAMPLES OF PARANOID PROJECTION A lively, overstimulated, and very active five-year-old boy, who was not usually aggressive, ran into my office and unexpectedly slapped me on the face. He immediately panicked and ran out to his mother: “Dr. Balas just slapped me,” he cried, pointing to his face. Fortunately, I had a good rapport with his mother and explained to her what had just happened with the two of us. It was clear that he must have scared himself by hitting me and that he disavowed his action by reversing roles and making himself into the victim. We weathered the episode, unlike in the next case. This woman in her thirties had lost her mother to cancer not long before. In therapy, we were exploring her lifelong ambivalent relationship with her mother. My patient had a vivid disturbing nightmare of her mother having her throat slit. As I was glancing down to write down her disturbing dream, the patient perceived me as having fallen asleep. She accused me of insensitivity and dropped her therapy abruptly. No attempt at discussion or exploration could

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save the treatment. My impression was that the patient had panicked at the amount of raw aggression that emerged in the nightmare. She then projected her rage onto me as instigator of the rage and as mother figure, and onto the therapy. She needed an immediate reason to exit and someone to blame for it. More broadly considered, the role of victim absolves one from responsibility for one’s own aggression. In spite of this abrupt rupture of the treatment, I received a note from her many months later thanking me for my help. OMNIPOTENCE WITH TRAUMA The patient in the earlier example on dissociative states devoted his life to fiercely protecting his family. He had heroically rescued family members as a young child—with courage, steadfastness, and his “je ne sais pas” response. However, he inaccurately believed he should always have the power of seemingly magical deeds of rescue. Therefore, if any member of his family was suffering, he would take it as a personal failure; he would become despondent and self-blaming. It took years of work to clarify that he did not have magical powers, even though his remembered childhood feats of rescue seemed miraculous. This exaggerated feeling of responsibility caused the patient much suffering, and to this day, he feels overly responsible for the happiness of the family. On the other hand, he gets furious that his son is not more available to him. His omnipotence expressed in his willingness to give of himself limitlessly may have bred a feeling of entitlement as compensation for past sufferings. THE PSYCHOLOGY OF THE EXCEPTION There are many examples of people who have suffered severely who then feel entitled to compensation (Freud [1920] 1974a, 31–32). These people may put themselves above the rules of society, even above the rules of external reality and are prone to magical thinking. This mentality may indicate superego deficiencies: “If my parents did not love me well enough, why should I respect their rules, the laws of the land” or “If the Fates did not smile on me, I do not owe obedience to the laws!” This attitude may lead to transgressions in persons who otherwise have good judgment. They find ways to rationalize breaking the rules. When such attitudes surface in treatment, the therapist has an opportunity to interpret their dangerous self-destructive consequences. To some extent, the example above fulfills those criteria of feeling entitled to be exempt from ordinary rules of law and of reality at large.



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SECRETS AND TRAUMA The analyst needs to be open and tolerate the uncertainty of not knowing what caused the trauma for a given individual. In one case, it took months to learn the full complexity of secrets affecting a brilliant eleven-year-old boy. Right after September 11, 2001, I treated this anxious boy, a top student, who had just moved to New York City with his parents. This child was a perfectionist in school. Loving skyscrapers, he and his parents had just visited the World Trade Center the week before the attack on the Twin Towers. For the first few months of treatment, it seemed the boy’s severe anxiety revolved around being new in New York and having arrived at a time of crisis. Only after many months of working with him four times a week did I discover a number of secrets. First, the parents had separated for several months before their move to New York and their marriage had almost failed. I had not been aware of the threat of abandonment by his mother, who had gone far away for several months without a firm plan of return. Nor did I know that upon her return this mother was overly indulgent and would hold this pubescent boy on her lap as if he were a little child. Other secrets also emerged: the father’s father had suffered from a major mental illness known by the whole community during the father’s childhood. As a result, the boy’s father lived in constant fear that the patient could inherit his grandfather’s condition. I also discovered that father and son would engage in very intense physical wrestling matches that were both stimulating and upsetting to the patient. In other words, there were secrets about intense family strife, threats of abandonment, and overstimulation, as well as the secret burden the patient shouldered to save the family honor by staying a top student. It was not just posttraumatic stress disorder (PTSD) precipitated by the attack on the World Trade Center, but a host of secret traumas. TRANSMISSION OF TRAUMA A young woman reported that her mother had died when she was five years old. She was raised by her hardworking father but was molested by an uncle for a period of time during her later years. She was never able to tell her father out of fear of losing face and insulting the uncle. After some work with me, she developed a career, married, and had children. When her oldest child turned five, just the same age as when she had lost her own mother, she found herself on the verge of leaving her husband and children, in love with another man. She came to me in this crisis, and I pointed out that she was causing her children to suffer just what she had experienced herself. The patient could not hear this message and went to another therapist, who encouraged her move.

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In this enactment of the transmission of the patient’s trauma, the therapy had become a casualty of her enacting her mother’s disappearance from her life, as she disappeared from my office. There is little room here to address the key issue of differentiating between benign and malignant regressive states, an important topic explored by Michael Balint and Ferenczi. Balint’s important technical point is that patients in a regressed state cannot hear the content of interpretations. Rather, they respond to tone of voice. Therefore, he advises analysts to keep comments simple and to save the more complex interpretations and reconstructions for later, when the patient is no longer in such a regressed state. The analyst should think more of providing a “holding environment” (Winnicott 1960, 588–89) and “primary love” (Balint 1968, 64), or “mirror transference” (Kohut 1971), in the early phases of treatment. The analyst needs to oscillate between empathy and maintaining an observing self. Because of the affective intensity in stories of trauma, it is hard to find a wider perspective. One feels pressure to become role responsive. However, a willingness to listen is potentially helpful in itself. The truth is that the analyst can become a casualty of the process. Some traumatized patients will test boundaries again and again. Just as they have been seduced, they will try to seduce the analyst in a misguided search to be a special favorite. CONCLUDING REMARKS In sum, working with traumatized patients requires humility and patience. One needs to attend to one’s own reaction and to protect oneself against heroic rescue fantasies. Also, one needs to be prepared for the fact that the patient may experience the analyst as a hostile perpetrator. If that is the case, the analyst needs to allow exploration of that role and not become overly defensive. Successful work with this group of patients requires willingness both to tolerate the painful role of witness and to acknowledge one’s own emotions, however unacceptable. It is helpful if the analyst has a good support system of her own. After arduous efforts over a long time, the patients may surprise both themselves and their therapist by their progress. Unexpected creativity or new adventures may ensue. All the while, the patient and analyst know that such changes would have been highly improbable without the treatment. REFERENCES Balint, Michael. 1968. The Basic Fault: Therapeutic Aspects of Regression. Evanston, IL: Northwestern University Press.



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Ferenczi, Sándor. (1933) 1994. “Confusion of the Tongues between the Adults and the Child.” In Final Contributions to the Problem and Methods of Psychoanalysis. London: Karnac Press. Freud, Sigmund. (1920) 1974a. “Beyond the Pleasure Principle.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 18. London: The Hogarth Press. ———. (1926) 1974b. “Inhibitions, Symptoms and Anxiety.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 20. London: The Hogarth Press. ———. (1906) 1974c. “Some Character Types Met with through Psychoanalytic Work.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 14. London: The Hogarth Press. Furst, Sidney, ed. 1967. Psychic Trauma. New York: International University Press. Greenacre, Phyllis. 1960. “Regression and Fixation.” Journal of the American Psychoanalytic Association 4: 484–502. Kohut, Heinz. 1971. The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders. Chicago: University of Chicago Press. Laub, Dori, and Nanette Auerhahn. 1993. “Knowing and Not Knowing Massive Psychic Trauma: Forms of Traumatic Memory.” International Journal of Psychoanalysis 74: 287–302. Lemma, Alessandra, and Susan Levy. 2004. “The Impact of Trauma on the Psyche: Internal and External Processes.” In The Perversion of Loss: Psychoanalytic Perspectives on Trauma, edited by S. Levy and A. Lemma. New York: BrunnerRoutledge. Oliner, Marion. 2012. Psychic Reality in Context: Perspectives on Psychoanalysis, Personal History and Trauma. London: Karnac Books. Winnicott, Donald. 1960. “The Theory of the Parent Infant Relationship.” International Journal of Psychoanalysis 41: 585–95. Winnicott, Donald. 1975. Through Pediatrics to Psychiatry and Psychoanalysis. London: The Hogarth Press.

23 Trauma and Inner Reality A Kleinian and Post-Kleinian Perspective Mariângela Mendes de Almeida

Psychoanalytically, since Sigmund Freud, trauma has been defined and ap-

proached in treatment as an experience or experiences that, due to their intensity and to the difficulties that the individual may have to deal with in them, are likely to bring long-lasting and disturbing effects to one’s own psychic organization (Laplanche and Pontalis 1986). Klein’s route ([1959] 1988) for developing psychoanalytic knowledge has highlighted even further the inner quality of the experience, considering even more archaic anxieties. As infants, we are exposed both to loving and aggressive impulses from the very beginning of our psychic existence, and these experiences are then continuously being modulated, intensified, and transformed, from our first primitive relational interchanges and throughout our lives. Within the object relations tradition, inspired by Kleinian explorations, the shape and impact of external events is highly colored by internal configurations and strengths in one’s own capacity to internalize their good aspects (from experiences both with others and in one’s own self). Thus, painful, attacking aspects of experience can be worked through in a live interchange between internal and external objects, where the relations between them from within the mind forms the core from which the personality expresses itself. This emphasis on the inner dimension is perhaps the reason why the word “trauma,” and the notion of a traumatic event coming from the outside, is not present as such in Kleinian clinical day-to-day vocabulary. However, we are consulted by people to whom extreme suffering has linked to external events or experiences that have impacted their lives (modulated of course by internal thoughts and feelings). The treatment in these

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cases does not have a specific denomination, as it deals with the comprehensive net of anxieties brought to the setting, which will then have a chance to be looked at in detail. We could say that the Kleinian view includes the potent presence of internal objects in their archaic quality, in the scenario where traumatic experiences impact, and in the way they are worked through within the personality and in the analytic relationship. Thus, in that sense, we do not specify which types of trauma can be accessed or which type of trauma can be treated by which method, but rather suppose that inner configurations, in their sensitivity to triggering elements that may raise recurrent anxieties, can always be brought to life within the analytic relationship. Looking through the lens of sensitive elements in constant reactivation within the psyche, these recurrent undigested experiences can be at the same time acute, situational, developmental, and complex. By this, I mean that they are acute because of the potential of intensity emerging in each new reactivation, situational in assuming a layer of psychic configuration lying latent under each manifestation in triggering situations, developmental in that they have been built up along the individual’s psychic history of internal objects, and complex in how these objects have been facing and containing the diversity of experiences. Thus, we are looking at a complex picture if we think about the singularity and plasticity of the psychic organization from the point of view both of the suffering patient (for whom the pain is always intense, acute, and overflowing) and of the attuned analyst, engaged in being receptive to the many faces of what is being transferred to him or her. Analysts’ kaleidoscopic containment implies empathic attention to the quality of pain being transferred to them. They develop a capacity to respond without getting defensive, avoidant, or retaliating, and an ability to be in touch with their own psyche to observe their emotional movements. Thus, analysts learn about the patient through countertransference and the process of transformation of sometimes primitive, raw elements that press forward, claiming psychic representation. In that context then, symptoms and diagnoses are also thought about in terms of the net of latent and manifest anxieties that may be either immediately or more remotely linked with traumatic experiences. We try, of course, to get close and identify obstacles that recurrently interfere with the individual possibility of relating creatively to the diversity of human links and emotional situations. Micro- or macro- “traumas,” in the sense of unmetabolized experiences, are always emerging in the analytic relationship, announcing themselves in recurrent repetitions. There is a significant difference as to when and whether analyst and patient see them as restated compulsions, destructive forces attacking live inner and intersubjective links, or claims and breaches for finding new tracks beyond compulsion, even if these are still feeble and rudimentary.



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Clinicians from some generations valuing Kleinian and post-Kleinian contemporary clinical developments, particularly those who have had the privilege of working with the live matter of primitive states of mind in children and infants, have been showing how “in this field of psychic effects of those traumatic experiences which have not yet reached a representation, we must find alternative ways of listening and interpreting” (Souza 2016). Analysis, in this view, has been seen as “a field where a containing object is built, as an experience of acknowledgement and hope—an experience that may not have been found in the relationship with the initial objects” (Souza 2016). Working in this psychoanalytic Kleinian/post Kleinian tradition, where these inner archaic realities are brought into the analytic scene, updated, and reactivated within the current relational environment with the analyst, my approach considers the constant interaction between internal and external objects. These may be intimately explored in the here and now of the analytic encounter through the transference and countertransference tools. I hope to be able to demonstrate this in the discussion of some clinical vignettes from work with children and parents in psychoanalytic treatment. Roussillon (1991) describes how the analysand tries to communicate to the analyst something that has not been heard, seen, or felt in his subjective history, or at least not in a sufficient way to be fully owned by the subject. In this situation, the unconscious does not refer to what was noticed and repressed, but to what did not find a subjective place to inscribe itself. For him, the analysands, as we can see with the examples to be described here, come not simply to ask for recognition of what has remained dead material in their history, they come to turn non-represented content into something possible to hear, see, or feel, inviting the analyst to share and reflect what is waiting for subjective appropriation, what can thus be born for psychic life. He associates this with the Kleinian concept of projective identification, which is expanded by Bion (1962) as the most primitive modality of communication, ordinarily taking place since the very early processes in every parent-infant relationship. In this chapter, I intend to highlight the possibility of intervention in the very early stages of the chain of trauma transmission, working microscopically, taking into account one’s own internal objects and internal-world configurations in their dynamic dialogue with the surrounding relationships. WORKING WITH THE INFANTILE SELF WITHIN TRAUMATIC IMPRISONING CHAINS I work clinically both in private practice and in community settings. Attention to very early parent-child relationships repeatedly requires that one contain painful experiences, some of them intergenerational, which are struggling

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to be worked through and to find representations in individual and family psyches. As part of outpatient units in mental health and child psychiatry/psychology services linked with pediatrics, developing services in parent-infant early intervention, I have seen children and parents/families struggling with negligence, abuse, and various degrees of violence (relational, social, sexual). I have also worked with very early mismatches in a child-parent relationship where traumatic elements in parental history have been significantly present in the establishment of the relationship with the infant. Through joint analytic work with parents and infant, the continuity of a traumatic chain through the generations may be intercepted and worked through both in the parent’s mind and in the constitution of a body-mind unit in the infant. In infants with early feeding difficulties, for example, where the first clinical window (Stern 1997) is open to challenge, we see how both the competencies and vulnerabilities within the parent-infant relationship—the resilience to overcome difficulties or the risk of crystallization of possibly transient difficulties—may be associated with undigested psychical realities in the parental history. These are reactivated in the parents’ contact with the newborn from the very earliest feeding interchanges (Mendes de Almeida 1993, 2012; Williams 1997a). In all these cases, it has been important to offer a containing field (Mendes de Almeida 1993, 2012) to both the mother/father’s and to the child’s anxieties in their infantile, primitive quality, discriminating between parental psychic contents and the child’s singular way of experiencing external and internal facts. ANNA: MICRO-TRAUMAS IN DIGESTION, THE INTERNAL PRISON We can see in the following vignette how undigested/traumatic contents, possibly resulting from primitive situations that are still struggling to be represented and emotionally acknowledged as one’s own through experience, may repeatedly appeal for containment within the analytic relationship. Work in the psychoanalytic object relations tradition may offer clear help in such situations. Anna is a small, fragile, delicate, passive, and accommodating baby, presenting with an intense failure to thrive at five months by significant food refusal. She’s described as a frightened, “nervy” baby by her intensely guilty mother, tormented for not having wanted her after an unexpected and conflicted pregnancy, with no support from her partner or family. The mother herself feels tense and distressed, and it’s not difficult to look at her daugh-



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ter’s early, unintegrated attempts to reach the breast as serious difficulties. This stirs up troubled feelings of anger, aggression, and blame in this mother’s inner world. The mother worries about there being something wrong with the baby or with her internal resources. (“I feel she’s punishing me, telling me that everything is horrible, that she’s not interested in anything.”) The context of such a self-fulfilling prophecy and vicious circle of refusal of milk or other food impacts as well on the infant’s lack of interest and apathy toward other emotional offers from mother or from the environment. When I meet them, mother and daughter are engaged in an anxious chain of cumulative microtraumatic situations of irritation, mismatch, depression, and lack of hope. In an over-identification process, the mother tends to see the child’s reluctance to feed as being colored by her own responses to unwanted indigestible realities. The mother describes Anna as actively “doing something to reject her food, to get rid of it, like coughing and making herself sick.” Within our conversations, she associates it with her own attempts to avoid pregnancy, not eating well, and blaming herself for having thought about abortion. The infant also has to struggle with a bombardment of “nervy” expectations and feelings, transmitted by facial expressions, tones of voice, avoidance, or vigor of body contact. These subtly overloaded interactions, which may also be returned by the infant in an unmetabolized way, through vomiting, firm shutting of mouth, and general lack of interest are an expression of what Gianna Williams (1997b) defines as the “no-entry syndrome.” This is the context in which an abrupt weaning had taken place two months before their arrival for the sessions, thus overlaying an opportunity for gradual elaboration of separation processes with confusion, pain, and lack of space for building up a mentally contained experience between mother and infant. In her avoidance of solids, even when growing older, Anna seems to be responding to this anti-containing element by protecting herself from what is felt as an external intrusion, refusing “lumps of reality” that she might feel as very difficult to chew, swallow, digest, and metabolize, both physically and mentally. She prefers to take in liquids or lick long-lasting substances (lollipops, for example) that would not, perhaps, put her so much in contact with hostile, aggressive and “devouring” impulses, which she might have held responsible for painful ruptures like her early weaning. Around seven months, Anna starts to chew peaches, still feeling more comfortable chewing things that last longer and that she could almost suck, not yet confident in taking in or swallowing “lumps.” We talked at that time about Anna’s way of taking something in cautiously and gradually, sensing carefully how much she is taking and how much still remains. The fear, shared apparently by both mother and Anna, of a destructive object inside, gains a new and painful light when it emerges during the

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sessions (not by chance when Anna is nine months), that the mother lost her own mother when she was herself a baby, also at nine months. These contents emerge in much more emotional detail than before, after the mother feels contained and comfortable that this may be something to look at and share to help her “digestion.” She does not know the cause of her mother’s death. Subsequently, she was placed in a children’s home and lost contact with her father. She describes, in a touched and touching way, that time of her life as “when I was Anna’s age,” which shows the unavoidable link in her mind between the two heavily loaded emotional instances. Nowadays, the mother wants to trace her past and know more about her own mother, but she is worried about “digging it up.” Both Anna and her mother may have fears about the omnipotent and destructive quality of their primitive impulses, activated during their experiences of sudden pregnancy, sudden losses, sudden weaning, and difficult experiences of mutuality in these early encounters. A repetitional chain of traumatic ruptures is exposed, with both the infantile self in the mother’s mind and the infant herself having to deal in loneliness with painful separations, not knowing, not being able or internally allowed to wonder, defending themselves by not wanting to know, not being able to internalize “lumps” that they are then being forced to psychically and physically swallow. The analytic setting creates an alternative containing space to receive these “lumps” of hard reality in a non-forceful way, gradually building up a rhythm of possible contacting and working through pain without needing to eject it. Empathic identification between mother and child, through contact with the suffering infantile objects within the mother and acknowledgment of the experience of the infant, allows the dyad to experience closeness, rather than avoidance and frightened distancing due to painfully merged internal realities. When Anna is ten months old, our sixth meeting shows a good picture of their internal world as transferred to the analytic setting and its possibility of transformation through our intervention. The mother sits with Anna on her lap initially and then puts the child in the center of the room, facing the toy box, her back to her mother. Anna relates to the box very timidly, sometimes even looking a bit afraid of touching or exploring the toys more fully. Most of the time she holds a brick tightly, moving her hand while sitting near the box. She maintains eye contact with me, sometimes looking relaxed and smiling, but moves very little and seldom explores the toys. Her mother comments that friends and people around her keep suggesting things for her to do and things for her to prepare for Anna, but nothing works, and she seems to feel the comments as an overload. I say it is a bit



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similar to how she felt during her pregnancy, with everybody giving different opinions and commenting on what she should do. She says that if people suggest something, she tells them to try that themselves, because she has tried everything and nothing has worked. I comment that it seems understandable that she feels lost among people’s suggestions. She may appreciate the “feeding,” but she may feel as if she herself is being force fed . . . and that even our conversation here may be felt sometimes as an overload. The mother seems to be touched emotionally by something in that observation, starting to cry and exposing some fragility and vulnerability that she seemed to have been trying to avoid previously in other sessions. During this conversation, I am struck by Anna’s passivity and lack of demand toward her mother and by her barren play with the same wooden brick. She is not withdrawn from eye contact, however, and from time to time, she looks at me in front of her. I comment that the way Anna is playing is similar to what her mother describes regarding her feeding (eating very little, restricted selection, not showing “hunger”). We start to talk about Anna’s play and playful moments, trying to explore her mother’s involvement with her in those situations. Her mother says that Anna likes to play quietly in her own space, and I wonder whether Anna, even when she appears content, might welcome and enjoy her mother’s approaches and attempts to play with her. Her mother then feels encouraged to come closer to Anna, redirecting her face toward the child and changing her own position in the chair, as if allowing herself a new perspective. Anna then engages in continuous eye contact with her mother while playing and exchanging with her the brick that she had previously held tightly in her hand. For the first time in the meeting, Anna actively demands contact, and from that moment onward, does not stop looking at and moving toward her mother, giving other toys to her mother, moving her arms and face in a more expressive and lively way. It appears that, given the opportunity, she would respond much more actively and show more interest in contact, toys, and—why not—even food. I point out to her mother the difference in Anna since the mother started to direct herself toward the child and play with her. The mother seems to agree; however, I feel her internal ambivalence, oscillating between feeling that our conversation is useful and feeling that I can easily be like one of those intruding presences who comment on what she should do to help Anna. But somehow, I feel that I can sustain that feeling of usefulness without having to convince her, and the gradual process of expansion in the child’s play with her mother shows a similar possibility of an evolving rhythm being built up in a microscopic, less persecutory, more turn-taking way.

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Anna continues to request her mother’s attention in gestures, looks, and smiles. We talk about how eager Anna seems to be to play with her mother and how she is now more interested in different toys from the box. We comment on how the mother’s more active engagement with Anna has made it easier for the child to explore different objects that she was not approaching before. It seems to offer a possible line of development to overcome Anna’s reluctance in exploring and taking in different kinds of external offers, including food. We can see in this vignette an example of a possibility of intervention at a micro-traumatic level, including the use of countertransferential feelings from the analyst resonating with the internal realities in patients, mobilizing different perspectives regarding the internal object’s “dialogue” within the patients and within their relationship, promoting different ways of looking and relating to each other. The possibility of a repeated history of avoidance, abandonment, apathy, and silence has not become a destiny that cannot be changed for them. The ghosts in the nursery (Fraiberg 1980) might open some space for toys, looks, playing, internal reflection, new perspectives, acknowledgment of need, acceptance of help, and attunement within the relationship (Stern 1997). ROY AND LYNN: THE EXTERNAL PRISON, WHOSE TRAUMA IS IT? A little four-year-old boy is brought to our services, as he is becoming very aggressive and violent and his mother is lost about how to deal with him. She tells us about her concern that the boy may become as aggressive as his father, who is now in prison. The mother wonders whether the boy may be angry, feeling uneasy with his friends because of having to explain that his father has done something wrong. She feels very doubtful about whether to take the boy to visit the father or to talk to him about details of her husband’s situation. She is herself full of fears about the boy blaming her for not being with the father anymore. As a result of all her doubts and fears regarding her own feelings toward her husband’s imprisonment, she becomes very tense and defensive every time the little boy asks about his father or talks about him. She does not know what to say and feels guilty, so she avoids talking about it. She is worried about the trauma her son might go through due to her husband’s situation. The analyst could also worry about that; however, it is more important to get in touch with the way the boy himself is experiencing these realities, not only the external facts, but especially what his internal representations of these events are—that is, the psychic reality as he is experiencing it in his singular way.



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We get very surprised when, in talking and playing with the boy, we see that the main anxiety he is experiencing is his father having “gone,” “disappeared” from his life. He is upset about his father not being with him, and this is more painful than the resonances about where exactly he is. He absorbs these concerns indirectly through his mother, who is herself very ambivalent about this relationship. She evades every opportunity to contain her little son’s natural questions and doubts about his father. He has in fact disappeared from their contact, from their conversation, and he is not being allowed to remain in their minds. I have worked along similar lines in cases where an external catastrophe or traumatic event takes place for a family, for example, with a woman and her three small children who lost their husband/father in a plane crash with many victims where he was one of the pilots. The media was in a furor about who had been responsible for the crash. Working on mourning issues was the central theme of our sessions, trying to be close to the internal world of each one of the subjects and at the same time to the impact on the family of the loss itself. Plus, mainly for the mother, there was the need to make sense of all the surrounding implications. The work with five-year-old Lynn is another example. Her father and maternal grandmother brought her to see me after her mother had been kidnapped and kept with the kidnappers for weeks. Her family struggled with the horror of the situation plus the terrible difficulty of not saying anything that would endanger the woman’s life. The clinical contact with the girl, her father, and her grandmother helped the family to find ways of talking to the child without overloading her or giving her conflicting messages that things were fine while she was picking up through all her senses that a drama was taking place. It was important not to leave the child alone with her own fantasies, sometimes of a self-blaming content, and above all, to acknowledge that what the child was experiencing was legitimate. At the same time, it was also essential to allow the child’s internal world to continue to find expression, despite everyone being very sensitive to anything that touched on the mother being at such risk. Allowing the little girl to play and draw in a psychoanalytic setting where the adults could feel contained and helped in making sense of that terror and allowing her to talk about her feelings regarding the absence of her mother, who was present in her mind and claiming a space within the family created a fortified link within the family network. Talking to the child at her level of questioning, rather than overloading her, helped her to integrate her perhaps not-yet-integrated perceptions of a traumatized environment. This allowed her to develop her own representation of that moment, and the family developed confidence about their strengths to overcome the different layers of pain.

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LORENZA: FREEING ONESELF FROM PRISON—DEALING WITH THE TRAUMA OF SEXUAL ABUSE Lorenza is a smart and articulate little girl of almost five years whose mother came to me due to concerns with the emotional effects of sexual abuse of the girl by her father. There are intense relationship difficulties between the parental couple, who are already separated (the mother had become pregnant one month into the relationship, and they only lived together for four months). Lorenza started not wanting to go to school, getting involved in little fights with friends, “lying,” and reporting to the mother that she was ashamed with other girls (for example, when going to the bathroom with them). As part of an advanced process of gathering legal evidence of abuse, the mother is committed to checking on and “registering” the child’s experience with the father (for example recording the child’s spontaneous statements after Lorenza had been staying with him) in order to be able to keep him away from the child. He has always had regular contact with Lorenza, in spite of Lorenza’s demonstration of difficulty in going to her father’s house. He lives with his own mother, very close to Lorenza’s mother’s home. Lorenza chats with her mother (in specific detail) about situations with her father and his girlfriend related to alcohol abuse and trips to motels. Our sessions, as allowed by their Health Insurance Plan, have limitations for frequency, but they include very intense work with the child and thoughtprovoking questions about the child’s psychotherapy alongside work with the mother. A Session with Lorenza

When we get to the consulting room, I find little rolls of pieces of paper on top of the cupboard sink and Lorenza with a cheeky face directing me to look at them. I wonder, considering her cheeky way, whether she may have brought them and left them there for me to find. However, I also find myself wondering: Had I been so careless as to not notice they were there before? (I identify this with emotional concerns related to seeing/not seeing and blaming oneself for not having seen—very common anxieties in parental care confronting abuse configurations). There was some seriousness and something very genuine in Lorenza’s discovery, as if he she was really surprising herself by seeing the paper rolls for the first time. In this atmosphere of surprise and playfulness I open the papers, small notepad sheets, and find drawings of little balls in a row, initially two, then in the next sheets, increasingly three, four, five. Under the little balls are wavy lines, in increasing quantity and size, suggesting a written message quality, as



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well as, especially in the first sheet, a little face-like image with the balls as the rounded eyes and the first wavy/snaky line as the mouth. It strikes me that the sequence of sheets gradually shows a coordinated increase in the number of elements and their size. I comment that it looks like there’s a face and a message there that is growing and growing. Have we found a secret message from a little girl, telling us something she wants us to notice and needs help with? Something is growing, growing, and she wants us to understand the message and help her. She makes a larger roll with her notepad sheets and new sheets from the consulting room, and sings along, in a very lively way, after trying successfully to remember the song: “The toad also has a son, also has a son, also has a son! The toad also has a son, also has a son, called tadpole. The son is called tadpole, is called tadpole, is called tadpole. The toad lives in the water, tadpole lives in the water. The toad also has a son, also has a son, called tadpole.” I talk to her: The toad and the tadpole are from the same family, huh? The tiny tadpole has a Mom and has a Dad too. There is a Daddy toad. The little girl of our message also has Mom and Dad, like Lorenza, who has a Mom and a Dad too. It may be that the message of the little girl Lorenza is for us to help her to understand these things that happened with Dad and Lorenza, which made the little girl become sad, confused, upset, without understanding how things are with this Dad. An insect/little mosquito comes along in the air. Lorenza tries to keep it away with the paper roll and says it’s the “penelongo”—daddy longlegs— (pernilongo/penelongo: long legs/long penis). I say she’s trying to defend herself from this penelongo that bothers her, that has bothered her and that came close to her body in a way that scared her and that she didn’t understand. She says: “It bites us.” I say: sometimes, grown-ups do things we don’t understand well, even Daddy may have done things that upset and hurt because they are things that grown-ups do with grown-ups and not with children. Lorenza is confused, because it’s her daddy, as the toad is the tadpole’s daddy. She wants to get to know this daddy more, as a daughter, but is also afraid of getting close to him. The mosquito “penelongo” goes near the wall and Lorenza goes after it with her roll, talking in a squeaky and exalted voice, moving her hands and legs in an increasingly restless way while “hunting” the penelongo, throwing her roll in the insect’s direction. She asks me to help her to throw her messages toward the penelongo, and I say that the little girl Lorenza asks me for help so that she can show that she doesn’t like this penelongo that does things that hurt. She wants the message to reach him so that this penelongo Daddy can understand what she feels and stop doing these things.

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While throwing the roll several times, she jumps and lands against the door, making a noise as if forcing the door. It comes to my mind that it may seem from the outside that she’s trying to get out, hitting and forcing the door, and her mother, having already expressed concerns about what happens inside the room and the therapeutic space, may possibly be worried, although the atmosphere of play might also be discerned from outside. I find out later that the mother had climbed up the stairs and was “listening.” She comments, when we leave, that she was worried about the noises at the door. “I’m a mother.” In this context, is Lorenza’s play of bashing the door with her body a desperate and healthy communication or a compulsive repetition perpetuating the abusive chain? The scene may be seen as a reproduction of the atmosphere of turmoil in internal objects, ambivalently claiming communication and seeking help when facing abuse but at the same time, evoking an abusive, invading reaction from supposed protecting elements in an endless repetition of an abusive chain. In my countertransference I had to deal with feeling myself “abused” by the possible suggestion—through the noise and bashing on the door—of us doing something in the room that might be threatening the child. At the end of the session, Lorenza wants to take the roll with her message and the consulting room sheets of paper with her. I comment that she wants to take to her mummy this message that she is trying to understand and defend herself from these things that happened with her dad. When she comes down, she puts the roll on her mother’s lap, and I comment, while her mother mentions that she was worried about the noises at the door, that Lorenza played a lot, even jumping near the door, talking about things that bother her and that if she wants, she will also show her mummy these messages she’s made. I thought about Lorenza’s conflicting feelings: wanting her mother to hear, repeating the excitement of an intimacy, leaving her mother out, or wanting her mother to come in/listen and protect—but protect her from something that she had not been able to protect her from? Reflecting upon Lorenza wanting her mother to hear us in the room, repeating the excitement of an intimacy that may be dubious and ambivalent to the child is one of the main challenges to people who face abuse. She may feel guilty about leaving her mother out of this “playful” and secretive contact with a dear meaningful figure, but at the same time, she wants her mother to come in/listen and protect her, both from an intrusive relationship but perhaps also from her excitement of keeping mother away. The rhythmic noise at the door, the child with me in the room, makes me feel in the countertransference as if we are like the couple in copula at the primary scene, and the mother is the excluded child, with Lorenza, taken by great excitement, putting herself in the place of the mother with the father in



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the Oedipal relationship. At the same time, she may be communicating, to all of us who can hear or feel, the despair, the painful impact, and the harshness of an abusive relationship. I was concerned about the doubtful possibility of restoring parent-child links, and the reestablishing of parental hierarchies. There were blurred differences between parents/adults and children, resulting in the pressure for abusive relations repetitions, for example, when listening to and reading the recorded and written reports of inquisitive conversations between mother and child regarding the abuse, with re-incidence of attempts to metabolize contents of perverse excitement. We had to struggle to differentiate child and parents in a parental hierarchy confused by the infantile needs within the parental couple, while keeping alive the space for their daughter to remain a child. Lorenza, rather than only being the child who has to be protected from abuse or who has to defend herself through abusing others, could have friends and enjoy many aspects of an ordinary development with pleasant interchanges. We had to face many traumas: the abuse itself, the maternal guilt for the failure in protection with its compensatory reactions and hyper-focus on sexual issues, the fear of acknowledging one’s own perceptions against other people’s wishes or expectations, and the internal turmoil around how to conceive of an experience that, on the one hand, has to be kept as a secret, and on the other, has to be reported and described in detail, with some possible developments that go beyond one’s own relational landscape. What is one’s own experience in this context, how to represent it, how to communicate it? An adult patient, having gone through a similar experience in infancy, which was very diffused in her mind, which made her avoid thinking about her relationship with her currently distant father, and which permeated all her current partnerships, brought to her analysis of seven years the image of a compressed “little package” that she and I could carefully and gradually unwrap. By microscopically describing Lorenza’s play and our dialogue in the above vignette, I have tried to give a hint of what the struggle to make sense of a situation like this may be. In our playing and talking about her drawings, body movements, and creation of paper figures, we were able to show the therapeutic relevance of allowing internal representations to take shape and be shared within a relationship that offers to contain and explore complex experiences, both pleasant and unpleasant ones. With our ability to think about our own reactions to projections and appeals for repetitions of abusing and abused characteristics, and in talking about these contents in a metabolizable way, as demonstrated in the clinical illustration, we hope to contribute to breaking the traumatic repetitive chain and substituting a less repetitive and more creative and benign cycle of psychic growth.

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FINAL CONSIDERATIONS: AGAINST BEING SWALLOWED BY THE VOID, THE POWER OF BUILDING UP INTERNAL REPRESENTATIONS I hope to have demonstrated one possible variety in which the psychoanalytic intervention, relying on detailed attention to patients’ internal world and objects and to our own internal responses to the object relations that take place in the clinical setting, can allow traumatic contents to be worked through, thus reducing their powerful effect of transmission through present and future relationships. In a microscopic, gradual, and seminal way, we can help parents/caretakers and children address the particular contents of their own anxieties. Different facets within their internal objects, dynamically related, can be revealed, so that trauma does not remain an undifferentiated block that then grows in secret and forbidden areas of emotional knowledge. Such trauma may have brought about, sometimes in more than one generation, different complications for family relationships and personality development. In clinical contact with patients, and also in historically and socially traumatized contexts, we may witness and experience how inner strengths can be swallowed in an endless battle with a repetitive continuous rebirth of devouring forces. However, we also take part in clinical and personal dramas where these strengths can also transform fates from within, by symbolic and representational communications of inner truth. The notion of trauma, in its repetition and dreadfulness, but also in its possibility of being overcome, seems to link up with our Kleinian dialogues within this chapter and the inner struggles described here in these psychoanalytic encounters. This challenge also represents vividly what moves us in the countertransferential dilemma of exposing such powerfully painful and delicate intimacies, with the wish that our communications with readers can resonate as a truthful therapeutic aim to be shared. REFERENCES Bion, Wilfred. 1962. Learning from Experience. London: Heinemann. Fraiberg, Selma, Edna Adelson, and Vivian Shapiro. 1980. “Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships.” In Clinical Studies in Infant Mental Health: The First Year of Life, edited by S. Fraiberg. London: Tavistock. Klein, Melanie. [1959] 1988. “Our Adult World and Its Roots in Infancy.” In Envy and Gratitude and Other Works 1946–1963. London: Virago Press. Laplanche, Jean, and Jean Bertrand Pontalis. 1986. Vocabulário da psicanálise. São Paulo: Martins Fontes.



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Mendes de Almeida Pinheiro, Mariângela. 1993. A Clinical Study of Early Feeding Difficulties: Risk and Resilience in Early Mismatches within Parent-Infant Relationship. London: Tavistock Clinic. ———. 2012. “Early Feeding Difficulties: Risk and Resilience in Early Mismatches within the Parent-Child Relationship.” In Looking and Listening: Work from the São Paulo Mother-Baby Relationship Study Centre, edited by Marisa Mélega, Mariângela Mendes de Almeida, and Mariza Leite da Costa. London: Karnac. Roussillon, Renee. 1991. “A função limite da psique e a representância.” Revista de Psicanálise da S.P.P.A. 14 (2): 257–73. Souza, Audrey Lopes de. 2016. “Construindo formas de comunicação: Revendo o conceito de interpretação representação na clínica do não representado.” Revista Brasileira de Psicanálise 50 (3): 60–75. Stern, Daniel. 1997. A Constelação da maternidade: O panorama da psicoterapia pais/bebê. Porto Alegre: Artes Médicas. Williams, Gianna. 1997a. “On Introjective Processes: The Hypothesis of an ‘Omega Function.’” In Internal Landscapes and Foreign Bodies: Eating Disorders and Other Pathologies. London: Duckworth. ———. 1997b. “The No-Entry System of Defenses: Reflections on the Assessment of Adolescents Suffering from Eating Disorders.” In Internal Landscapes and Foreign Bodies: Eating Disorders and Other Pathologies. London: Duckworth.

24 Trauma Treatment from the Winnicottian Perspective Adrian Sutton

Three preliminary clarifications are required before presenting clinical material illustrating approaches derived from Winnicott’s formulations.

THERE’S NO SUCH THING AS A “WINNICOTTIAN” Winnicott did not seek to establish a separate school of psychoanalysis and “did not want followers, but people who could think for themselves” (Stekelman 2016). He sought to help refine the fundamental principles of psychoanalysis so as to establish firmer foundations for understanding its value and limitations. His approach is based on acceptance of the existence of conscious and unconscious mental processes, which are manifest through personal experience and relationships in ways that unfold developmentally, and are characterized “by close observations of early relationships and how these patterns reappear throughout the life cycle” (Stekelman 2016). It is a dynamic and developmental approach in which potential for progression and for regression along developmental lines are both present in health. This present contribution is an illustration of seeking to work in a Winnicottian tradition. WHAT IS THERAPEUTIC FOR THE PSYCHE? Winnicott’s approach can be understood as the study of psychoanalysis as a “translational psychoanalysis” equivalent to, or perhaps part of, translation medicine (TM), the “interdisciplinary branch of the biomedical field supported by three main pillars: benchside, bedside, and community. The 281

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goal . . . is to combine disciplines, resources, expertise, and techniques . . . to promote enhancements in prevention, diagnosis, and therapies” (Cohrs et al. 2016). For psychoanalysis, benchside and bedside are the consulting room, analytic couch, and the analyst’s experience in being with the patient, whereas the community is the world of intimate and wider relationships and social structures that constitute a facilitating or impeding environment. The psyche and the soma are inextricably interwoven, and psychotherapeutic opportunities may arise through both physical and emotional care. In considering the therapeutic applications of psychoanalysis, we can describe a spectrum: at one end is direct, exclusive contact for a patient with a psychoanalytic practitioner (intensive psychoanalysis); at the other, a “psychoanalytically informed therapeutic case management” (PITCM)1 (Sutton 2000, 5), at the extreme of which the psychoanalyst may act solely as a consultation or supervision resource to those involved with the everyday and therapeutic care and have no direct contact with the patient. TRAUMA, ADJUSTMENT, AND DEVELOPMENT Although the ICD-10 criteria for “Reaction to severe stress and adjustment disorders” (World Health Organization 2016) and DSM-5 “Posttraumatic Stress Disorder” (American Psychiatric Association 2013) are recognizable for all practitioners, individual or general developmental processes are not central in producing nuanced diagnostic formulations. For Winnicott, a trauma “is that against which an individual has no organised defence so that a confusional state supervenes, followed perhaps by a reorganisation of defences, defences of a more primitive kind than those which were good enough before the occurrence of the trauma.” His descriptions of the consequences can be applied across all age ranges: if ego structure is more robust and resilient, there will be “a line of life and [she] will retain a capacity to move forward and backward (developmentally),” but if not, “their personalities will have to be built round the re-organisation of defences [which] must needs retain primitive features such as personality splitting” (Winnicott cited in Abram 1996, 77–78). USING WINNICOTT TO ORIENTATE PRACTICE WITH TRAUMATIZED PEOPLE The following case studies from the UK and Uganda illustrate key aspects in my application of Winnicott’s formulations.



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Clinical Example 1: Chronic and Acute Trauma

Kirsten was eight years old, the third-eldest child of a large sibling group who had been present when their father killed their mother by stabbing her. She was more feisty and challenging than her siblings. In a consultation with her and her nine-year-old sister as part of a PITCM approach, she engaged sufficiently to begin with, telling me that she was frightened at night and having difficulty getting to sleep. Acknowledging how difficult it was for her to trust me enabled her to begin telling me about this in more detail. Both girls talked about seeing blue flashing lights when they switched the lights off in the bedroom they shared: but they could not identify any source of the lights. In our initial contacts soon after the killing of their mother, the girls had been able to tell me a few pieces of information about the actual night, but subsequently found it too difficult: Kirsten explicitly refused to talk about the events. I thought the blue flashing lights were posttraumatic symptoms— linked to the police cars and ambulance that had arrived at the refuge where they had been staying when their mother was killed. I told them that although they had said before that they did not feel able to cope with me talking about their mother’s death, I felt I had to talk about it because I thought the lights were telling us that this needed to happen. I thought these symptoms were able to form because the girls had been provided with carefully adapted, safe care in their temporary home, where they were provided with a true asylum. The background that came to light through the children’s assessment and therapeutic care was that their parents had had an extremely volatile relationship: the children had all witnessed violent arguments and physical attacks. Periodically there were tantalizing brief episodes when their father was almost childlike in his enjoyment and sharing of simple pleasures, such as camping trips. The experiences of each of the children were different, given their range of ages, personal characteristics, and interpersonal relationships. The latter was of particular note in terms of the survival value of the unconscious use of each other as objects for projection and identification. It became clearer over time that Kirsten’s “feistiness” was a mixture of an expression for all the children of their lack of trust in the adult world and a sign of False Self mechanisms, as she became their advocate and safeguarding superintendent. She did, however, respond positively to knowing that her father would be in prison for the foreseeable future. Although there were no continuing symptoms or signs that would “earn” a PTSD diagnosis, the evidence of False Self mechanisms remained of serious concern. However, psychotherapy was not available. Adolescence presents major challenges to False Self mechanisms and structures. Kirsten’s siblings’ developmental progress had decreased their need for her as participant in their projective and identificatory processes.

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This, in conjunction with her own internal processes, led to a very turbulent adolescence. Clinical Example 2: Ensuring a Developmental Perspective

Beatrice was thirteen years old when seen in the clinic with upsetting thoughts about her dead father, anxiety, a disrupted sleep pattern, and disturbing dreams. During the first five years of her life, northern Uganda was still a conflict zone, but twenty-five years of insurgency and civil war was drawing to an end. Her father had died of an AIDS-related illness when she was five. Her presentation was formulated as a posttraumatic disorder in the context of her descriptions of preoccupying, upsetting memories of her last contacts with her father. She was offered a form of narrative therapy, which sought to lay to rest the original traumata using materials to mark out and find a route from the original trauma to the “objectively” safe present. I was asked to join one of her consultations because Beatrice’s initial progress had stopped and she was suffering significant distress and disruption. In hearing the story of Beatrice’s history, assessment, and therapy, I felt a developmental perspective on her clinical presentation was lacking. Here was a girl passing through puberty, with its currents and countercurrents, particularly in resolving Oedipal conflicts, whose father had died of a sexually transmitted illness. His illness had been transmitted to his wife, and Beatrice had been born HIV positive. Not only had he abandoned her by dying, he had also given her mother a life-threatening illness through marital infidelity and had caused her to be born with the sword of Damocles hanging over her. Beatrice did not speak English, so her therapist explained my presence and why she thought it would help if she allowed me to join them; she agreed to me staying. Her therapist intermittently broke off from her interactions to explain what was being said and how activities with the small dolls and string related to this, contextualizing this in their previous work. Mainly I said little beyond ensuring that I understood clearly. But as the session continued, I felt my concern about the need for a more developmental orientation was confirmed. Her therapist and I then had a longer discussion in Beatrice’s presence. I put my thoughts to the therapist as a hypothesis to be considered. I explained that I thought the potentially traumatizing issues needed to be understood in terms of personal conflict, conscious and unconscious. I thought her difficulties might not simply arise from sadness at the loss of her father and any overwhelming anxiety she had experienced at the time of his death, but also fury at this death, particularly in the context of his HIV status. I thought there was a strong likelihood that her current symptoms were driven by intense ambivalence about her father. To be a loving daughter to the memory



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of her father, as he had urged, when she felt such rage, would be extremely difficult. Trying to use her therapy to find a route through to the present as a place of safety could not succeed despite her best efforts because there was no refuge in the present internal world, even in the presence of external safety. Her father was present in her life in being dead. Her disturbance was driven by inevitable adolescent turmoil with the need to work through and resolve her early conflicts, perhaps through the emergence of new defense structures. Beatrice’s therapist had worked with me in this way before, and she listened and clarified issues with me. I asked if she thought my formulation made sense and, if so, how she might use it in the ongoing therapy. She then described to Beatrice what we had been talking about, phrased in her own way but presenting the developmental context and how we wondered if what needed to be understood fully was that home was not a refuge for her as represented in the narrative therapy approach: it was not an escape from the upset derived from and associated with her father’s death, nor a safe place to travel toward and arrive at. It did not provide a refuge from her anger with her father, which in turn caused her intense distress. As I observed Beatrice listening intently, she visibly changed, becoming more relaxed and spontaneous rather than reserved. She engaged in conversation to expand on the importance of this developmental understanding of her distress that fully appreciated her current traumatic experiences associated with, and derived from, not only historical events, but also healthy developmental conflicts. Acknowledgment of her hatred and rage allowed these to become integrated into her relationship with her therapist. This provided Beatrice with the opportunity to accept and be acceptable in having these emotions, with the hope of peace of mind to come. In the immediate period after this, she quickly experienced relief from her acute symptoms. Clinical Example 3: The Antisocial Tendency as an SOS Signal

David was seven years old when he was brought to the children’s clinic by the housemother caring for him in a children’s village that had been established to care for orphans and abandoned children in northern Uganda. The village consisted of a number of individual houses on a purpose-built campus with an associated school. David’s housemother had cared for him for two years; he had been the youngest of the thirteen children she cared for until the recent arrival of two other younger children, when his behavior changed markedly. David had assaulted these children a number of times in very dangerous ways. He could not be left unsupervised, and his housemother and other associated staff were stretched to the breaking point. Very little was known of David’s early life. Prior to coming into the children’s village, he had lived with an

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elderly infirm “aunt” in a village in the bush. She had taken him into her care after his parents had abandoned him: their whereabouts were not known. I was told he had been isolated and had “only the monkeys for friends.” Assessment indicated that David would require major environmental adaptation, and there was doubt about whether this would be possible in his present setting. I thought it was immensely difficult for David, who had established a good relationship with his housemother, to now have to contend with having to share her with the new arrivals, who were physically and emotionally vulnerable. Given the severity of his early deprivation, this provoked intense envy without him having developed any robust defense mechanisms against this. The newcomers’ vulnerability was a provocation to him. His behavior could be understood as a manifestation of hope in returning to the previous state of relative equanimity (the antisocial tendency). I discussed this formulation with the housemother and the senior management team of the village immediately to try and establish some greater safety in the short term while exploring further possibilities. Even if psychotherapy had been available, it was unlikely that it would have benefited David, due to the degree of his early deprivation, since “not having had primary experience, [such children] cannot make a transference, they have not reached guilt or anxiety. They need . . . primary experience with a therapist, who must do something for a child which would normally happen spontaneously to a mother and child during the first months of life. This is work involving synthesis, not analysis” (Dockar-Drysdale 1990, 75). Such children need a “planned therapeutic environment.” David needed to be considered in the context of a number of children, giving rise to serious concern. The response involved a program of training, consultation to staff, and assessment and discussion about individual children. The training included formal teaching about psychoanalytic concepts such as projection, identification, and containment/holding in relationships. We emphasized the importance of providing a containing environment for the staff, particularly the housemothers, in contending with the impact of the children’s projections if burnout and acting out against the children by staff was to be avoided. This work continued intermittently over a period of at least two years, with all staff integrating the concepts into their roles and responsibilities with the children and each other. The teaching on projective identification and containment came to occupy a particular importance in helping understand the feeling of “I don’t know what’s got into me” when difficulties arose. Two years after the original referral, David was still in the village and was thriving and able to live safely alongside his foster-siblings.



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Clinical Example 4: Autonomy, Spontaneity, and Play

The True Self is an expression of autonomy present before altruism even in the simplest form of conceiving of others, let alone taking their interests into account. Its impulsivity can transform into spontaneity and further into the world of play, in which children can make a world of their own where expression, integration of experiences, and working through of trauma can be possible. In assessment, one looks for whether themes arise and can spontaneously develop, whether themes become persistent and unprogressive, or if inhibitions and disruptions occur through primitive defenses or breakthrough of unmodified impulses. Different schools have differing views about the nature of response to the child’s activity. At one end of the spectrum, therapeutic activity remains only observational and interpretative. Moving across the spectrum, active participation is a tool used with discretion in managing the therapeutic process through to the therapist’s activity, including the added component of developmental help when there is “a developmental distortion such that developmental help is required to set a function going again” (Edgcumbe 2000, 19). The following excerpts are from the treatment of a child who brings into focus the issues of autonomy, the nature of the child’s and the therapist’s informed consent to the therapeutic process, and the form of the therapist’s activity (Sutton 2001). Dwayne, five years old, was referred because of unprovoked attacks on other children; his victims were always bigger than he was. Assessment indicated that a predominating contribution was his fear of the bigger children. He experienced their simple physical presence as an attack, so in his mind, his “unprovoked” attacks were retaliation. His background history included his mother having had difficulties before parenthood and a complicated relationship with his father, from whom she subsequently split up. What might have simply been a complicated start became even more challenging because Dwayne was born with a dangerous condition of his upper respiratory tract and esophagus (tracheo-esophageal fistula [TEF]; see Sutton 2013, 57–65). This required repeated surgery, starting in the neonatal period, with successful treatments being completed by the time he was fifteen months old. Dwayne’s father had maintained contact with him, but this ceased after Dwayne told his mother that his father was doing things to his genitals and threatening him when his mother was not present. Dwayne made rapid progress symptomatically, but then he wanted to circumscribe the areas of his life that I should talk about. He wanted me to desist from mentioning his TEF and what his father had done to him. My approach was to address this as an issue of his autonomy, my responsibility, and

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our shared awareness that his wish stemmed from the fact these things were important. The following sequences illustrate this. In a session where his bodily anxieties again came to the fore, we had been talking about him being born with a TEF, his prohibition, and his feeling that I sometimes tried to trick or force him into something. I reminded him how it was important that he knew I could talk about these things. I emphasized that my job was not to attempt to force him to talk, but that all the things he did and said to me made me know that these were important for him but that he was too anxious to talk about them. Dwayne considered this carefully and said he did not know when he would be ready to talk to me about these things. Eighteen months into treatment, bodily preoccupation again came to the fore. He was consciously conflicted, having both powerful interest and intense anxiety. Dwayne then spontaneously mentioned his father. I reiterated that I knew he still found it very difficult to talk about events with his father and that he still needed to know that I was able to think about them and knew it was safe to talk about them. He told me that he knew about a dad who had actually killed his child and followed this by saying that his dad had threatened to throw him out of the window and shoot him. Dwayne was afraid he might actually do this. We talked about how what his father had done was wrong and how frightening it had been to be alone with him. I linked it with the fear that he sometimes felt with me, anxious about what I might say. When Dwayne was nearly two years into his therapy and just over eight years old, he was busy using the modeling clay and at times talking with me. I was observing him closely and thought the material related to his bodily anxieties. I thought the “doing” was important, even if he was not conscious of what it meant, so I continued not to comment on it. There was silence a few minutes more and then he suddenly and rather theatrically put his hand to his head and said: “Oh no! What am I letting myself in for!” Simultaneously he looked up at me with a mixture of a smile and a sigh of resignation. As he looked across at me, we shared the smile. I did not feel any need to make a comment: the interpretation was Dwayne’s own. Abusive experiences are attacks on autonomy, and recovering from their effects involves complex personal and interpersonal negotiation, which may be helped by the therapist’s engagement in the child’s activity,2 including points at which disengagement is needed, perhaps constituting “developmental help.” Dwayne was a king and I was his servant. I played my part and found that King Dwayne was a cruel master. I thought this reflected his own persecutory experiences, evident in his original presentation. I thought his developmental progress was evident in the way that play could be a medium for processing, rather than simply being enactment. However, there was an aspect of his



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imperiousness that also showed his sadism, and this needed to be addressed. I decided to use my assigned role in his play to challenge this. I stated firmly that I was resigning as his servant because he was trying to force me to do things using threats: I was not prepared to live in fear of him continually giving me impossible things to do. I would only participate if I could negotiate a proper contract. The play then proceeded on this basis. The theme reemerged strongly as the end of his therapy approached. With three sessions to go, Dwayne told me he that he didn’t want me to talk about what things meant. He wanted to make music and got on with doing this, very creatively using the things available. Later, sitting with his back to me but positioned so that he could see me in a mirror, he asked: “Dr Sutton, why am I doing this?” I told him I had a number of thoughts about it, and the discussion led to a conversation that included and integrated many themes from the whole of his therapy. During his last session, I let him know that I was thinking about the meaning of what he was doing but that I was not sure that he would want to know my thoughts. He told me I would need to wait for him to be ready. I was quiet, as I thought I was observing processes that reflected the healthy repression and sublimation of latency, not simply primitive defense mechanisms. He could now choose a course of action without this having to be absolute compliance to an internal or external threat. When Dwayne said he was ready, I opened up a conversation about “out of sight, out of mind.” I said there were things that he wanted kept out of sight, for example what had happened with his father. I reminded him how I had approached this by making it clear that the reasons for not wanting to talk about him were the same reasons that made it important that I made it clear that I could think and talk about them. Dwayne congratulated me on getting something right! Dwayne was re-referred two years later because he had been approached in a sexually intrusive manner by an adult man: as described by Dwayne, it was a voyeuristic episode and did not involve physical assault. He managed the situation well but subsequently had nightmares and other anxiety symptoms comparable to those at the original referral. Dwayne initially resisted referral, but when the problems persisted, his mother was more insistent. By the time I saw him, there had been some symptom relief, which I attributed to his mother’s thoughtful responses. I saw Dwayne for three consultations. He told me straightforwardly about what had happened and his current symptoms. I reminded him of his previous mixed feelings about me and his therapy, putting this alongside his reluctance to see me again. I recapped how we had approached these and Dwayne spontaneously talked about his memories of therapy, some of which were very detailed and put in terms of how different he was now. He was able to talk

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without undue discomfort about some things he had previously attempted to circumscribe. The overall assessment was that his mother’s responses and the process of three consultations had successfully contained this crisis and opened issues, which were predictable issues as he approached puberty. His symptoms resolved and he did not experience significant problems through his adolescence. For Dwayne, psychotherapy was an important contributor to the facilitating environment, which enabled him to establish a good developmental trajectory. The experience of my adaptations to him at different stages was a key component in managing his engagement through their modulating function as opposed to the modifying function of interpretation (Meltzer 1967). In broad terms, this enacts respect for the function of defenses and the patient’s vulnerabilities and strengths in order to offer a model of trustworthiness in challenging archaic fears. Respectful and timely responsivity in the form of participant observation, spontaneity in interchanges, and the management of the transference in silence and in words left Dwayne better equipped for inevitable developmental challenges and unexpected events. Clinical Example 5: Parenthood as Challenge and Second Chance

Winnicott was a champion of children without idealizing them or engendering ideas of “perfect parenting.” He sought to avoid blame and understood the importance of promoting responsibility based on recognition of resources. Childbirth and parenthood can be traumatizing in themselves. Adverse experiences from earlier life may be reawakened. This final clinical example illustrates how the trauma of childhood and adulthood intermingled. Of particular importance was the idea that if we help a parent parent, then we help a parent in a potentially psychotherapeutic way (Sutton and Hughes 2005; Winnicott 1958). Mrs. T had hidden abuse by her parents throughout her childhood and into adulthood and parenthood. The abuse had been physical and emotional with the further element of witnessing the battles between her parents. These facts remained secret to her wider family throughout the process of in-patient treatment for anorexia nervosa in adolescence and for a considerable period of contact with the Child and Family Psychiatry Service, until she was safely enough engaged in therapeutic work. Despite her childhood trauma making her profoundly conflicted about any professional involvement, she had come to trust a pediatrician who had been involved with her daughter’s care from the neonatal period. There were serious problems in her relationship with Becky, fifteen months old, so she accepted a referral at the suggestion of this pediatrician who accompanied



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her to the first appointment. At the end of this appointment, I told Mrs. T that I thought I could be of use but that she needed to decide about this herself, given the intensity of her mixed feelings. She contacted me six months later and then commenced a long-term involvement. Partly driven by resources, there was a period of consultations involving the nuclear family, mother and Becky, and individually, before embarking on individual therapy for her daughter and concurrent sessions for Mrs. T, which were open to her husband but which he did not attend. Early in the process of therapy becoming established, I heard about the feeding difficulties there had been with her daughter. This led me to ask if she had ever had any eating difficulties herself. She said, “My mother told me not to tell you.” I then heard about her severe adolescent difficulties, which had led to inpatient psychiatric treatment. She described her battles with the staff and her parents. She had been defiant, uncooperative, and sometimes lied to the staff. Her parents had regularly lied to staff as well, but if there was any disagreement, they were always believed and she was not. I had already developed an interest in the link between such adolescent difficulties and their effect on parenting, and after a time I asked Mrs. T if she would mind if I obtained her psychiatric records. She agreed, but I immediately recognized that I had made a mistake: the request arose from my need, not the needs of the child-parent couple. It also meant that Mrs. T could be put in the position of fearing I would believe the notes and not her if they differed—a replication of the adolescent constellation. I did not obtain the notes, and at the start of the next session I apologized to Mrs. T and explained why I thought I had been wrong. Mrs. T said that she had been anxious about me getting the records in case they altered my view of her, even though she had felt free in giving consent. I saw Mrs. T’s adolescent oppositional behavior as a manifestation of Winnicott’s formulation of the antisocial tendency, which indicates a healthy assertion of the True Self, rather than delinquency. My own behavior had been an episode of acting out in the countertransference, an egocentric response, just as her parent’s behavior had been. However, my acceptance of blame was pivotal. Finding a transference parent of this form led to Mrs. T describing the extent of her severe physical and emotional abuse in childhood, particularly including the use of lies: this had in fact continued into her adulthood, including parenthood. Through my concurrent, collaborative work with her child’s therapist, she experienced a couple available to her and alongside her, able to see her ability and wish to be more of the mother her daughter needed. An unexpected addition to the legacy of trauma came to light after she had another baby. When she returned home with her new baby, memories of the puerperium with Becky flooded back. It transpired that she had had an

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undiagnosed puerperal psychosis during which she had believed Becky was the Devil and experienced auditory hallucinations emanating from Becky, denigrating her and threatening her life to the extent that she did not get out of bed because it would mean passing by Becky’s cot. CONCLUSIONS Just as victims may not want to be defined by their abuse, so should we also avoid defining a need for treatment or the form of treatment by the nature of events people have experienced. The case examples seek to emphasize the importance of understanding any person not through events in their lives or surface signs and symptoms but through and in their personal internal world and development, their experiences in intimate relationships, and their wider social context. Only then can we properly consider what place we and the tools we possess should have in their lives. If our involvement is misdirected, or our tools misused, we may replicate a nonadaptive, failing environment. For the healthiest patients, their patience may enable them to make use of the good we have to offer without overburdening themselves. For those of most concern, this may compound reliance on False Self and other maladaptive mechanisms. NOTES 1.  A term coined to capture the spirit of negotiating and working with the internal and external world. 2.  I use the word “activity” rather than “play,” since Winnicott emphasized the importance of differentiating between the use of games, toys, and other materials as a means of creative exploration, working through trauma or conflicts, as opposed to simply enacting conflicts or reenacting trauma. The latter indicates inhibition in mental life while the former two indicate the presence of play as a means of using healthy developmental processes to overcome difficulties and integrate experience (see Winnicott 1971).

REFERENCES Abram, Jan. 1996. The Language of Winnicott: A Dictionary of Winnicott’s Use of Words. London, Karnac Books. American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth edition. (DSM-5). Washington, DC: American Psychiatric Association.



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Cohrs, Randall, Martin Tyler, Parviz Ghahramani, Luc Bidaut, Amir Higgins, and Paul Shazad. 2016. “Translational Medicine Definition by the European Society for Translational Medicine.” New Horizons in Translational Medicines 3 (2): 86–88. Dockar-Drysdale, Barbara. 1990. The Provision of Primary Experience. London: Free Association Books. Edgcumbe, Rose. 2000. Anna Freud: A View of Developmental Distortion, Disturbance and Therapeutic Techniques. London: Routledge. Meltzer, Donald. 1967. The Psycho-Analytical Process. Perthshire, UK: Clunie Press. Stekelman, Sharon. 2016. “Working in the Winnicottian Tradition.” Squiggle Foundation. http://squiggle-foundation.org. Sutton, Adrian. 2000. “Dependence and Dependability: Winnicott in a Culture of Symptom Intolerance.” Psychoanalytic Psychotherapy 15 (1): 1–19. ———. 2001. “Consent, Latency and Psychotherapy or ‘What Am I Letting Myself in For?’” Journal of Child Psychotherapy 3 (27): 319–33. ———. 2013. Paediatrics, Psychiatry and Psychoanalysis: Through Countertransference to Case Management. London: Routledge. Sutton, Adrian, and Lynette Hughes. 2005. “The Psychotherapy of Parenthood: Towards a Formulation and Valuation of Concurrent Work with Parents.” Journal of Child Psychotherapy 2 (31): 169–88. Winnicott, Donald. 1971. “Playing: A Theoretical Statement.” In Playing and Reality. Harmondsworth, UK: Penguin Books. ———. (1958) 1982. “The Anti-Social Tendency.” In Collected Papers: Through Paediatrics to Psychoanalysis. London: Hogarth Press and the Institute of Psychoanalysis. ———. 1989. “The Mother-Infant Experience of Mutuality.” In Psycho-Analytic Explorations, edited by Clare Winnicott, Ray Shepherd, and Madeleine Davis. London: Karnac Books. World Health Organization. 2016. Internal Classification of Diseases, 10th Revision. Geneva: World Health Organization.

25 Theoretical and Clinical Implications of the Concept of the Zero Process An Ego-Psychology Perspective Joseph Fernando

My primary work on trauma has been in developing certain basic concepts

as an extension of the ego psychological point of view in order to better comprehend the traumatic process, its aftermath, and its clinical treatment. These concepts are the product of an interplay between clinical observation, therapeutic work, and theoretical clarifications and innovations. In this chapter, I will present some conceptual innovations of my theory and will outline some of the implications for understanding social trauma and clinical technique that result from this way of conceptualizing what trauma is, and what it is not. I first presented my ideas related to what I call the “zero process” in my book on defenses (Fernando 2009), and developed them further in more recent papers (Fernando 2012a, 2012b). I am in the process of writing a larger work, a book that explores many of the implications of the zero process. THE TRAUMATIC PROCESS

The traumatic process is a psychobiological response usually brought on by environmental impingement, although other factors play their part to a variable extent. The term “trauma” is used both narrowly, to refer to the impingement, and more broadly, to refer to the intrapsychic process that it brings about and to its aftereffects. The specific psychological response, whatever the causative factors, is a characteristic form of regression in which certain important ego functions are temporarily put out of commission. Let’s take as an example a situation in which civilians in a chaotic war situation are attacked in a forest by group of soldiers, and a number of them are killed as one of the group, a teenager, looks on before managing to escape. At 295

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first, the boy feels fear, confusion, and anxiety. One may be tempted to say that these feelings, if they escalate to the extreme of fright, are what constitute trauma. But it is quite possible to be frightened and not suffer the usual aftereffects of trauma: phobic avoidances and reliving the event in dreams and flashbacks, as well as certain forms of behavioral repetition. The traumatic process begins somewhere beyond fright. There seems to be a tipping point at which the shutdown of many higher-level ego functions begins, and once it begins, it quickly and uncontrollably proceeds. When this happens, the one descriptive word used by almost everyone is “numb,” the opposite of a strong feeling. This is the conscious sign that the shutdown is underway. At this point, the boy would not be feeling fright but would be struck, if reporting the incident afterward, by how he had stopped feeling, how time seemed slowed down and things seemed strangely bright and then unreal, how certain unimportant perceptions, such as leaves on the ground, were emblazoned in his mind. He might remember seeing his father being beaten and shot, but it might have all seemed unreal. He might have felt horrified, but in a kind of detached way, as if it were not even he who was horrified. He might have found he was running, but it might have seemed as though he were not deciding or willing these things. Thus, there can be changes in the level of consciousness and perceptual changes. The exact nature of these changes will vary, but the fact that they are present is the outward sign of what I have called the ego shutdown. An important fact to take into consideration in comprehending the effects of this shutdown is that our experience of the present moment, which feels to us to be an immediate given, is actually the product of a good deal of psychic work. This work is done at very high speeds, compared at least to the slow-speed processor we refer to as consciousness. Incoming perceptions are sampled based on expectations and compared to already existing models of the inner and outer world. Usually only a small sample is taken, but as the situation becomes more novel, more of the immediate perception is admitted in—which is one reason why new experiences, such as the first time you drive somewhere, are felt to take so much longer than repetitions of the experience. But even with a novel experience, what we think of as our immediate experience of the present is already a construction, based on perceptual input and on our models of the world and ourselves. We could refer to this as the first-order construction of the present. It precedes such second-order processing as connecting the experience with language and eventually consolidating long-term memories of it, which involves the abstraction of elements of the memory and the integration of these elements with thousands of other memory aspects at various levels of abstraction. Many illusions rely on the fact that we construct experience based on our models, and they expose this aspect of how we perceive,



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as do neurological injuries that knock out parts of the brain that subserve the process of reality construction. I would contend that the ego regression or disablement during trauma interferes with, in fact often brings a halt to, this first-order construction of the present moment. Experience then becomes strange because it lacks, or has in only small measure, elements of this construction. Thus, our young man in the example feels a distortion of time sense. Perceptual elements are experienced as not being integrated with each other; feelings are not felt; he himself is not fully integrated into the experience; and the background connections we usually make between the present experience, our expectations, and our past, which allow the present to feel both familiar and as something that belongs to us, cease to exist. It will all feel very strange and unreal to him. People may describe him as “in a daze” when they find him after he has run off. The problem for him will not be that this daze will last forever, but that his unprocessed memories will. And they will also behave rather strangely. THE ZERO PROCESS The breakdown of the first-order construction of the present moment interferes with normal memory formation. The bits and pieces of perception during the trauma do not, in the psychical sense, become part of the past. After the fact, there can be a process of belated construction in which the person relives aspects of the incident and dreams of it, as its bits and pieces are slowly assembled into a more regular experience, which can then become a memory that is abstracted, distorted, and otherwise treated as we treat the rest of our past. But if the trauma is too large, too extreme, and if it has become connected with repressed conflicts, then this process of belated mastery is cut short each time it starts up, by various defensive maneuvers. All of these things will be the case for our unfortunate teenager, who will resist reliving what he saw not only because of the horror of it, but also because it has become embroiled in various repressed aggressive and sadomasochistic conflicts. What he has now is a set of unintegrated perceptual fragments, which will live on in a perpetual present. In fact, he will now live in two worlds: the regular reality of the objective present and another reality, the perpetual present of his trauma. This will influence his reactions in many ways, including the familiar triggering of reliving by concrete perceptions that resemble something in the trauma—for instance, seeing a soldier approaching, as well as various avoidances and repetitions of parts of the trauma in displaced form. I have coined the term “zero process” for this form of posttraumatic mental functioning. I mean the term to indicate that this is another of the major ways

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in which the mind organizes and processes affects, perceptions, and memories, to be contrasted with the primary and the secondary processes, which were described by Freud ([1900] 2001a, [1923] 2001c). The contents of the zero process exist in a frozen state. There is neither the constant movement seen in the displacements and condensations of the primary process nor the thoughts and integrations of the secondary process. They exist in a binary, on/off state. The person is either completely unaware of them or else they are absolutely present, for instance in flashbacks, and dominate their experience. A useful, and not inaccurate, shorthand way of thinking of this is that the contents of the zero process act not as memories but as present experiences. In fact, they are not even fully in the present, but are always about to happen or just happening. This makes sense for an incident that was not fully constructed into a present experience because of the ego shutdown. At the psychical level, the occurrences have not yet happened but are always pushing to happen, to be experienced as an immediate present. This also explains, without the need for a death instinct beyond the pleasure principle (Freud [1920] 2001b), the powerful push to repeat the trauma. The contents of the zero process (we could call them memories, but they are quite different from what we usually think of as memories) act in some ways like the drives of the primary process or id, in that they incessantly strive for expression or discharge, the particular form of zero process discharge being the immediate living out of bits of traumatic experience. Thus, we can think of the contents of the zero process as residing at a point between the present and the future, always about to happen, sometimes happening, but never happening so fully that they become part of the past. In the case of our teenager—to go back to the example—he would carry forward the zero process memories from what had happened to him as a terrifying future, which he would then try to stop from happening. This may lead to anxiety, depression, and lack of energy, as he has to constantly keep up his defenses against these. Let’s imagine that he got married, settled down in what would by then be East Germany, and had a couple of children. The aftereffects of trauma vary considerably and are quite individual, but a common enough negative scenario would involve the father being emotionally distant and depressed, and then at times harsh or even violent with his children. (In reality, multiple factors interacting in complex ways determine reactions such as this, but for the purposes of explication, I have isolated the single traumatic one.) Of course, these reactions would affect the children’s development in various ways—for example, leaving them with a harsh, and at the same time inconsistent, superego and a longing for paternal love and guidance. These would be the nonspecific second-generation effects of the trauma. There would also be specific effects, mediated by the special nature of the zero pro-



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cess. There are many reports in the literature of an uncanny living out of the parent’s traumatic past by their children (Bergmann and Jucovy 1982; Fromm 2012, have many examples), who in many cases had never been told about the traumatic experiences. The nature of the zero process explains what goes on in such instances. The parent is not transferring a set of memories to their child. Rather, the parent lives, even if unknowingly, in another reality, and the child preconsciously picks up on this reality and then lives it out in various ways. The child’s reactions to reality are of a different order—they carry the mark of that reality—compared to reactions to even very strong fantasies or memories. The parent would have various fear-based reactions; he or she might talk in strange ways about certain things or else subliminally betray the details of this other reality. The children would feel very powerfully that they were living in two realities, and this would be true at the psychical level. In our example, the man’s children may react to authority figures as being extremely dangerous, but without knowing why. But what is striking are the very specific effects. For instance, one of the children may feel scared when going into forests, even though the father had never talked of what had happened, while another child might find that the family has moved to the area, again unmentioned, where the massacre in the father’s adolescence took place. These betray the true nature of the zero process as something more like a continuing reality than a set of memories. SOCIAL TRAUMA The idea of the zero process would seem to apply to acute, overwhelming trauma. How does it apply to various other forms of social trauma described in this book? Of course, living in a totalitarian regime can mean being subjected to this form of acute trauma through police brutality, torture, and other abuse by state authorities, and the descriptions offered above and discussion of treatment to follow below would apply directly. At one remove from this is the intergenerational transmission of this sort of trauma, also described above, and also partaking of characteristics of the zero process. In a society where there is a good deal of brutalization by the state taking place, it is easy to see how intergenerational transmission would mean that the traumas will have a much wider impact, as many of the children are subject to secondgeneration effects, and other family members such as spouses also suffer in various ways. But what about chronic trauma? The term has at least two distinct meanings. One refers to ongoing impingements at the same level as originally caused by an acute trauma. For instance, in our example, if the traumatized

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man flew into rages and beat his children badly, one would expect them to have a set of acute traumas. In fact, what happens is somewhat different. The first beatings, and some others, would lead to the sort of ego shutdown and formation of zero process memories in the children that their father experienced during his trauma. But people adapt, and so if the beatings continued, rather than leading to a traumatic ego shutdown, they would to some extent be expected, and the child would use various defenses, often related to this ego shutdown but now under ego control—so a partially controlled regression— to avoid being fully traumatized. As an example, a patient of mine who was beaten quite badly and often by her father would go into a fantasy—so far into it that she would lose awareness of the outside world and the beating—and would be on a beach or taking part in some adventure while her father was beating her. These sorts of adaptation do not completely prevent traumatization, but they blunt it and often enough keep it at bay at the cost, in the long run, of certain changes in character that can be detrimental. I will discuss the characterological effects of both types of chronic trauma just below, after describing the other form of chronic trauma. The second type of chronic trauma involves environmental impingements that are lower in intensity than acute traumas, but usually much higher in quantity and pervasiveness. To keep with our hypothetical traumatized children who would have grown up in East Germany, this type of chronic trauma within the family might involve such things as a depressed, withdrawn, and unfriendly father and an overwhelmed mother who does not know what to do with him. In the social surrounding, there would be the overwhelming control exercised by the state and the lack of freedoms in many areas. There would be propaganda, some of which, at least, might be seen to be untrue when compared to experience. Should these be considered traumas? One could say that this is merely an issue of definition. But there are also clearly observable phenomena, some of the characteristics of which I have described above, that are usually designated as trauma. I think there is much to be gained by using the term “trauma” to describe the specific process of ego shutdown, as well as its quite varied but very characteristic consequences. If we do this, I would say that many of the environmental impingements—such as the extreme state control of people’s lives—are not in and of themselves traumatic. In saying this, I do not mean that such control or other impingements cannot, and in fact may not often, lead to trauma—such as being arrested at night by the police, and hearing that your neighbors have reported on you. However, the control by itself, along with many other aspects of daily life, will affect development in children and the adaptations, attitudes, and character of adults, but are not traumatic.



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One source of confusion might be that people will often use traumatic to mean extremely upsetting or having a very bad effect. Thus, to say something is not traumatic can be understood, incorrectly, as meaning that it is not so harmful. But, as an example, this kind of state control, if extreme and exercised throughout a person’s development, can have much worse consequences than, for instance, a car accident even if it is not as traumatic. It is worth making the distinction between traumatic and non-traumatic environmental impingements, because they exert their influence by different mechanisms and thus require somewhat different clinical approaches. I described above how acute trauma leads to a second reality of unprocessed memories and effects (the zero process) in people. These exist beside sufferers’ present reality and affect their perceptions and behaviors in various ways. Continued acute traumas lead to these zero process realities as well as to certain more repetitive coping strategies, such as escape through fantasy or persistent dissociation. Non-traumatic environmental impingements exert their influence largely through shaping normal adaptive mechanisms, such as habitual behavior patterns and basic defenses. These adaptive mechanisms are a necessary part of everyone’s development, whatever social milieu they are raised in. Not only are these mechanisms unconscious, but their effects are not usually noticed by the person at all (as we say, they are egosyntonic). They are one contributor to what we usually refer to as a person’s basic character, with other contributions coming from constitutional factors and from stable compromise formations related to internal conflicts, for instance the Oedipal and pre-Oedipal ones that have been the main subject of psychoanalytic studies. In this book, Huppertz notes that his patients did not comment on or notice their character trait of passivity, which seemed to be a product of the East German Communist system. Strictly speaking, this trait was not a symptom—something that confronts the person as an alien, unwanted intrusion into their life—but rather, part of the person’s character and identity. Instead, the patients complained about their symptoms, such as depression. CLINICAL TECHNIQUE Much has been written about the treatment of trauma over the last few decades, both within psychoanalysis and outside of it. Different contributors in this book give ideas related to their own area of specialty or theoretical orientation. Rather than repeat what others have already said, I will highlight those aspects of my ideas that may differ, based on a specific development of ego psychology, from other approaches. Most agree that in treating trauma,

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key issues are trust, building the therapeutic alliance, and working with the transference and countertransference. What do the ego psychology perspective and the theory of the zero process have to add to this? I would suggest they add the specific theoretical ability to differentiate different forms of mental functioning, and thus, they help us to develop various differentiated forms of intervention. True trauma, and the zero process that it leaves in its wake, leads to the situation of a person living in two realities, although he or she is not fully aware of the second one. This second, traumatic reality leads to displaced repetition at the individual level, but also at the societal level when large numbers have been traumatized. Within therapy, the patient will mention the events in a bland manner, devoid of feelings, and if asked for more details, will often drift off into other topics, and certainly will not come back to the topic in the next session. (An interesting contrast is the patient who immediately tells you of how they have been badly treated and traumatized by one and all, from their family on down. Such a patient is almost always suffering from some version of borderline personality in which the internal feeling of being overwhelmed by uncontrolled feelings and drives is projected onto the external world. This is overwhelmingly caused by the primary process, not the zero process.) Within psychoanalysis, and to some extent outside of it, a view has taken hold that trauma involves the shutting down of all perceptual memory registration, so that only procedural and emotional memories from the trauma survive. This, along with influences from postmodern theories—which insist that because of various distorting influences we can never really know the past—has led many to adopt a technique that advocates, through transference and countertransference, sole reliance on the emotional reliving of traumas, which are often then reconstructed, without any perceptual memories, as taking place in early infancy. There are epistemological problems with the postmodern view that are beyond the scope of this chapter to enter into, but even from a purely clinical standpoint, this procedure is deeply flawed. Those who have been traumatized are left with zero-process perceptual proto-memories: not integrated, not processed, and dissociated and repressed. These are part, along with emotional and procedural memories, of the zeroprocess traumatic past-as-present that lives within the patient. This present will at times repeat within the analysis, opening up avenues for therapeutic work. But I have seen many patients who have been in therapy with therapists for years and who never brought up in their previous therapy—or only in a very bland and dismissible manner—traumas that turned out to be determinative of their problems. I mean no dismissal of the abilities of these therapists in reporting this, as the same has happened many times to me with patients who have returned after previous work together. Trauma loves to hide. Un-



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like drive conflicts and relational conflicts, which push for repetition within the transference/countertransference and will usually emerge eventually with an empathic, patient attitude, trauma needs judicious levels of activity for its analysis. Some of this activity is simply the analysis of defenses, such as, for instance, pointing out that the patient keeps changing or avoiding the topic of certain incidents that may have been traumatic. Or that they keep repeating “I don’t know” in a very characteristic manner when they try to think of certain incidents, which may be a manifestation of an attempt not to think about or know. Usually such measures start things moving. This is where the judiciousness in using activity comes in. The defenses that block access to the traumatic memories are there for a good reason, and one has to push a bit, open things up, but then pull back enough to let the person control the pace, and repeat this process many times. And, most important in the analysis of trauma, one has to be open with the patient about exactly what one is doing. Trauma involves loss of control and of the ability to understand and process the event. Explaining not just what one is doing, but also something about the nature of trauma itself and what one thinks may have happened is not intellectualizing; rather, it provides the patient with the verbal and intellectual scaffold that they lacked during the trauma so they can keep from falling into uncontrolled regression as they approach it. What the concept of the zero process can do for us, as a form of mental functioning quite different from the primary or the secondary processes, is allow us to both understand the presentation of trauma and to build rational therapeutic tools for its treatment. We can understand why some attitudes— such as expecting that all the important material will appear in the transference and countertransference if one takes a caring and patient attitude, which applies at least to some extent in the drive/defense conflicts between the primary and secondary processes—can lead us astray with the zero process. While repression and denial are used against traumatic memories, the zeroprocess reality that the patient lives with or fears in the future is often dealt with by simply not thinking about it (avoidance), and by reluctance (Kluft 2000), both of which hardly seem like defenses in the usual sense. Yet their use makes sense if we realize that the patient is dealing not with memories but with a frightening present reality at the psychic level. Thus, they understandably evince reluctance and avoidance in terms of looking at the reality, which really means experiencing it. If one understands this correctly, one will not feel that one is somehow being too pushy or is accessing something that is more superficial. Again, working with avoidance and reluctance has to be done carefully, and the art of this method is in pushing just enough, and in a friendly, even humorous manner at times, and then letting the patient dictate the pace for a bit. It is exactly the opposite of what happened during

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the trauma: one pushes to make something rather than nothing (the numbness of the trauma) happen. But it is essential to not push too much and to give the patient enough control so that too much doesn’t happen, as it did at the height of the trauma. The fact that the zero process is psychically a present or future occurrence, not a memory of the past, can also help us in understanding better what the patient is dealing with, and interpreting it as such. For instance, after a good deal of work with a trauma, including analyzing denial, the patient often will say, “I am convinced that it happened, and yet it somehow doesn’t seem that it’s something that did happen—it feels unreal.” In this situation, it is often helpful to say something like, “Your feeling may be correct. It hasn’t happened yet. We can see how the occurrence is always in your future, about to happen or happening. Our job is to continue to put the pieces of it together so that, eventually, it finally really happens and becomes fully real to you, and then it can become part of your past.” Of course the person’s doubt about the reality has defensive aspects, but this kind of intervention helps the patient get in touch with the true nature of what they are dealing with and to engage in the process of analyzing it. While this involves a good deal of reliving within the transference and countertransference, this is only part of what is not so much a reconstruction as a construction for the first time of what happened in the trauma. From the zero-process proto-memory fragments, one constructs the memories that would have formed had the ego shutdown of the trauma not intervened. From this point of view, construction of the trauma can be seen not as the intellectual exercise that it is sometimes pictured as, but as vital to its analysis. In our example, only when the middle-aged man, now in therapy, finally had the full experience, was fully in the experience of the attack by the soldiers, would he construct a first-order immediate experience of the event, and then more regular memories of it, the sort that can be integrated with other memories, abstracted, reshuffled, distorted, and even repressed. And only when his trauma becomes a part of his past will he and his family not be haunted by it as a ghostly present, living alongside the objective present. But what about the impingements of the social surroundings? Because the adaptations to this surround are part of the person’s basic approach to the world—his character—it is necessary here too, to be more active in bringing the character attitudes to the person’s attention. Usually the best way to do this is to point out that some of the problems patients complain of are a direct result of these attitudes, such as passivity, even if they find the attitudes unproblematic. The goal is to lift the reaction from an automatized, unproblematic one to something that the person is aware of, in order to explore its roots. In this case, the working-through process of going over countless examples from the past and present, and allowing emotional expression in relation to each, is the key. Unlike acute trauma, there are not one or a few unprocessed



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events, but rather thousands of events that have shaped the person’s attitudes. Here too, while the transference-countertransference arena of course plays its part, it is important to reconstruct for patients the external influences that shaped their basic way of interacting with the world, and to analyze character as it appears within and outside of the analysis. CONCLUSION The patients whom Dr. Huppertz describes were generally unaware of the existence of their passivity and other character anomalies, and they also often talked of their more acute traumas with little affect. A number of the patients got some help but then drifted away from therapy. I have argued in this chapter that in these situations of either overwhelmingly traumatic or pervasive external impingements, we need certain adjustments in technique in order to both engage the patient and bring the realities that they have faced into the therapy in a workable manner. In a short chapter such as this, I have only been able to outline briefly a few aspects of an ego psychological approach to these issues at the theoretical and clinical level. Societies shape the character of their members, but they are also haunted by shared zero-process structures that are felt as completely real and have a tremendous influence on their history. By zero-process structures, I refer to past traumatic occurrences that live on as present realities. What Volkan (2014) describes as “chosen traumas” of a society, and “deposited representations,” fall in this category. Introjects—internal objects that have the quality of external ones—are also zero-process structures, and they carry the past of personal and societal traumas into the present, waiting to be revived as the introject comes alive in the present-day totalitarian leader. What is really interesting is to trace the way in which these zero-process structures, the past carried into the present as psychic structure, are then made real again in the present, through totalitarian leaders, ideology, and real aspects of how the society is run. Understanding how this happens is work that still remains to be done. But it would allow us to link acute traumas of the past, both individual and societal, to the chronic environmental conditions that come to embody them in the present that a totalitarian society imposes on its members and that shapes their character, as the past becomes present once more. REFERENCES Bergmann, Martin, and Milton Jucovy, eds. 1982. Generations of the Holocaust. New York: Basic Books.

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Fernando, Joseph. 2009. The Processes of Defense: Trauma, Drives, and Reality—a New Synthesis. Lanham, MD: Jason Aronson. ———. 2012a. “Trauma and the Zero Process.” Canadian Journal of Psychoanalysis 20: 267–90. ———. 2012b. “Trauma und der zeroprozess.” Psyche—Zeitschrift für Psychoanalyse 66: 1043–73. Freud, Sigmund. [1900] 2001a. “The Interpretation of Dreams.” In Standard Edition of the Complete Psychological Works of Sigmund Freud, Vols. 4–5, edited by James Strachey. London: Hogarth Press. ———. [1920] 2001b. “Beyond the Pleasure Principle.” In Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 18, edited by James Strachey. London: Hogarth Press. ———. [1923] 2001c. “The Ego and the Id.” In Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 19, edited by James Strachey. London: Hogarth Press. Fromm, Gerard, ed. 2012. Lost in Transmission: Studies of Trauma across Generations. London: Karnac Books. Kluft, Richard. 2000. “The Psychoanalytic Psychotherapy of Dissociative Identity Disorder in the Context of Trauma Therapy.” Psychoanalytic Inquiry 20: 259–86. Volkan, Vamik. 2014. Psychoanalysis, International Relations, and Diplomacy: A Sourcebook on Large-Group Psychology. London: Karnac.

26 Extreme Traumatization Conceptualization and Treatment from the Perspective of Object Relations and Modern Research Sverre Varvin

In the twentieth century, civilians increasingly became targets in wars, totalitarian regimes, and internal conflicts. This trend continues into this century. The basic social unit in all societies, the family in its different forms, is thus increasingly under attack in these war zones, with serious consequences for the mental health and the development of its members. RESPONSES TO TRAUMATIZATION The accepted use of trauma concepts is highly problematic. The word “trauma” implies something static and reified, like a “thing” in the mind, and this usage tends to divert attention from the dynamic and reorganizing processes in the traumatized person’s mind, body, and relations to others that happen after being exposed to atrocities. These are processes that depend on the level of personality organization; past traumatizing experiences; the circumstances during atrocities; and, most importantly, the context that meets the survivor afterward. It is the person’s responses to atrocity, as well as the responses of others and of societies as a whole, that to a large degree determine the fate of the traumatized person and her group. Research has convincingly confirmed the importance of the response to the traumatized person afterward, beginning with Hans Keilson’s seminal work on Jewish children survivors after the Second World War and also later researches (Gagnon and Stewart 2013; Keilson and Sarpathie 1979; Simich and Andermann 2014; Ungar 2012). Psychoanalysis is one such societal response, both in its practical therapeutic form and as a comprehensive theory for understanding the mind’s relation to the body and the general context of the trauma. 307

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TRAUMATIZATION AND ITS RESPONSES Traumatized persons struggle with mental and bodily pains that are difficult to understand and difficult to put into words. The pains may be expressed as dissociated states of mind, as bodily pains and other somatic experiences and dysfunctions, as overwhelming thoughts and feelings, as behavioral tendencies and relational styles, and as ways of living. The effects of both early and later traumatization may show themselves in many diagnostic categories where the symptoms characterizing PTSD are only one form. Manifestations related to traumatization in the psychiatric illness picture may include depression, addiction, eating disorders, personality dysfunctions, and anxiety states (Leuzinger-Bohleber 2012; Purnell 2010; Taft et al. 2007; Vaage et al. 2010; Vitriol et al. 2009). Common to all these manifestations will be deficiencies in the representational system related to the traumatic experiences. The traumatic experiences are painfully felt and set their marks on the body and the mind without, however, being inscribed in the mind’s life narratives. They are not symbolized, or are deficiently symbolized, in the sense that they cannot be expressed in narratives in such a way that meaning can emerge that can be reflected upon. The traumatic experiences remain in the mind as dissociated or encapsulated fragments that have a disturbing effect on mood and mental stability (Rosenbaum and Varvin 2007). EXPERIENCE TENDS TO BECOME DEPRIVED OF EMOTIONAL MEANING As a rule, extreme traumatization (like rape and torture) eludes meaning when it happens and it precludes also forming an internal third position where the person can create a reflecting distance to what is happening and what has happened. The inner witnessing function, so vital for making meaning of experiences, is attacked during such extreme experiences, impeding the individual from being able to experience on a symbolic level the cruelties they undergo. When the external witnessing function that can contain the pain also fails, the traumatized person is left alone. The result is often that these experiences remain as fragmented bits and pieces that can express themselves only in bodily pain, dissociated states of mind, nightmares, and relational disturbances. The traumatized person will try to organize experiences in unconscious templates or scenarios that are expressed in different more or less disguised ways in relation to others and self. When working psychoanalytically with traumatized patients, the analyst inevitably becomes involved in these un-symbolized, fragmentary,



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and usually strongly affective scenarios related to the patient’s traumatizing experiences. This happens from the first encounter with the patient and is mostly expressed in nonverbal interaction with the patient. It may take a long time before these manifestations are given a narrative form that in meaningful ways can be put into a historical context that relates to both the traumatic and pretraumatic experiences. To achieve this end implies hard and painful emotional work on both the patient’s part and that of the analyst. There is increasing evidence that psychoanalytic therapies are helpful for traumatized persons in comprehensive ways, in that such therapies can help address crucial areas in the clinical presentation of complex traumatization (complex PTSD [Herman 1992]) that are not targeted by other currently socalled empirically supported treatments. Psychoanalytic therapy has a historical perspective and works with problems related to the self and self-esteem, enhancing the person’s ability to resolve reactions to trauma through improved reflective functioning. It aims at internalization of more secure inner working models of relationships. A further focus is work on improving social functioning. Finally, and this is increasingly substantiated in several studies, psychodynamic psychotherapy tends to result in continued improvement after treatment ends (Schottenbauer et al. 2008). Patients with complex traumatization often live in difficult social, economic, and cultural situations, and thus treatment needs to be integrated with rehabilitation procedures and often with complicated somatic treatments. Treatment and rehabilitation of the traumatized will therefore often need to be conducted by a team, and when and how to implement psychoanalytic therapy must be carefully evaluated. Furthermore, patients will need constant support from the team and social services. TRAUMA AND THE SOCIAL CONTEXT For these not symbolized and insufficiently symbolized experiences to approach some kind of integration and be given some meaningful place in the individual’s mind, they need to be actualized and given form in a holding and containing therapeutic relationship. This implies that the analyst must accept living with the patient in areas of the mind that are painfully absent of meaning and at times filled with horror. As a rule, however, this is not sufficient: without acknowledgment of the traumatic events at the societal, cultural, and political level, the individual and the group’s work with traumatic experiences may be extremely difficult. Without this affirmation, the traumatized person’s feeling of unreality and fragmentation connected with the experiences may continue.

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This was the case for many people after the Second World War in the West, where the official slogan, to a large degree, was that one must go on living and put the past behind (Eitinger 1965, Askevold 1980). One of the most difficult contributors to personal suffering in such massive social traumatization as, for example, the Cultural Revolution, genocides (Rwanda, the Balkans, Kampuchea), and now in the Syrian disaster is the helplessness felt when observing close family, especially children, being maltreated and killed and being powerless to help or protect them. This underlines the importance of Niederland’s seminal insights on survival guilt (Niederland 1968, 1981), a theme that became very much marginalized in the trauma literature for many years. THE DYNAMIC AND STRUCTURE OF EXTREME TRAUMATIZATION To sum up: how trauma affects a person depends on the severity, complexity and duration of the traumatizing event, the context, the developmental stage, the way in which traumatization affects internal object relations—for example whether earlier traumatic relations are activated (Opaas and Varvin 2015)—and the support and treatment offered after the event. Phenomenology of Traumatization

Being traumatized is experienced by both children and adults as something unexpected that should not happen. It creates a situation where they feel a profound helplessness and have an experience of being abandoned by all good and helping objects. This profound feeling of helplessness and being abandoned may be carried over into the posttraumatic phase, where the survivor to a larger or lesser degree, and depending on the circumstances, may develop a deep fear of an impending catastrophe where one will be helpless and where nobody will help or care. An inner feeling of desperation and fear of psychosomatic breakdown with fear of annihilation may ensue, and much of posttraumatic pathology may be seen as a defense against this impending catastrophe. This impending catastrophe reflects the early fear of breakdown experienced in infant life. Posttraumatic anxieties are deep and comprehensive, and may best be understood as annihilation anxiety (Hurvich 2003) or nameless dread (Bion 1962). Traumatization effected by human beings influences internal objectrelations scenarios in different ways. Early traumas that bear some similarity to the present traumatization may be activated, causing the present trauma to be imbued with earlier losses, humiliations, and traumatic experiences.



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Even early safe-enough relationships can be colored by later traumatizing relationships (Varvin 2013a). Unbearable losses may bring the traumatized to eternally seek a rescuer or substitute in others (Varvin 2016a). Complicated relations to the traumatizing agent, the circumstances, and other relations involved may be actualized in the transference. Identification with the aggressor is a well-known term (Hirsch 1996) first coined by Anna Freud. In a recent work, Henningsen (2012) described the phenomenon of “concrete fusion” (konkretistische Fusion), which refers to the situation where the traumatized person internalizes the traumatizing object, and a part of the self fuses with this traumatizing object in order to keep the object inside and, in this way, avoid the complete object loss that characterized the traumatizing experience. This merged self-object relation may become split off and kept more or less encapsulated, hidden in the personality and appearing during a later crisis or traumatization, and it may be actualized in the transference relationship in therapy. Thus the traumatized person internalizes important aspects of the traumatizing scenario in the form of a self-object relation that might be more (or often less as in concrete fusion) differentiated and/or fragmented, being self-negating in various ways. The actualization of these scenarios might take dramatic forms in the analytic process. RELATION AND SYMBOLIZATION One salient task in psychotherapy with traumatized patients is to enhance a metacognitive or mentalizing capacity that can enable the patient to deal more effectively with traces and derivatives of the traumatic experience. This implies helping the patient out of mental states characterized by concreteness and lack of dimensionality. Mental traces of traumatic experiences are “wild” in the sense that the person has no capacity to organize and deal with them, no inner container in relation to an inner empathic other that can help give meaning to experience (Laub 2005). These mental traces are presented to the mind in a way from the “outside” and experienced as alien and threatening. The ego meets an overwhelming abundance of stimuli and impressions that disturb the regulating functions of the mind. The psychic apparatus may be pushed toward states of extreme anxiety and catastrophe (Rosenbaum and Varvin 2007). There is thus an experience of loss of internal protection related to the internal other—primarily the loss of the necessary feelings of basic trust and mastery. An empathic internal other is no longer functioning as a protective shield, and the functions that give meaning to experience may no longer work. Attachment to and trust in others may be perceived as dangerous,

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reminding the person of previous catastrophes. Relating to others, for example in psychoanalytic psychotherapy, may be felt as a risk of reexperiencing the original helplessness and the feeling of being left alone in utter despair. Withdrawal patterns may be the consequence, creating a negative spiral, as withdrawal also means the loss of potential external support (Varvin and Rosenbaum 2011). The effects of trauma may thus be long-standing and complex. They may affect several dimensions of the person’s relations with the external world and cause disturbances at the bodily-affective level to the capacity to form relations with others in the group and family and on the ability to give meaning to experience. The traumatized person is living with historical experiences that are not formulated but painfully and nonverbally represented in the body and in the mind. The task of therapy is to allow these experiences to emerge in the transference relationship so that words and meaning can be cocreated, even if the experiences themselves by all human standards are cruel and devoid of meaning. The cultural and societal dimensions are thus not outside the psychic space but are an integral part of the ways of experiencing self and others. The intention to humiliate has often a gender-based cultural background that has become part of the inner traumatic experience. This has consequences for analytic work. Raping a woman to humiliate the husband and destroy familial stability places the woman in a doubly humiliating position, but it will also leave the man in a precarious situation that may be impossible to overcome. This is one dynamic behind the tendency to be silent about such atrocities. They may, however, be actualized in the therapeutic relationship as actions, unbearable countertransferential feelings, and they may become present in most disturbing ways. This may happen when the analyst is drawn into relational scenarios where he/she becomes part of the emerging trauma-related scenes that the patient hitherto has struggled with alone. Actualization and enactment may thus be a possibility for these scenarios to, at least to a certain degree, be symbolized and reflected upon, which I will try to show later. Actualization, Projective Identification, and Enactment

From the start of therapy, the traumatized patient will involve the analyst in an un-symbolized and unconscious relationship where the patient communicates by acting out, and in this way presents important aspects of the traumatic experiences (Varvin 2016b). In this way, what is called trauma, but which in fact is the patient’s reaction to and struggle with the repercussions of her experiences, will be present from the beginning of the contact. Treatment of “the trauma” is not something that comes later when a trauma narrative is told, as is believed by exposure therapists.



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What the patient communicates touches the analyst and may hook on to unconscious, not worked-through material on her/his side, resulting in action that at first sight is not therapeutic, what is called countertransference enactment (Jacobs 1986). These enactments on the analyst’s part may, however, be a starting point for a possible process of symbolization, in order to make these implicit experiences conscious (Scarfone 2011). It should be underlined that enactment actually involves a collapse in the therapeutic dialogue where the analyst is drawn into an interaction where she/he unwittingly acts, thereby actualizing unconscious wishes of both her/ himself and the patient. It may be a definable episode in a process with more or less clear distinctions between the pre-phase, the actual moment, and the post-phase or may be part of a prolonged process in therapy (Jacobs 1986), or both, as was the case with the clinical material presented below. Enactments appear thus as an unintentional breakdown of the analytic rule of “speech not act” and may imply a new opportunity of integration or, conversely, may hinder the analytic process. Enactments can come as a total surprise but can also be identified in, for example, fantasies and thoughts and feeling states that were there beforehand (Jacobs 2001). Most often, it is a surprise, and it is only afterward that it is possible to look at what happened. Then, if things go well, there will be an understanding of the processes that were at work. In the context of traumatization, enactments may represent a possibility for symbolizing material related to traumatic experiences. Scarfone holds that “remembering is not, when it works, a simple act of ‘recalling’ or ‘evoking.’ It implies the transmutation of some material into a new form in order to be brought into the psychic field where the functions of remembering and integration can occur” (Scarfone 2011). In connection with traumatization, enactments can thus be seen as the actualization of relational scripts or scenarios where unconscious, un-symbolized material is activated in both patient and analyst. This is often seen as an unavoidable part of the analytic interaction, and outcome depends on the analytic couple’s ability to bring the enactment into the psychic field. The pressure is usually understood as starting from the patient, although mutual or reciprocal pressure may be seen (McLaughlin 1991; McLaughlin and Johan 1992) where analysts’ conflicts reinforce the patients’ tendency to act out. An unconscious fantasy is actualized in the transference, the pressure is mediated via projective identification, and the analyst “acts in” due to unresolved countertransference problems. I will briefly try to illustrate aspects of these processes with material from the treatment of a severely traumatized woman.

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THE BODY’S UNBEARABLE PAIN A. came from a middle-class family in a large city in an Asian country. She was the only girl and had three brothers. Her mother was somewhat modern and supported her in her struggle to get an education. Her father, much older than her mother, was strictly religious and conservative. Thus, her experience was to be raised in the crossfire of the conflict between her mother’s and her father’s view of what was appropriate for a girl. According to tradition, girls should not have any education; at the most, they would attend Quran School, something A. felt to be deeply unjust. She pursued her intention to get an education with a stubbornness that undoubtedly was inspired by her father’s attitude. She experienced two episodes of sexual assault between the ages of seven and nine years, which she described as very frightening and potentially traumatizing. She developed into a person who took care of other people’s problems, and she was extremely afraid of offending or hurting others. She had few friends. After high school, she was educated as an assistant nurse and worked in the poorer part of the city, where she became aware of the enormous poverty and suffering in her country. While working in a legal social organization, she met her husband, who held a leading position in a political movement. They had two children who were eleven and thirteen years old respectively at the start of treatment. Shortly after her children were born, the political climate deteriorated and mass arrests began. Her husband and several members of his extended family were arrested. Eight of them were soon executed. Her husband survived but was heavily tortured. Soon afterward, she was arrested with her two small children, then four months and two years old. A. and her two children spent two years in prison; some of their experiences were beyond human understanding and, for her, beyond words to describe. She was gradually able to talk about them during therapy, but she gave the impression that much was too difficult to recount. She could not talk with her husband and others in her family, as she did not want to cause them pain. Her husband had experienced too much himself in prison and suffered from prolonged periods of sleeping problems, nightmares, and somatic pain. A. and her husband were separated for a long time after she was released from prison, as he lived clandestinely and later fled. TRAUMA STORY: A SHORT SUMMARY First, they were in a prison in a small town for about a year. A. and her two children had to live in a small cell, less than one square meter in size, as she



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recounted. As it was impossible to stretch out when sleeping, she developed a technique of bending her legs backward in order to rest and to give the children more space. At the beginning of therapy (about ten years later), she was still obliged to sleep in that position to get some rest. Food was scarce and hygienic conditions were poor. At a time when her youngest child was about to die of hunger and thirst, the guard brought contaminated milk that instantly made the child extremely sick and brought him nearer to death. For extended periods, she had to stand, hooded, against the wall, not allowed to sit or take care of the children, who had to crawl on the floor. They could hear the screams of people being tortured, and the mother was hit while the children watched. They were then moved to a larger prison in a central city. Here they were placed in a large, overcrowded cell. She had to curl up to give space to the children and to her fellow prisoners. The fellow prisoners were regularly tortured, and bleeding and maltreated persons were a common sight. Many had their toes or fingers cut off, some became lame, and some were killed in front of her and the children. She described one experience as follows: And in every cell we were about 70 at the time. And then they came, placed themselves in the middle of the room, turned around several times pointing, and then suddenly stopping, and the finger pointed at one of us. The rest of us had almost stopped breathing while this man turned around, now it will be me, just by chance. When one person was pointed at, the rest of us could breathe again, but we were devastated for the person who had been selected. Because we did not know. Is it torture or execution? (pause). And I remember my friends, they were fetched at 4 o’clock in the night for execution and we were not allowed to get up and say our thanks and say goodbye And it was like that, if the fellow-prisoners took my children on the lap, they got whipped.

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This experience highlights the paralyzing fright that became a part of her personality. She said during the follow-up interview: “Before, I was afraid of everything, all the time. Now it is totally changed. I will never forget you.” She added that she had not been aware it was fright. During the five years she stayed in her home country after being released from prison, she and her family were constantly harassed. She was several times taken for “interrogation,” as it was called—sometimes for days, sometimes for months—and was maltreated. She was harassed on the street and was constantly afraid of being killed. When she understood there was a real danger that her children might be taken away from her and that she herself could be put in prison for a long time, she decided to flee. After her flight, she had had numerous physical ailments: pains in different parts of her body (back, chest, stomach, legs, and headache), breathing problems, and recurrent urinary tract infections. She had also developed an intractable curvature of the spine (thoracic-kyphosis). She suffered from intrusive memories and nightmares relating to traumatic experiences, extreme anxiety, and depression. Sadness seemed to inhabit her. TREATMENT PROCESS The psychotherapy was conducted face-to-face with a total of 165 sessions. The first year of therapy was with an interpreter. The patient expressed the desire at the beginning of the therapy to “learn enough Norwegian to express myself.” When she decided to do without an interpreter, this was, at least partly, motivated by mistrust. The analyst formulated the focus of the psychotherapy in the following way in the first session: “to find what happens inside you when you experience pain, when you become sad or full of melancholic thoughts, and if there can be ways you can work with yourself to feel better in your body without having to take medicine” (which she didn’t want). The instruction given at the beginning of therapy was an invitation “to try to say whatever came to your mind,” with an additional explanation of the meaning of this related to her cultural beliefs. This was, as could be expected, a rather difficult task for her. Having been interrogated numerous times, this invitation naturally evoked resistance. One main aim was to help her to talk in general and in particular about difficulties regarding both the current situation and her past experiences. She often behaved in a passive way, expecting to “get treatment,” which was related to her cultural tradition (doctors give treatment) but also her helplessness and lack of feelings of agency in relation to her pains.



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She often regressed into a passive-aggressive position, demanding that her therapist “make her well.” “When will I be well, doctor?” and “When will the pains go away?” were recurrent questions. The transference implications of this demand, putting the therapist in the difficult position of being the helpless helper and thereby preparing the ground for disappointment, were obvious, and proved difficult to clarify. She sought a variety of somatic treatments while in therapy (often when disappointed by or mistrusting the therapist). The therapeutic process could be divided in three phases: 1.  The rapprochement phase (sessions 1–18): The first verbalization of traumatic memories and the establishment of a preliminary alliance occurred during this phase. The immediate effect was a spontaneous improvement in her depression and some of her somatic problems. 2.  Resistance and mistrust (sessions 19–90): In this phase, she had many somatic complaints, very often openly distrusted the therapist and she quit therapy twice. 3.  Phase of autonomy (sessions 91–165): Here she was able to make mental connections on her own and work with what frightened her in her daily life, and thus gain considerable autonomy. I will now focus on some aspects of the transference-countertransference relation. She involved the analyst in an un-symbolized relationship communicated by projective identifications, action, and affective pressure (Varvin 2013b). The effects of her overwhelming experiences were in this way present from the beginning. Her way of relating and communicating was intense, and this activated the analyst’s own unconscious material, resulting in unintended, unconscious countertransference enactments. I will try briefly to illustrate aspects of these processes with A. After the long period of resistance and mistrust, where her fright of being humiliated yet again became a major focus, things loosened up and she began to link present terrors with her prison experiences and other atrocities. This resulted in increased inner freedom and also a more autonomous life. She began to see friends, moved around in the city more freely and even learned to drive a car. She realized that she had been frightened of almost everything at the beginning of therapy, and a process started where she could identify what made her afraid and the roots of her fears. For example, she panicked when her husband touched her ears. This she could connect with the time in prison when she was hooded and had to watch her children with her ears. She got anxiety when hearing voices from the radio, reminding her of the messages in the prison from the loudspeaker, broadcasting who should be tortured. The

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color black made her almost paralyzed: the connection to the black-dressed men in the prison became clear when the analyst wore a black jacket. An enactment episode ran as follows: She came to the session complaining of intense back pain and demanded to lie on the couch. When the analyst moved his chair closer, feeling encouraged by her increased freedom in the consulting room and hoping for a closer contact, she became stiff, full of anxiety and silent. It took some sessions to clarify that the scene represented a seduction situation, reminding her of assaults she had experience in the prison. The analyst’s wish for closeness, after long and frustrating resistance and aggression from the patient, represented for her a violent, sexual approach. The unconscious roots of the analyst’s wish and the not very cautious way it was acted out, was material for self-analytic work. A brought experiences from her prolonged and complex traumatizing experiences into the consulting room and involved the analyst in scenarios of distrust and attack that were difficult to understand and emotionally hard to contain. A marked changed occurred when she was able to realize that she was indeed afraid, that something she experienced in the here and now made her stiff with fright. This was a starting point for a historicizing process where she was gradually able to make connections between present terrors and earlier experiences, as described above. This was an amazing process where she seemed to have internalized the analyst’s constant efforts to contextualize her present fears. In this process, she increasingly insisted on making these connections by herself. Furthermore, she started to relate to her pretraumatic childhood experiences. She gradually realized that she, after her prolonged traumatization, had remembered her life as filled through and through with anxieties, where there were almost no “safe points” that she could relate to, none anchoring in earlier safe-enough relational experiences that could have given her at least some feeling that the world could be safe. One example demonstrates this: her fear of the color black brought back memories of a strict and quite cold grandmother. When reflecting on this, she realized that these memories, after her prison experience, were “colored in black.” She remembered her experiences when grandmother took her for weekly baths at the village’s public bath. At the end of the bathing rituals, she was taken to a deep well in a rather dark place to be thoroughly washed. She remembered she had been afraid but realized that the blackness had generalized and had colored the memories of grandmother. When this was sorted out over time, other good memories appeared, and being together with grandmother at the public bath appeared in another light. Washing was seen in a different context, and in that way, her grandmother emerged as a rather kind person, and her childhood gradually “became better.” I think this part of her work with the past, demonstrated the retroactive (nachträglich) work of extreme



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traumatization, and especially how it activates early fears of breakdown. Psychoanalytic therapy thus worked retrospectively to reorganize memories from early parts of her life. REFERENCES Askevold, Finn. 1980. “The War Sailor Syndrome.” Danish Medical Bulletin 27 (5): 220–24. Bion, Wilfred R. 1962. Learning from Experience. London: Heinemann. Eitinger, Leo. 1965. “Concentration Camp Survivors in Norway and Israel.” Israel Journal of Medical Science 1 (5): 883–95. Gagnon, Anita, and Donna Stewart. 2013. “Resilience in International Migrant Women Following Violence Associated with Pregnancy.” Archives of Women’s Mental Health 4 (17): 303–10. doi: 10.1007/s00737-013-0392-5. Henningsen, Franziska. 2012. Psychoanalyse mit traumatisierten Patienten: Trennung, Krankheit, Gewalt. Stuttgart: Klett-Cotta. Herman, Judith Lewis. 1992. “Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma.” Journal of Traumatic Stress 5: 377–91. Hirsch, Mathias. 1996. “Forms of Identification with the Aggressor According to Ferenczi and Anna Freud.” Prax Kinderpsychol Kinderpsychiatr 45 (6): 198–205. Hurvich, Marvin. 2003. “The Place of Annihilation Anxieties in Psychoanalytic Theory.” Journal of the American Psychoanalytic Association 51: 579–616. Jacobs, Theodore. 1986. “On Countertransference Enactments.” Journal of American Psychoanalytical Association 34: 289–307. ———. 2001. “On Misreading and Misleading Patients: Some Reflections on Communications, Miscommunications and Countertransference Enactments.” International Journal of Psychoanalysis 82: 653–69. Keilson, Hans, and Herman R. Sarpathie. 1979. Sequentieller Traumatisierung bei Kindern. Stuttgart: Ferdinand Enke. Laub, Dori. 2005. “Traumatic Shutdown of Narrative and Symbolization: A Death Instinct Derivative?” Contemporary Psychoanalysis 41 (2): 307–26. Leuzinger-Bohleber, Marianne. 2012. “Changes in Dreams—From a Psychoanalysis with a Traumatised, Chronic Depressed Patient.” In The Significance of Dreams: Bridging Clinical and Extraclinical Research in Psychoanalysis, edited by Peter Fonagy, Horst Kächele, Marianne Leuzinger-Bohleber, and David Taylor. London: Karnac. McLaughlin, James T. 1991. “Clinical and Theoretical Aspects of Enactment.” Journal of American Psychoanalytic Association 39: 595–614. McLaughlin, James T., and Morton Johan. 1992. “Enactments in Psychoanalysis (Panel Report).” Journal of American Psychoanalytic Association 40: 827–41. Niederland, William G. 1968. “Clinical Observations on the ‘Survivor Syndrome.’” International Journal of Psychoanalysis 49 (2): 313–15.

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———. 1981. “The Survivor Syndrome: Further Observations and Dimensions.” Journal of American Psychoanalytic Association 29 (2): 413–25. Opaas, Marianne, and Sverre Varvin. 2015. “Relationships of Childhood Adverse Experiences with Mental Health and Quality of Life at Treatment Start for Adult Refugees Traumatized by Pre-flight Experiences of War and Human Rights Violations.” Journal of Nervous and Mental Disease 203 (9): 684–95. doi: http://dx.doi .org/10.1097/NMD.0000000000000330. Purnell, Chris. 2010. “Childhood Trauma and Adult Attachment.” Healthcare Counselling and Psychotherapy Journal 20 (2): 9–13. Rosenbaum, Bent, and Sverre Varvin. 2007. “The Influence of Extreme Traumatisation on Body, Mind and Social Relations.” International Journal of Psychoanalysis 88: 1527–42. Scarfone, Dominique. 2011. “Repetition: Between Presence and Meaning.” Canadian Journal of Psychoanalysis/Revue Canadienne de Psychoanalyse 19 (1): 70–86. Schottenbauer, Michele A., Carol R. Glass, Diane B. Arnkoff, and Sheila Hafter Gray. 2008. “Contributions of Psychodynamic Approaches to Treatment of PTSD and Trauma: A Review of the Empirical Treatment and Psychopathology Literature.” Psychiatry 71 (1): 13–34. Simich, Laura, and Lisa Andermann, eds. 2014. Refugee and Resilience. London: Springer. Taft, Casey, Danny Kaloupek, Jeremiah Schumm, Amy Marshall, Jillian Panuzio, Terence King, et al. 2007. “Posttraumatic Stress Disorder Symptoms, Physiological Reactivity, Alcohol Problems, and Aggression among Military Veterans.” Journal of Abnormal Psychology 116 (3): 498–507. Ungar, Michael. 2012. The Social Ecology of Resilience: A Handbook of Theory and Practice. New York: Springer Verlag. Vaage, Aina B. P. H. Thomsen, D. Silove, T. Wentzel-Larsen, T. Van Ta, and E. Hauff. 2010. “Long-Term Mental Health of Vietnamese Refugees in the Aftermath of Trauma.” British Journal of Psychiatry 196 (2): 122–25. Varvin, Sverre. 2013a. “Psychoanalyse mit Traumatisierten: Weiterleben nach Extremerfahrungen und kompliziertem Verlust” (Psychoanalysis with the Traumatised Patient: Helping to survive extreme experiences and complicated loss). Forum der Psychoanalyse: Zeitschrift für klinische Theorie und Praxis 29 (3): 372–89. ———. 2013b. “Trauma als nonverbale Mitteilung” (Trauma as nonverbal communication). Zeitschrift für psychoanalytische Theorie und Praxis 28 (1): 114–30. ———. 2016a. “Atrocoties against Mother and Child Re-presented in the Psychoanalytic Space.” In The Status of Women: Violence, Identity, and Activism, edited by Vivian Pender. London: Karnac Books. ———. 2016b. “Psychoanalysis with the Traumatized Patient: Helping to Survive Extreme Experiences and Complicated Loss.” International Forum of Psychoanalysis 25 (2): 73–80. doi: http://dx.doi.org10.1080/0803706X.2014.1001785. Varvin, Sverre, and Bent Rosenbaum. 2011. “Severely Traumatized Patients’ Attempts at Reorganizing Their Relations to Others in Psychotherapy: An Enunciation Analysis.” In Another Kind of Evidence: Studies on Internalization, Annihila-



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tion Anxiety, and Progressive Symbolization in the Psychoanalytic Process, edited by Norbert Freedman, Marvin Hurvich, and Rhonda Ward, et al. London: Karnac. Vitriol, Verónica G., Ramón U. Florenzano, Kristina P. Weil, and Dafna F. Benadof. 2009. “Evaluation of an Outpatient Intervention for Women with Severe Depression and a History of Childhood Trauma.” Psychiatric Services 60: 936–42.

27 CONTEMPORARY SELF PSYCHOLOGY AND ITS TREATMENT OF TRAUMATIZED PATIENTS Koichi Togashi and Amanda Kottler

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chapter focuses on treating traumatized patients from a theoretical framework originating in Heinz Kohut’s “psychology of the self” (Kohut 1977, 1984). Our particular form of treatment is, however, influenced by the contemporary relational turn in psychoanalytic theory and understands traumatization1 in a relational and social context. As such, it includes working with the existential anguish caused by living in a world that we believe is traumatizing and alienating. From this perspective, we recognize that traumatized patients, while living in such a world, yearn for, and actively seek out, ways of experiencing an “at home” feeling (Kottler 2014, 2015; Togashi and Kottler 2015) of “being human among other human beings”2 (Kohut 1984). Our treatment, appreciated in this way, falls within a hermeneutic framework. We refer to it as “the psychology of being human” (Togashi 2014a, 2014d; Togashi and Kottler 2012, 2015; Weisel-Barth 2015). Our treatment differs from Kohut’s (1971, 1977) “psychology of the self,” which focuses on facilitating, with the help of “selfobject experiences,” the building of a cohesive “self.” From this perspective, traumatization involves a state of fragmentation of the self that emerges “as the direct consequence of a specific narcissistic injury, as a consequence of the unempathic,3 overburdening response of a selfobject” (Kohut and Wolf 1978, 420). This is considered a form of pathology that Kohut called a “disorder of the self,” which, in the wake of trauma, leads to a breakdown of the experience of “being human among other human beings” (Kohut 1984). In contrast, the framework of the “psychology of being human” shifts the emphasis, theoretically and clinically, from focusing on how people experience themselves as cohesive or not, to the ways in which they do or do not experience themselves as being human among other human beings. This 323

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framework sees all human beings as potentially traumatized and understands the considerable complexity of the relationship between trauma and a sense of being human. It considers that a sense of being human is always at risk of being destroyed by events that occur in the traumatizing world in which we all live. However, it believes that the actual experience of being human emerges as a consequence of surviving in an uncontrollable, unpredictable, and unknowable world and, as a result, having faced its impermanence and its limitations. This includes facing the radical alterity of the Other (Baraitser 2008; Orange 2010). We believe, therefore, that an opportunity to experience the feeling of being human among other human beings is presented through one’s struggle to come to terms with the reality that, through no choice of one’s own, the world is in fact traumatizing and potentially alienating. TYPE OF TRAUMA AND SYMPTOMS From this perspective, we do not understand or clarify trauma in terms of the emerging symptoms or the type of traumatic events that might have triggered them. While symptoms such as those of PTSD (American Psychiatric Association 2013) would need to be treated actively, occasionally medically, with a view to reducing this particular form of suffering, the actual symptoms presented are not a primary therapeutic focus from our perspective. We consider symptoms as manifestations of the way in which human beings have managed to survive in the traumatizing world they inhabit (Togashi 2014a). Further, we reflect on and, together with our patients, make sense of the function that the presenting symptoms perform in the way our patients behave in the world (Togashi and Brothers 2015). Our central emphasis, then, is on the subjective meaning of the suffering that patients experience as human beings, and on the repetitive and characteristic ways that each person has found to survive in the traumatizing world. From this perspective, symptoms are not seen as pathological or as indicative of an illness. To summarize: our focus is not on the kind of trauma a person has suffered, nor on the symptoms experienced in the wake of trauma. It is on the subjective meaning of trauma in an intersubjective, cultural, and historical context. In this sense, our framework allows us to treat any type of trauma, including for example acute, situational, complex developmental, relational, and historical trauma, without necessarily using traditional psychiatric diagnostic criteria. For descriptive and clinical purposes, we prefer to think of and to understand trauma from two angles followed by Togashi (2017): (1) existential trauma, which is embedded in a person’s anguish about being—in an unpre-



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dictable, uncontrollable, and unknowable world—and (2) relational trauma, which is rooted in a person’s struggle to accommodate to being in a relationship with another while attempting to maintain an authentic sense of personal agency. These classifications are not necessarily linked to particular types of events but, generally, existential trauma follows experiences of natural disasters or social trauma such as war, industrial accidents, terrorism, and genocide. Relational trauma generally follows experiences of, for example, emotional and sexual abuse, emotional neglect, domestic violence, or bullying. The two kinds of experience are often difficult to differentiate, as the experience of a single event frequently involves both kinds of trauma. Traumatic experiences of alienation as a result of otherness or difference, for example, as a result of ethnicity, gender, sexual preference, disability, or economic disparity, straddle both types of trauma. In the treatment of existential trauma, our main focus is on exploring the subjective meaning of our patient’s living in the world, together with our own existential vulnerability (Brothers 2008; Stolorow 2007, 2008; Togashi 2014a, 2014b, 2014c, 2014d). Stolorow (2007) emphasizes that trauma is not a pathology to be cured. For him, the experience of trauma confronts patients with their human limitations, finiteness, and impermanence. It is an experience of context-embedded unbearable emotional pain, which can be integrated only by being understood by another who knows “the darkness of our common finiteness” (Stolorow 2010, 35). In other words, to treat existential trauma psychoanalytically our framework aims at helping patients to find a way of being human in this world—the same traumatizing world the therapist lives in—while at the same time facing and coming to terms with its uncontrollability, unpredictability, and unknowability. This differs from the way relational trauma is generally discussed, as a person’s struggle to balance the way he or she accommodates to an interpersonal environment with that of maintaining, from an other-centered perspective, a sense of personal agency and of being him- or herself in relationships with other human beings. Brandchaft (2001) discusses this struggle by describing an intersubjective process in which a child is forced to accommodate to her parents’ or caretakers’ wishes because of their inability to relate sufficiently to her different needs. He emphasizes that the child, afraid of the devastating loss of emotional connection, is compelled to comply. Consequently, she is likely to suffer the loss of the space and the capacity for reflection on her experience of herself and of the relationship. This type of trauma is organized around ongoing coercion and deception between the child and the caretaker. In this

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process, the child’s authentic self is demolished in the face of the subjectivity of the other. This is a pattern that is likely to repeat itself in the intersubjective space between therapist and patient. Importantly, this kind of traumatization also has the hallmarks of existential trauma. CONCEPTUALIZATION OF THE TREATMENT With the above in mind, our perspective focuses almost exclusively on looking for, and making sense of, the ways that patient and therapist first experience the dialogue and relationship that unfolds between them. Second, it considers the way that therapist and patient, if all goes well, manage to cocreate an “at home” feeling (Kottler 2014) in what we refer to as a “relational home” (Stolorow 2007, 2008). It is in this home that the patient finds another human being who is willing to share the same impermanence and human limitations. In this process, from our perspective, the most significant emphasis is on how and what unfolds between patient and therapist while they make sense together of the fundamental psychological meaning of their having met in this world (Togashi 2014c). Treatment from our perspective involves two important processes. The first is a need for therapists to become aware of, and come to terms with, the fact that they too are vulnerable in this traumatizing and alienating world, and have also been traumatized by it. They must therefore also face the human limitations, finiteness, and impermanence of the human world. Significantly, psychoanalytic theories and clinical practices can be traumatically limited and limiting. Therapists must recognize that they are not trauma-free professionals who can diagnose and cure trauma from a distance. The second significant process is a patient’s and a therapist’s growing capacity for an I-Thou dialogue (Buber 1999), which focuses on how each has found a mutually respectful and acceptable way of “being” together in this newly developing relational home. Especially, we believe it is significant for both patient and therapist to build a dialogue “on the themes of how the therapist and patient happened to meet and have been together in this traumatizing world, how both parts of the analytic dyad experience their relationship as honest and authentic, and whether or not the therapist and patient can find themselves in each other” (Togashi 2014d, 277). In this process, therapist and patient both work through the sense of uncertainty that arises out of living in this world (Brothers 2008). To illustrate our framework we turn to two clinical examples presented at a psychoanalytic conference.



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Togashi discusses his work with Miyuki, in her late twenties, who had keloid scars on her face from childhood burns. “Miyuki was traumatized by her facial scars and related insults” and “did not enjoy sharing her emotional experience with” her therapist. “She alienated herself by not seeing others as unique human beings. Even after years in treatment, she was still able to maintain that it did not matter who her therapist was” (Togashi 2016, 16). This changed when her therapist realized that he was seeing Miyuki as a generic “traumatized person,” an object who needed treatment from an “objective” professional. Imagining himself with scars on his face led him to realize that, in this unpredictable world, he could easily have been in her position but that luckily he was not. This helped Miyuki feel safe enough to tell him that the world was “cruel and heartless,” something she had never articulated before because it would reveal that she was “too vulnerable to live in this world.” A discussion followed about the unpredictability, uncontrollability, and unknowability of living and being in this world. The discussion expanded to one about the unplanned but significant meaning of the encounter between Miyuki—the person unlucky enough to be scarred, and her therapist—the person lucky enough not to be scarred. They talked about how there was no rational reason for them to have met and how incredibly lucky she felt to have a therapist who turned out to be open, empathic, and authentic. This process gradually enabled Miyuki to feel “at home” enough to recognize her therapist not as a generic trauma-free professional, but as a unique human being much like herself. This empowered Miyuki to ask what her therapist saw when he looked at her scars. Of course, this was an extremely difficult question that, like the metaphorical elephant in the room, had been on their minds from the beginning of the therapy. However, neither had verbalized this because of the uncertainty of whether or not the relationship was sufficiently secure. The freedom to ask the question facilitated a sharing of her excruciatingly painful experiences of feeling ugly. Our framework believes that they were only able to speak about this because her therapist recognized that her issue was one that he, as a fellow human being, could easily have had to bear himself. Frie’s description of a bilingual therapy with the son of Holocaust survivors also illustrates our framework well. Frie is the son of German postwar immigrants to North America. Although he grew up in Canada, he carries the burden of guilt and shame connected to his German background. Both his grandfathers were German soldiers in World War II and belonged to the generation of perpetrators and bystanders. His patient, Daniel, was from Austria, in his forties, and he sought a German-speaking therapist. He found

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this in Frie, whose first language was German. Daniel suffered from “depression, anxiety, and experienced strong feelings of anger” (Frie 2011, 138). It was natural for him to be concerned about two issues: Why his therapist, who was so obviously not Jewish, spoke fluent German, and what his therapist’s background was, given the history of Nazi Germany. Understandably, it took a long time before Daniel felt at home enough to voice his concerns, while the therapist empathically remained acutely sensitive to how Daniel might be fantasizing about Frie’s background. When they were finally able to have this discussion Frie carefully considered not only how Daniel felt about his intergenerational pain, but also how Frie’s family had suffered during World War II. However, they were only able to actually articulate Frie’s until then unspoken personal and familial history after discussing the significance of their encounter and acknowledging that they both lived in a traumatizing world, which their ancestors had also shared. This difficult conversation facilitated the establishment of a relational home for Daniel and his therapist. Both vignettes include a process in which, although uncomfortable, patient and therapist were finally able to speak the unspeakable. Both cases also show how their capacity to do this, as fellow human beings in a shared traumatizing and alienating world, stemmed from a dialogue focusing on the significance that their encounter had on the patient’s experience of being human among other human beings. An important aspect of what we have described above requires further discussion. We believe that trauma often reveals itself in the form of something unspoken in the intersubjective field. This is evident in the two cases above. Togashi (2016) refers to this as an “intersubjective taboo.” Unlike the Freudian taboo (Freud [1913] 1955) that relates to incestuous wishes that cannot be spoken, an intersubjective taboo refers to an unspoken connection that exists between therapist and patient. The experience differs from repression or dissociation because patient and therapist are, to greater or lesser extents, aware of the unique link between them—that is, that they share a painful experience—silently. It remains unspoken—and hence a taboo—while the relationship remains too vulnerable for it to be verbalized. The tension and silence differ from a rupture of or mistrust in the relationship in the sense that if working within this framework, therapists with a sense of relational confidence and intention will foster a process in which both participants make sense of it all together. The taboo often emerges as a manifestation of the particular traumatized vulnerability that has been experienced as a result of not feeling at home. The quest for open dialogue about the taboo therefore creates a space for the development of a relational home. Ultimately, it is essential that the therapist



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(and patient) carefully observe and articulate how the “unspoken” has transformed into authentic honesty in the therapeutic dialogue. Without this, we believe a patient’s recovery and transformation is superficial. CONCLUSION Traumatized patients whose sense of being human is at risk experience time as remaining frozen and bound up in the traumatic events experienced by them. These patients cannot tolerate uncertainty. As a consequence, the world and the human beings in it are divided into extremes: either friend or foe, or, on the side of the patient or not on their side (Brothers 2008). This is not only true of our patients. Therapists, as human beings, have also experienced trauma and need to be conscious of the fact that they might also make sense of the world by dividing it into extremes. The intersubjective field is thus uniquely organized by the minds of both traumatized therapist and traumatized patient within a continuum of two extremes. There are the conjunctions and the disjunctions. Both therapist and patient must understand and be willing to acknowledge that their experiences of society, culture, gender, sexuality, and a range of other discourses are likely to have been traumatizing to some extent and will influence them in particular ways. This will include their interests in psychotherapeutic work and the habitual ways in which they conduct their relationships, including, for therapists, all of their therapeutic relationships. In this paradigm, a therapist’s honesty, authenticity, and sincerity about the impermanence and uncertainty of their own being in the world and the limitation of the psychoanalytic method they apply should be incorporated into the distinct treatment elements of the approach. Therapists must be prepared to see and allow for the unknowable—the unpredictability and the contingency of any phenomena that they witness in this world (Togashi 2014c)—including everything they witness and experience in the therapeutic process. A patient and a therapist’s ongoing management of the intersubjective space and their effort to have an honest dialogue with each other will be the patient’s first ever feeling of “being human among other human beings” (Kohut 1984). What will make this process possible is a therapist’s ability to recognize the element of chance involved (Togashi 2014c). Depending on how the cards were dealt, she could easily have been the patient traumatized by a mugging and a rape. And, as difficult as it is to accept, if things had been different in the world in which she grew up, she could also have been the assailant. In other words, through this dialogue and the empathic process involved, therapists working from within this framework are able to imagine

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the curative possibility and reality of finding themselves in their patients. Equally significant and curative, the process allows a patient to recognize that his therapist is able to find herself in him (Togashi 2009, 2012). The consequences are life changing. The experience enables an authenticity and honesty in their relationship, without feeling shame about the vulnerability, pain, and anguish of living in this world. From what we have said above, it should be clear that we do not view personality as developing in particular ways as a consequence of historical trauma. We see that personality incorporates the historical, cultural, and relational contexts in which it has developed. From this hermeneutic perspective, we also believe that history, culture, and human relationships are all organized around what we understand as existential trauma, which drives the particular need for a relational home. A sense of belonging through human relationships, social systems, and human cultures are all ways in which human beings seek relational homes. In this space, in a relational home, patients find and experience themselves as being human among other human beings who know, understand, and can tolerate the same limitations and restrictions that all of us as human beings experience. Our framework and treatment model of working with trauma facilitates this process. NOTES We express our gratitude to Dr. Roger Frie for giving us a permission to use the summary of his case and for his editorial assistance with regard to the case material. 1.  We use the word “traumatization” to indicate the transformation of psychological and physiological states as a result of exposure to stressful events, relationships, and/or social and political conditions. We use the word “trauma” as a collective term to indicate a psychological state resulting from traumatization. 2.  Heinz Kohut theoretically elevated this feeling at the end of his life to the most significant experience involved in what he considered a successful treatment from his framework. He died before he was able to elaborate on this (see Togashi and Kottler, 2015). 3. Kohut’s psychology of the self focused entirely on the concept of “empathy,” which has always been a central aspect of his theory.

REFERENCES American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders. Fifth edition (DSM-5). Washington, DC: American Psychiatric Association.



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Baraitser, Lisa. 2008. “Mum’s the Word: Intersubjectivity, Alterity, and the Maternal Subject.” Studies in Gender and Sexuality 9: 86–110. Brandchaft, Bernard. 2001. “Obsessional Disorders: A Developmental Systems Perspective.” Psychoanalytic Inquiry 21: 253–88. Brothers, Doris. 2008. Toward a Psychology of Uncertainty: Trauma-Centered Psychoanalysis. New York: Routledge. Buber, Martin. 1999. Martin Buber on Psychotherapy: Essays, Letters and Dialogue. Syracuse, NY: Syracuse University Press. Freud, Sigmund. (1913) 1955. “Totem and Taboo.” In Psychological Works of Sigmund Freud, Vol. 13. London: Hogarth Press. Frie, Roger. 2011. “Irreducible Cultural Contexts: German-Jewish Experience, Identity, and Trauma in a Bilingual Analysis.” International Journal of Psychoanalytic Self Psychology 6: 136–58. Kohut, Heinz. 1971. The Analysis of the Self. Madison, CT: International Universities Press. ———. 1977. The Restoration of the Self. Madison, CT: International Universities Press. ———. 1984. How Does Analysis Cure? Chicago: University of Chicago Press. Kohut, Heinz, and Ernest Wolf. 1978. “The Disorders of the Self and Their Treatment: An Outline.” International Journals of Psycho-Analysis 59: 413–25. Kottler, Amanda. 2014. “Feeling at Home, Belonging and Being Human: Kohut and Self Psychology.” Paper presented at the 37th Annual International Conference of the Psychology of the Self, Jerusalem, Israel. ———. 2015. “Feeling at Home, Belonging and Being Human: Kohut, Self Psychology, Twinship and Alienation.” International Journal of Psychoanalytic Self Psychology 10: 378–89. Orange, Donna. 2010. Thinking for Clinicians: Philosophical Resources for Contemporary Psychoanalysis and the Humanistic Psychotherapies. New York: Routledge. Stolorow, Robert. 2007. Trauma and Human Existence: Autobiographical, Psychoanalytic, and Philosophical Reflections. New York: Routledge. ———. 2008. “The Contextuality and Existentiality of Emotional Trauma.” Psychoanalytic Dialogues 18: 113–23. ———. 2010. “Ontologizing Is Not Pathologizing: Reply to Ilene Philipson.” International Journal of Psychoanalytic Self Psychology 5: 34–36. Togashi, Koichi. 2009. “A New Dimension of Twinship Selfobject Experience and Transference.” International Journal of Psychoanalytic Self Psychology 4 (1): 21–39. ———. 2012. “Mutual Finding of Oneself and Not-Oneself in the Other as a Twinship Experience.” International Journal of Psychoanalytic Self Psychology 7 (3): 352–68. ———. 2014a. “Certain and Uncertain Aspects of a Trauma: Response to Doris Brothers.” International Journal of Psychoanalytic Self Psychology 9 (4): 289–96. ———. 2014b. “From Search for a Reason to Search for a Meaning: Response to Margy Sperry.” International Journal of Psychoanalytic Self Psychology 9 (2): 108–14.

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———. 2014c. “Is It a Problem for Us to Say, ‘It Is a Coincidence That the Patient Does Well’?” International Journal of Psychoanalytic Self Psychology 9 (2): 87–100. ———. 2014d. “A Sense of ‘Being Human’ and Twinship Experience.” International Journal of Psychoanalytic Self Psychology 9 (4): 265–81. ———. 2016. “From Traumatized Individuality to Being Human with Others.” Paper presented at 39th Annual IAPSP Conference, Boston, October. ———. 2017. “Being Thrown into the World without Informed Consent.” Psychoanalysis, Self and Context 12 (1): 20–34. Togashi, Koichi, and Doris Brothers. 2015. “Trauma Research and Self Psychology: How 9/11 Survivors Integrate the Irrationality of Wide-Scale Trauma.” Paper presented for the 38th Annual IAPSP Conference, Los Angeles, October 17. Togashi, Koichi, and Amanda Kottler. 2012. “The Many Faces of Twinship: From the Psychology of the Self to the Psychology of Being Human.” International Journal of Psychoanalytic Self Psychology 7 (3): 331–51. ———. 2015. Kohut’s Twinship across Cultures: The Psychology of Being Human. London and New York: Routledge. Weisel-Barth, Joyce. 2015. “An Ethical Vision: Response to Drozek’s ‘The Dignity in Multiplicity.’” Psychoanalytic Dialogues 25: 463–71.

28 Relational Psychoanalysis and Trauma The Significance of Witnessing and Containing Adrienne Harris

From many perspectives, trauma creates an odd and enigmatic sense that

something has happened and yet, also, something has disappeared. There is a residue, a remnant, and a radioactive aftermath of something horrible and yet blanked out (Gampel 1998). I start with a quotation from Sam Gerson: “Absence, rather than being a trauma that is transmitted from the past, might be better thought of as a trauma of not being able to forge connections across time and between past, present and future” (Gerson 2009, 201). Very often, and in ways that lead to confusion and uncertainty in the traumatized person and their attendants, the very crucial question, the status of the traumatic event in reality, is put in doubt. This is complex. In a certain sense, everyone implicated in some way in an apparently traumatic event wants to undercut, to fudge, to disavow, to airbrush out something that is also, in the same moment, palpable and reliably present. It is perhaps ironic, certainly perplexing, that the enigmatic status of the traumatic event is its most hideous, insidious, and inevitable characteristic. This problem is inscribed in the history and evolution of psychoanalysis. Freud was ambivalent about the question of the reality of trauma. Ferenczi consistently held to the importance of the reality of trauma as an external event, whatever its internal consequence (Ferenczi [1911] 1952, 1929, [1931] 1955, [1932] 1988). He paid a terrible price. Bonomi, in two volumes (Bonomi 2015, 2018), has pursued and focused on an analysis of the Freud/Ferenczi struggles around trauma and its vicissitudes. His work also undertakes a close reading of Freud’s struggle to distance himself from an attention to explicit evidence of sexual trauma and a retreat (partially a retreat from his engagement with Fliess) from the seduction theory. Bonomi’s reading of Freud’s analysis of, and his flight from, the 333

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dream of Irma’s injection, and from the botched surgery and treatment of Emma Eckstein, attest to Freud’s anxieties about the implications of a trauma theory in relation to sexuality and hysteria. Bonomi’s demanding insight is to notice and consider Freud’s anxious identifications with at least some of these hysterical patients. We might say that in the conflicts between Freud and Ferenczi, and in Freud’s own deep internal conflicts, we encounter the first moment of what will be called and become a relational theory of trauma, a focus on the reality of external events and on the complicated patterns of identification and disavowal and intersubjective transactions (conscious and unconscious) that are the ubiquitous outcome of traumatic events. To address or interrogate the relational approach to trauma entails historical reconstruction. Theoretical innovation entails movements that are almost always forward and backward. Relational psychoanalysis arises formally with the publication of Greenberg and Mitchell’s (1983) consideration of different models of object relations and is pursued in a series of publications by Stephen Mitchell and others from the mid-1980s to his untimely death in 2000 (Harris and Mitchell 2004; Mitchell 1988, 1993, 1997, 2000a, 2000b, [1981] 2002; Mitchell and Aron 1999a, 1999b). These writings set the outlines of a relational perspective: a focus on intersubjectivity, on a two-person model of mind and treatment, and a firm commitment to the reality of trauma. Mitchell and Greenberg begin by crafting a landscape for psychoanalysis in which a one-person, as opposed to a two-person, system of psychological metapsychology is delineated. These authors grouped object-relations theories of different provenances (Klein, Winnicott, neo-Freudian) in opposition to more single-valenced drive theories. In this division, we have the beginnings of a focus on the force of the external world upon the intrapsychic and the individual. Later developments have focused on the unfolding of gender and sexuality, a critique of heteronormativity (Benjamin1988, 2004; Corbett 1993, 2009; Dimen 1999; Harris 2009; Saketopoulou 2014) and a careful reconsideration of the unconscious (Cooper 2000, 2010; Corbett 2014; Gerson 2009). It is this attention to the external, to that which will be introjected, that allows for a new interest in trauma and its effect on character. But a small r relational approach to trauma predates this work in the 1980s. Retrospectively, one can find a relational model of trauma lurking in Winnicott, in Andre Green, in Fairbairn, in Loewald, and above all in Ferenczi and Reich. Trauma and the centrality of the intersubjective was also prominent in the Latin American field theorists who established a midcentury psychoanalytic world in Latin America (Baranger 2009; Baranger and Baranger 2006; Bleger 1967).



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SANDOR FERENCZI Trauma and traumatic effects on character arise early and systematically in the work of Sandor Ferenczi (Aron and Harris 1994; Harris and Kuchuck 2016). The theoretical basis for thinking about the power of external effects on mind and body are present as early as Ferenczi’s important essay on introjection (1911), intended to balance the concerns for the defensive uses of projection. This essay—a masterpiece from Freud’s point of view—sets the stage for a consideration of the power of real events on psychic experience. During the First World War, Ferenczi, too old for direct military service and qualified in psychiatry, served in a hospital near Budapest. He wrote about war neuroses in a sensitive and thoughtful essay in 1917 (Ferenczi 1928; Harris 2016). His work in that essay offers direct clinical evidence of the powerful disabling of psychic, affective, and motoric functioning in the aftermath of war shock. His essay is full of quiet, almost shocked observation. The wards of the small psychiatric hospital he was stationed in are filled with men caught, paralyzed, and frozen at the moment of horror and danger. Ferenczi begins in mystery and then finds an empathic link to the power of the external invasion of damage and danger and its destruction of mind and psyche. Intriguingly, we know that while stationed in this hospital Ferenczi began to take notes and read for a book he was imagining and undertaking on sexuality. The book, eventually Thalassa, is an extraordinary celebration of eros in its most intricate and subtle and multiply configuring forms. Clinging to life and the intense potential of the life instinct in a setting devoted to the management of broken men, broken by the horror of that war, perhaps it was reparative for Ferenczi to work on sexuality and femininity. Surely, the particular quality of shell shock in World War I and the pervasiveness of serious trauma among combatants must have been one of the key experiences underwriting Ferenczi’s insistence on the relation of trauma to external and environmental events. Later, in the Confusion of Tongues paper (Ferenczi 1932), contested by Freud in a difficult and painful last exchange with Ferenczi and suppressed from publication for decades, the explicit role of externally originating trauma—in the form of what he termed childhood rape—took center stage. In that article, two ideas emerge toward the understanding of trauma, particularly in the relational canon. First, he writes about identification with the aggressor, giving a rich phenomenological account of the experience of sexual molestation and noting that to escape the unbearable affects, including shame and terror, the traumatized person introjects and identifies with aspects of the perpetrators. We might see in those passages that Ferenczi is beginning to outline the process of intergenerational transmission of trauma, as he

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considers that the abusing adult’s guilt as well as anger, anxiety, and desire are all passed to the child in a process that robs the child of any ability to distinguish inside from outside, self from other. The trauma of abuse begins before an assault on the body and psyche of the child and a perpetrating of confusions about identity, responsibility, and boundaries. We might also see in Ferenczi’s account, a preliminary understanding of how abused persons become perpetrators. Secondly, in that essay, Ferenczi speaks of the crucial element of “witnessing” in being able to work through the experience of sexual assault. In this essay, Ferenczi notes the more usual fate of sexual trauma in childhood, namely the assault itself followed by denial or erasure of the perpetrator’s attack. Ferenczi makes clear that the silencing of a traumatized person constitutes one of its most lethal effects. Witnessing has gone on to be a central preoccupation of relational work, appearing most pronouncedly in Sam Gerson’s seminal paper, “When the Third Is Dead” (2009). In this paper, he draws from literature and documentation from the Holocaust to argue that when an individual or a collective fails to witness a trauma, the victims of such trauma are left in a hopeless and dangerous state. BROMBERG AND DISSOCIATION A modern account of trauma and its effects is developed in the work of Philip Bromberg (1998, 2006), an interpersonal psychoanalyst who was powerfully influenced by Chistopher Bollas as well as Stephen Mitchell. Bromberg saw dissociation as a powerful and inevitable move, from subtle to massively violent shifts in self-state that arose in the face of events, including, though not limited to, relational trauma. One of the most interesting observations he makes is to note that, particularly but not exclusively in childhood, a person may have to sacrifice his/her mind’s integrity to maintain connection to a dangerous or frightening other. Attachment may well win out over safety, but at great cost, as the person gives up the integrating functions of thought and affect in order to keep some tie in the relational world. Slade (2014) and others focus on this aspect of attachment trauma: the plight of the person whose source of safety is profoundly dangerous. Bowlby, one sees, was working on the dangers of loss and separation from the early 1960s. Bromberg’s ideas rest on a model of shifting self states, a more horizontal model of mind and its splits and fissures. He has been interested in many variations on the degrees and intensities of dissociation. What makes this work so crucial for an understanding of trauma is his exquisite sensitivity to



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the danger of intolerable affect, pain, and fear, and experiences where psychic and sometimes physical survival is at stake. Bromberg is very precisely differentiating what he is addressing from other models of repression. He is attending to the sometimes subtle and sometimes dramatic alterations in presence and “going on being,” a phrase much used by Winnicott, and subjectivity. Splits can be almost undetected, and they can leave massive holes and chasms in functioning. Something goes on; something disappears. Bromberg’s (1998, 2006) ideas about dissociation rest on both a twoperson model of intersubjective transactions and on a model of mind characterized by vertical rather than horizontal splits. These concepts in a series of publications have been enormously generative of the ideas of many trauma theorists: Howell and Itzkowitz (2016), Davies and Frawley (1994), and others. Dissociation ranges across many degrees of freedom. It can make much living and past experience simply inaccessible. It can create characters of emptiness and alienation and characters whose broken minds and bodies compromise daily living and relationships in deep and fundamental ways. ATTACHMENT TRAUMA For many clinicians, attachment trauma and dissociation are deeply and irrevocably interwoven. A common reaction to trauma is a freeze, a rupture in the usual patterns of physical, cognitive, and affective life. What the attachment theorists have spent many decades now detailing is the powerful reorganizations that occur when the primary figure, supposed to be the “secure base” for the emerging child, is either absent, dangerous, anxious, depressed, or all of the above. Attachment trauma is above all rooted in the work of John Bowlby (1988) and in the research and clinical offshoots in England and in the United States that took up his basic model. Trauma arising in the intricate and subtle and very early relatedness between infant and primary caregiver shapes many capacities and possibilities for life. Bowlby was the first to inaugurate such a powerful early role of archaic experience and relational scenes of mother and infant. This took him into government work and into the role of advising government agencies, doctors, and families regarding the evacuation of children from war zones and the more general practice of care of children in hospital. What Bowlby’s insights and determination set in motion in psychoanalysis and clinical psychology was a very fine-grained attention to the intricacies of the early interactions. Variables of soma, affect, sensation, and preverbal communication all came under the careful scrutiny of researchers and clinicians. Kinds of attachment—secure, insecure, or disorganized—could be

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tracked in later patterns of engagement and symptomatology. Although never accepted and welcomed into the psychoanalytic infrastructure, Bowlby’s work, and the research and clinical insight it generated, can be said to have revolutionized many current understandings of relational trauma. INTERGENERATIONAL TRANSMISSION OF TRAUMA The work of tracing intergenerational effects of trauma has been important to the relational tradition, but it also appears in the work of psychoanalysts who do not identify as relational. This illustrates a very familiar element in relational theorizing. This tradition is often integrative, braiding features from other perspectives, always mindful of the potency of the external world, the real relations, the reality across generations, the power of historical and social forces to traumatize the individual, child or adult. Here the interactions move vertically and horizontally. Faimberg (2004) notes that the powers of disavowed narcissistic identifications that have become alienated in the experience of one generation are projected into the next. Abraham and Torok (1984) and Apprey (2006, 2015) pay particular attention to the odd characteristics of the intergenerational messages, often passed and received unknowingly to both sender and receiver. The unconscious elements in these transmissions are particularly salient in the periods of early attachment (Salberg 2014). With the renewed interest in and English translation of Jean Laplanche’s (1989) work, one sees the care of certain writers (Scarfone 2015; Widlocher 2003) in differentiating infantile sexuality and child sexual abuse. This spectrum is crucial to consider and will include transmissions that are normally not abusive, however, but simply excessive. This is an area that requires sensitivity and tact to parse out the inevitable arrival of sexuality from forms and processes embodied in the other, that is, from outside. It is an alien form, from another or others and these forces have a role in the constituting of subjectivity and unconscious experience. There is now a wide array of theorists who stress the intergenerational transmission of traumatic effects. While not all of these figures self-describe as relational or interpersonal theorists, all are addressing the transfer from a parent figure to a child of some material that is often quite disguised and obscure in its provenance or its meanings. Faimberg termed this process the “telescoping of generations,” and she saw this as the disavowal and evacuation of alienated identifications from parent into child. This is certainly relational (with a small r), as it is a process that assumes an interactional model in which unconscious projections impose on the next generation materials and identifications that remain out of awareness for both generations. Abraham



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and Torok (1984) stress the enigmatic aspects of these transmissions. Messages expressed across the generations remain enigmatic to both sender and receiver, a situation that makes therapeutic recovery very difficult. Apprey (2006, 2015) captures this in his notion of the “pluperfect errand,” an experience where a mission is sent from one generation to the next that is simultaneously necessary and impossible. A patient in middle age has fears of the street and of being out alone, even in the daytime yet is initially remarkably incurious about them. With a task involved or someone to meet, the problem dissolves, but as an aspect of solitary life, the fear is both embarrassing and confusing. For a long time this fear was untethered to any developmental experience and only reluctantly tied to parental messages. Even more split off were the motives and history of these parental messages. Their origin in periods of extreme danger in the parent’s childhood remained opaque and protected for a long time. When these links were finally tolerable for the patient, and the deeply painful early history of the parent was clearly visible, another intriguing structure revealed itself. This parent could never be abandoned, although remaining with the parent entailed living out the intolerable amounts of anxiety. And, in a way that Apprey would have been interested in, this requirement outlasted the parent. Long after the parent’s death, the terrified child—both in memory and in the remembered history across both generations—required sustained attachment, an impossible task across history and death. For me, one crucial figure to consider in this regard is J. Henry Rey (1998), who describes a particular trope in many analytic and therapeutic projects. The patient carries a hidden project: the wish and intention is not to change himself/herself but to have the analyst fix and repair the damaged and dying internal objects of the patient. The damaged other needed to be fixed before the patient could change—another impossible task, a melancholic and omnipotent solution. WAR TRAUMA We can trace the relational interest in war trauma to Ferenczi. In an exploration of Ferenczi’s explicit work on war trauma (Harris 2016), I found a deeply observant clinical account of hospitalized soldiers’ acute paralyses and frozen states. In the essay, Ferenczi walks the reader through the ward of the hospital he is working in and begins to build a case for the depth of trauma induced by that war. Whatever force Ferenczi’s own history exerted on his work and theorizing of sexual abuse trauma, it is clear from this essay in 1917 that the war had a deep effect on Ferenczi’s understanding of trauma.

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What is often shattering to realize is that the insights born from combat or treatment of war trauma during a conflict disappear remarkably quickly in the aftermath of war. Davoine, Gaudilliere, and Fairfield (2004) track the appearance and disappearance of a focus on trauma in psychiatric literature. In the 1940s, 1948 to be exact, several years after the war but into the Cold War, the U.S. Army commissioned John Huston, the Hollywood director, to make a film about trauma-disabled veterans of World War II. That film, Let There Be Light, made at an army hospital on Long Island and cut back from very extensive footage shot by Huston, was described by a journalist who had seen it in a preview as “one of the greatest anti-war films ever.” At that point, it was withdrawn by the Army and remained out of circulation for over forty years. The film featured soldiers on sodium pentothal and under hypnosis recalling terrifying moments in battle, following which they broke down. Today the film looks rather mild in its depiction of trauma, but at the time, in a public world committed to the “good war” from which all returned safely whole, it was deemed too frightening to be seen in public. Not until the Vietnam and post-Vietnam era did the relational and prerelational psychoanalytic world take up war trauma. A very under-read figure Chaim Shatan (a colleague of relational pioneer Emmanuel Ghent) did powerful theoretical and clinical work, arguing that military training favored a psychotic relation to reality and a desperate reliance on stringently heteronormative visions of masculinity (Shatan 1989). In the post-Vietnam era, Boulanger (2002) produced his work on veterans with PTSD (a term brought into its modern meaning by Shatan). Along with a number of others, Boulanger tracks the public silence around war trauma and the subsequent alienation. Davoine et al. (2004) have argued that it takes half a century to process a traumatic event like war. Yet it is hard not to see that part of that lengthy process includes long periods of denial. SECONDARY TRAUMATIZATION AND VICARIOUS TRAUMATIZATION As clinicians along many orientations began to take up work with traumatized persons—whether adult onset, attachment trauma, dissociation, or some integrated form of traumatic experience—it was impossible not to notice the effect of trauma work on therapists and clinicians of various kinds. In several publications, I (Harris 2009, 2016; Harris and Sinsheimer 2008) have been involved in understanding the difficulty clinicians have in self-care. It is slowly becoming more usual to inquire into the effect of trauma work upon the psychologist or psychiatrist treating the trauma (Boulanger 2002).



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It is probably not possible to simultaneously stay deeply engaged with a traumatized patient unfolding an experience and remain in a psychically protected space. We say very little about this, although clinical stories circulate anecdotally and informally that speak to the psychic costs of trauma work. Listening to a group of law enforcement workers describe their tasks, I heard one woman describe the task of screening child pornography in order to decide whether the events being filmed and shown reached some level of criminality where the filmmakers would be indictable. With virtually no clinical experience to guide her or her staff and directors, she was surprised she could not get the images out of her head. THERAPEUTIC TOOLS Relational therapeutic techniques are very explicitly not a narrowly prescribed set of tools and moves. If we think of relational theory as a landscape or a tent, we find a variety of treatment modalities, unified perhaps only in their attention to the reality of external forces on traumatized individuals and their view of treatment as a social, interactional process. Davies and Frawley (1994), who initiated the relational attention to child sexual abuse, stressed the shifting self-states, the requirement placed on the analyst to inhabit the analytic couple process—the space of the perpetrator, the victim, the witness, and/or the failure of witnessing. A working assumption of many relational accounts of trauma keeps a focus on enactment or the repetition of aspects or simulacra of the abuse in the clinical dyad. Enactments, repetition, the reactivation of dissociated self states, all in the presence of a witnessing analyst, are the material conditions of therapeutic change and working through. A somewhat different approach appears in the work of Reis (2009) and others, who describe the process as “being-with” or “accompanying.” He and others in this perspective take witnessing as a careful and quietly reflective attunement. A very interesting instance of this appears in Gerson’s When the Third Is Dead (2009). He recounts the experience of Helen Bamberg, a young nurse present at the liberation of a concentration camp, and therefore among the first to bring help and care to the camp inmates. She describes people in various terrible states of distress and suffering and most importantly takes note that any explicit empathic joining of the suffering, any exclamations of horror, actually made things worse. People in these states of extreme suffering felt their pain and damage was shameful and contaminating. Bamberg learned to sit quietly, often as people rocked back and forth on the ground. She quietly rocked with them. This is the kind of accompaniment that Ries is proposing. In a way, perhaps evoking Levinas, the analyst or treating person

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is responsible for the suffering of the patient, but does not colonize that person with floods of affect and already-emerged meanings. If witnessing is to be an important and useful clinical tool in trauma work, the forms of witnessing need to be attuned and delicate. Inherent in many relational projects is the attention to the power and ubiquity of the bi-personal field. From Ferenczi, we draw on the idea of unconscious-to-unconscious communication, and from many different kinds of field theory, one draws on embodiment, on representations that may not ever reach a symbolic level but are registered in the intersubjective spaces in treatments. Ferenczi is particularly known for his focus on communication that seems to bypass consciousness, imagining that people can register each other’s experience without full symbolization and awareness. Communication follows a somatic path or an affective one. Trauma work is destabilizing for the analyst, hence the interest in secondary traumatization. Entanglements and experiences at the level of soma, of subliminal states of registration and experience, are the hallmarks of working with trauma. Changing states in the analyst, anxieties and bodily manifestations—sleep states, dizziness, and altered states of consciousness—constitute the heart of the material in treating trauma. We have become more and more attentive to these dimensions of experience and intersubjective experience. Thinking of intergenerational transmission of trauma in particular, we pay attention to the kinds of affects and experiences that are difficult to describe: startles, triggers, evacuated blankness, Fairbairn’s evocative phrase “falling forever.” Relational work on trauma often operates in experiences that feel regressed, enigmatic, bizarre, even. Relational work on trauma draws on the work on intergenerational transmission from Faimberg (2004), Apprey (2006, 2015), and others, in viewing the transmissions as often unknown and unknowable to sender and receiver. Some dire communications of danger and anguish arrive from one generation to the next without any decoding instruction manual. A patient lived well into middle age with acute terrors of being on the street, of being alone on city streets, without ever connecting these states to his parent’s experience in Germany in 1937, when as an adolescent that parent faced shameful assaults and near-death experiences. No one spoke of the Holocaust in the household, ever. The piecing together of this history and its sequel passed on by the patient to his offspring, took careful, patient process in treatment. What was also revealed in this treatment process was the profound attachment the patient felt to the trapped adolescent on the streets of a German town in 1937. Time and space became unsettled. It was in a sense always 1937. Everyone in the family was trapped in this history.



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This very familiar and oft-seen feature of trauma treatments raises an interesting intergenerational project. It was the marvelous insight of Jean Henri Rey that patients often arrive in treatment on a secret mission. It is not actually to get better or to change, but rather to have the analyst heal the damaged internal objects they carry. Traumatized patients carry unmetabolized histories that are not fully their own. Recovering from trauma often requires putting to rest various half-dead figures from the patient’s histories. Trauma work might be said to be the movement from melancholy to mourning, often a most devastating process. We radically underestimate the power of history. Its effects are very often quite opaque to us. This is the daunting work of exploring and resolving intergenerational transmissions. In the past year, four new collected editions of work on trauma and history have been published (Alpert and Goren, 2017; Grand and Salberg, 2017; Laub and Hamburger, 2017; Salberg and Grand, 2017). This remarkable confluence of publications tells us of the importance of this project of recovery and bears witness to the complex role time and resilience play in outcomes. There are overlapping projects in these books: the Holocaust, genocides in a variety of circumstances and cultures, accidents of nature, the role of social surroundings, the potential for activism and engagement, and intergenerational transmissions. There are, equally strikingly, important new and unique preoccupations: the danger to the environment, the interplay of psychoanalytic work and activism, the understanding that early and often nonverbal interaction is a potent conduit for traumatic transmissions, the secret losses that resist our efforts to acknowledge and process, and the long ordeal of recovery from war trauma for veterans and civilians. Dori Laub, active in several of these publications, tracks the long history of being able to bear his mother’s testimony and the tremendous anguish of, and resistance to, hearing the testimony of survivors of concentration camps, those who were unable to find a way back to their life and family, and remained hospitalized and unacknowledged by our larger culture. REFERENCES Abraham, Nicolas, and Maria Torok. 1984. “The Lost Object—Me: Notes on Identification from within the Crypt.” Psychoanalytic Inquiry 4: 221–42. Alpert, Judith, and Elisabeth Goren, eds. 2017. Psychoanalysis, Trauma and Community. New York: Routledge. Apprey, Maurice. 2006. “Difference and the Awakening of Wounds in Intercultural Psychoanalysis.” Psychoanalytic Quarterly 75: 73–93. ———. 2015. “The Pluperfect Errand.” Free Association 77: 15–28.

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Aron, Lewis, and Adrienne Harris. 1994. The Legacy of Sandor Ferenczi. Hillsdale, NJ: The Analytic Press. Baranger, Willy. 2009. “The Dead-Alive: Object Structure in Mourning and Depressive States.” In The Work of Confluence: Listening and Interpreting in the Psychoanalytic Field. London: Karnac Books. Baranger Willy, and Madeleine Baranger. 2006. “The Analytic Situation as a Dynamic Field.” International Journal of Psychoanalysis 89: 795–826. Benjamin, J. 1988. The Bonds of Love: Psychoanalysis, Feminism, and the Problem of Domination. New York: Pantheon. ———. 2004. “Beyond Doer and Done To: An Intersubjective View of Thirdness.” Psychoanalytic Quarterly, 73: 5–46. Bleger, José. 1967. “Psycho-Analysis of the Psycho-Analytic Frame.” International Journal of Psychoanalysis 48: 511–519. Bonomi, Carlo. 2015. The Cut and the Building of Psychoanalysis, Vol. 1. London: Routledge. ———. 2018. The Cut and the Building of Psychoanalysis, Vol. 2. London: Routledge. Boulanger, Ghislaine. 2002. “Wounded by Reality: The Collapse of the Self in Adult Onset Trauma.” Contemporary Psychoanalysis 38: 45–76. Bowlby, John. 1988. A Secure Base: Parent-Child Attachment and Healthy Human Development. New York: Basic Books. Bromberg, Philip. 1998. Standing in the Spaces: Essays in Clinical Process, Trauma, and Dissociation. Hillsdale, NJ: The Analytic Press. ———. 2006. Awakening the Dreamer: Clinical Journeys. Hillsdale, NJ: The Analytic Press. Cooper, Steven. 2000. “Mutual Containment in the Analytic Situation.” Psychoanalytic Dialogues 10: 169–94. ———. 2010. A Disturbance in the Field. New York: Routledge. Corbett, Ken. 1993. “The Mystery of Homosexuality.” Psychoanalytic Psychology 10: 345–57. ———. 2009. Rethinking Masculinities. New Haven, CT: Yale University Press. ———. 2014. “The Analyst’s Private Space: Spontaneity, Ritual, Psychotherapeutic Action, and Self-Care.” Psychoanalytical Dialogues 24 (6): 637–47. Davies, Jody, and Mary Gail Frawley. 1994. Treating the Adult Survivor of Childhood Sexual Abuse: A Psychoanalytic Perspective. New York: Basic Books. Davoine, Françoise, Jean-Max Gaudillière, and Susan Fairfield. 2004. History Beyond Trauma: Whereof One Cannot Speak, Thereof One Cannot Stay Silent. New York: Other Press. Dimen, Muriel. 1999. “Between Lust and Libido.” Psychoanalytic Dialogues 9: 415–40. Faimberg, Haydee. 2004. The Telescoping of Generations. London: Karnac. Ferenczi, Sandor. 1929. “The Unwelcome Child and His Death-Instinct.” International Journal of Psychoanalysis 10: 126–27. ———. [1911] 1952. “Introjection.” In First Contributions to Psycho-analysis. London: Karnac.



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———. [1931] 1955. “The Confusion of Tongues.” In Final Contributions to the Problems and Methods of Psycho-analysis. London: Karnac. ———. [1928] 1980. “Two Types of War Neurosis.” In Further Contributions to the Theory and Practice of Psychoanalysis. New York: Brunner-Mazell. ———. [1932] 1988. The Clinical Diaries of Sándor Ferenczi. Edited by Judith Dupont, translated by Michael Balint and Nicola Z. Jackson. Cambridge, MA: Harvard University Press. Gampel, Yolanda. 1998. “Reflections on Countertransference in Psychoanalytic Work with Child Survivors of the Shoah.” Journal of American Academy of Psychoanalysis 26: 343. Gerson, Samuel. 2009. “When the Third Is Dead.” International Journal of Psychoanalysis 90: 1341–57. Grand, Sue, and Jill Salberg. 2017. Trans-Generational Trauma and the Other: Dialogues across History and Difference. New York: Routledge. Greenberg, Jay, and Stephen Mitchell. 1983. Object Relations in Psychoanalytic Theory. Cambridge, MA: Harvard University Press. Harris, Adrienne. 2009. “You Must Remember This.” Psychoanalytic Dialogues 19: 2–21. ———. 2016. “Ferenczi on War Neurosis.” In The Legacy of Sandor Ferenczi: From Ghost to Ancestor, edited by Adrienne Harris and Steven Kuchuck. New York: Routledge. Harris, Adrienne, and Steven Kuchuck. 2016. The Legacy of Sandor Ferenczi: From Ghost to Ancestor. New York: Routledge. Harris, Adrienne, and Stephen Mitchell. 2004. “What’s American about American Psychoanalysis?” Psychoanalytic Dialogues 2: 165–92. Harris, Adrienne, and Kathy Sinsheimer. 2008. “The Analyst’s Vulnerability: Preserving and Fine-Tuning Analytic Bodies.” In Bodies in Treatment, edited by Frances S. Anderson. London: Routledge. Howell, Elizabeth, and Shelley Itzkowitz. 2016. The Dissociative Mind in Psychoanalysis. New York: Taylor and Francis. Laplanche, Jean. 1989. New Foundations for Psychoanalysis. London: Blackwell. Laub, Dori, and Andreas Hamburger. 2017. Psychoanalysis and Holocaust Testimony: Unwanted Memories of Social Trauma. New York: Routledge. Mitchell, Stephen. 1988. Relational Concepts in Psychoanalysis. Cambridge, MA: Harvard University Press. ———. 1993. Hope and Dread in Psychoanalysis. New York: Basic Books. ———. 1997. Influence and Autonomy in Psychoanalysis. Hillsdale, NJ: The Analytic Press. ———. 2000a. Relationality. Hillsdale, NJ: The Analytic Press. ———. 2000b. Relationality: From Attachment to Intersubjectivity. Hillsdale, NJ: The Analytic Press. ———. [1981] 2002. “The Psychoanalytic Treatment of Homosexuality: Some Technical Considerations.” Studies in Gender and Sexuality 3: 23–59. Originally published in International Review of Psychoanalysis 8: 63–80.

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Mitchell, Stephen, and Lewis Aron, eds. 1999a. Relational Psychoanalysis. Hillsdale, NJ: The Analytic Press. ———. 1999b. Relational Psychoanalysis: The Emergence of a Tradition. Hillsdale, NJ: The Analytic Press. Reis, Bruce. 2009. “Performative and Enactive Features of Psychoanalytic Witnessing: The Transference as the Scene of Address.” International Journal of Psychoanalysis 90: 1359–72. Rey, Jean Henri. 1998. “That Which Patients Bring to Analysis.” International Journal of Psychoanalysis 69: 457–70. Saketopoulou, A. 2014. “Mourning the Natal Body: Developmental Considerations.” In Journal of the American Psychoanalytic Association 62: 773–806. Salberg, Jill. 2014. “The Texture of Traumatic Attachment; Presence, Ghostly Absence in Traumatic Transmission.” The Psychoanalytic Quarterly 84: 21–46. Salberg, Jill, and Sue Grand. 2017. Wounds of History: Repair and Resilience in the Trans-Generational Transmission of Trauma. New York: Routledge. Scarfone, Dominique. 2015. Laplanche: An Introduction. New York: The Unconscious in Translation. Shatan, Chaim. 1989. “Happiness Is a Warm Gun: Militarized Mourning and Ceremonial Vengeance.” Vietnam Generation, Men, Women and Vietnam 1 (3): 127–52. Slade, Arietta. 2014. “Imagining Fear: Attachment, Threat and Psychic Experience.” Psychoanalytic Dialogues 24: 253–66. Widlocher, Daniel, ed. 2003. Infantile Sexuality and Attachment. New York: Other Press.

29 Trauma Work via the Lens of Attachment Theory Gaslight—Reality Distortion by Familiar Attachment Figures Orit Badouk Epstein

On knowing what you are not supposed to know and feeling what you are not supposed to feel. —Bowlby (1988)

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written as a play, Gaslight is a film noir (Cukor 1944), set in Edwardian times in England, that tells the story of Paula (Ingrid Bergman), who finds the body of her murdered wealthy aunt, who had adopted her as an infant, in the house where they lived together in London. The police fail to find the murderer. Looking fragile and disoriented, the bereft and traumatized Paula is then sent to Italy to study music while being told that she must forget all that had happened. In Italy, she is courted by her piano teacher, Gregory Anton. The vulnerable Paula falls in love with him, they get married, and the couple eventually returns to her aunt’s abandoned house in London. Once settled in, Paula finds a letter, which she shows to Gregory, who clearly looks agitated by its contents, since he has a lot to hide. He then slowly begins to torment her psychologically in various subtle ways, such as dimming the gaslights in her bedroom and hiding objects and then returning them to their place. Meanwhile, he continuously tells her that she is not looking well and should lie in bed. Having clearly been left vulnerable by her traumatic early life, the confused Paula begins to doubt her own reality and her health gradually deteriorates. The rest of the film is a bit of a clunky thriller with a happy ending. Ultimately, the tables are turned and Paula says to Anton, “It isn’t here. You must have put it there. Are you suggesting that this is a knife I hold in my hand? Have you gone mad, my husband?” Despite this, it is a classic film, and its strength lies in its psychologically accurate storytelling, which was way ahead of its time. 347

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There has been a revival of the use of the term “gaslighting,” which is now used to describe controlling and denying a person’s sense of reality to the point that it becomes distorted. Gaslighting happens not only domestically but also culturally and interpersonally, as we can see in politics and the media. For example, at the Wellcome Collection museum in London, the exhibition States of Mind: Tracing the Edges of Consciousness was shown from February to October 2016. The exhibition’s main message concerned the question: Is memory always a reliable tool? We can sometimes be fooled by “false memories,” as our brain fills in gaps using prior information and experience of the world or is deceived by suggestive images. A. R. Hopwood explores our surprising vulnerability to this in his photographic installation in the show, False Memory Archive: Crudely Erased Adults. This form of distorting propaganda is meant to control people’s notions about the credibility of memory, and the idea that dissociative disorder is iatrogenically created. In his essay on Politics and the English Language (1946), George Orwell wrote, “[The English language] becomes ugly and inaccurate because our thoughts are foolish, but the slovenliness of our language makes it easier for us to have foolish thoughts.” He added, “If thought corrupts language, language can also corrupt thought.” I find this idea to be quite fitting in the term “false memory.” Traditionally, one might also equate the term “gaslighting” with men who try to possess and control women. Understanding how to treat people with mental health issues has improved greatly in recent years, yet we still hear of cases where the power dynamics between men and women remain corrupted. Unlike the happy ending of the film, some severely gaslighted women do end up being placed in mental institutions after their husbands convince the authorities that their wives are crazy. The association between women’s behavior and their being labeled crazy has a long and infamous history in many cultures. The word “hysteria,” defined as behavior exhibiting excessive or uncontrollable emotions of fear and panic, has been regularly associated with women. Until the early twentieth century—when the medical field was mostly ruled by men—female hysteria was the official medical diagnosis for a truly massive array of symptoms in women (including, but not limited to, the loss of appetite, nervousness, irritability, fluid retention, emotional excitability, outbursts of negativity, excessive sexual desire, and a tendency to cause trouble). It is so pernicious, even as we creep toward equality, that many women don’t even recognize that they are powerless victims. “Current debates about the validity and aetiology of Dissociative Identity Disorder (DID) echo early debates about hysteria and also other trauma based phenomena such as dissociative amnesia” (Brand et al. 2016). By labeling hysteria as a medical issue, men did not then have to respond to behavior that challenged



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masculine belief structures. Instead, labeling women as hysterical made it easier to diminish women’s concerns and maintain men’s control. Still, the gaslighting phenomenon is not merely misogynistic and exclusive only to men. Fundamentally, it is one’s belief that it is okay to subjugate, possess, and own another human being, and by doing so to overwrite their reality to the point of annihilation of that person’s selfhood. Ariel Leve, in her book An Abbreviated Life (2016), writes about her need for precise information, which is a legacy of her outlandish childhood. In an interview, she says, “I’m very meticulous. If I’m having a conversation with somebody and they get a fact wrong, I’m ‘No, you said that on Wednesday, not Thursday.’ It drives people nuts. But when you’ve been on the receiving end of gaslighting, a compulsion for accuracy can be a survival mechanism. . . . Gaslighting means, ‘To manipulate someone by psychological means into questioning their own sanity.’” She adds, “I was always logging events, partly to keep track of reality, having had my reality challenged so many times” (Leve, quoted in Ronson 2016). As with dissociation, there is a matter of degree as to how far the denial of one’s reality may go in leading to the point of feeling, as Leve describes it, “sequestered—alone and separate. I’d function but not participate” (Ronson 2016). We can also see an extreme case of such distortion in the chilling film Dog Tooth (Lanthimos 2009), where a father infantilizes, controls, and programs his adult family. The film begins with the family listening to a tape recorder and practicing the parent’s linguistic perception of the world in order to prevent the children from being exposed to real-world experiences. For example, the word “sea” means “armchair,” “motorway” means “strong wind,” and “pussy” means “a big light.” The film was influenced by the Josef Fritzl case in Austria. For those of us who work with survivors of extreme abuse, the brutal chasm and dissociation that families who use mind control create is evident. A child may be brainwashed by a parent’s presenting childish euphemisms for physical functions, unexplained religious beliefs, social practice, and taboos. The client I am presenting in this chapter was born into a family of organized abuse. She experienced gaslighting by her mother for most of her life and has clear memories of her mother repeatedly telling her on a daily basis: “Darling, you were always quite dramatic,” “you never had much stamina.” “You do have a tendency to exaggerate things. You were such a happy baby; I don’t know what you are talking about!” K arrived to therapy on crutches. She had just turned thirty-eight. She looked like a mixture of a child and an old woman who could barely tolerate another day of life. Yet her facial expression was opaque, with a placid smile that appeared compliant and detached. On our first meeting, she told me she

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had come across my book Ritual Abuse and Mind Control: Manipulation of Attachment Needs (Badouk Epstein, Schwartz, and Scwartz 2011), and suddenly it all made sense. Viscerally, K always felt that something terrible of the worst kind had happened to her, but when she confronted her mother by telling her, “I think I was sexually abused,” her mother, in her customary dismissive and dissociative manner would say: “You always had a vivid imagination.” On a conscious level, K remembered most of her life in a hazy and blurred manner. She was born to white, middle-class parents and was the eldest of four. Her father was a businessman who worked abroad and the family traveled around. Later, when K was four, the parents got divorced, and her mother remarried a man who, according to K, came from a very creepy and scary family. Before seeing me, K had spent ten years with a therapist, who told her that there was no evidence whatsoever to back her fantasies. During the 1980s, psychoanalysis treated real trauma as in contradiction to psychoanalysis itself. Psychoanalysis was used in the service of treatment for neuroses and their concomitant unconscious fantasies, and not for the consequences of a real event, be it from exposure to war or sexual violence, or for secondgeneration survivors of the holocaust. After World War II, John Bowlby was an avid observer of societal and individual adversity in the face of real-life events such as war, poverty, childhood neglect, and abuse. He insisted that separation and loss made real life events more difficult. No other psychoanalyst at the time was saying this. In an interview he gave in 1990 to C. Fortun (1990), he said: “In my psychoanalytic training there was an extreme pressure to turn your back on real-life events, but I never swallowed it. Dreadful!” Still, psychoanalytic theory has a lot to offer us in working with traumatized clients, in the form of concepts such as transference, countertransference, and techniques to understand and contain unconscious affects, such as unbearable anxiety, shame, and guilt. This rift was in part due to Freud’s abandonment of his trauma/affect theory in favor of the role of sexual phases, fantasies, and the concept of repression. The rift is also due to a dissociation that occurred in the psychoanalytic world of the time. The incidence and prevalence of real trauma was largely denied or ignored. Teachers of psychoanalysis at that time were very much against dissociation as a defense against real trauma. They labeled dissociation as a deviation and even defection from real theory. They claimed they had never come across a patient with multiple personalities (Nicolai 2016). It is only with the emergence of attachment research and in particular, disorganized attachment and the new school of relational psychoanalysis, that dissociation began to receive a wider attention. In addition, it has been noted that



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social, scientific and political influences have since converged to facilitate increased awareness of dissociation. These diverse influences include the resurgence of recognition of the impact of traumatic experiences, feminist documentation of the effects of incest and of violence toward women and children, continued scientific interest in the effects of combat, and the increasing adoption of psychotherapy into medicine and psychiatry. (Brand et al. 2016)

In their article “Ethical Standard: Truth and Lies” (2016) the traumatologist and researcher Bethany Brand and Linda McEwen argue that many reporters and some academics from the False Memory Society, including Debbie Nathan and Elizabeth Loftus respectively, have misconstrued research. Many cases involved child abuse, delayed memories of abuse, and sexual assault. They argue that this “witch hunt narrative” as Ross E. Cheit (2014) calls it, “has negatively impacted traumatised individuals,” in the service of: 1.  Keeping children from testifying in court based on their presumed suggestibility, even in cases with strong corroborative evidence of abuse. 2.  A view that delayed disclosure of sexual abuse, a common phenomenon with victims of child abuse, undermines the credibility of such reports. 3.  An effort to undermine the professionals, frontline workers and institutions who assist victims of child abuse (Brand and McEwen 2016). They collectively called upon the American Psychological Association (APA) to investigate the possible breach in ethics involved in Loftus resigning her APA membership after reportedly being tipped off by a key APA leader that an ethical complaint about her had been received at APA. Brand goes on to say, “It is important that the public and mental health professionals learn the degree of exaggeration and inaccuracy in some publications about child abuse cases and memories of abuse, and that we help correct these errors.” This I perceive as another form of public gaslighting. In another recent publication, Brand et al. write, One of the most frequently repeated myths is that DID is iatrogenically created. Proponents of this view argue that various influences—including suggestibility, a tendency to fantasize, therapists who use leading questions and procedures and media portrayals of DID-lead some vulnerable individuals to believe they have the disorder. Trauma researchers have repeatedly challenged this myth. Dalenberg and colleagues concluded from their review and a series of metaanalyses that little evidence supports the fantasy model of dissociation. (Brand et al. 2016)

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Adding: The correlations between trauma and dissociation were as strong in studies that used objectively verified abuse as in those relying on self-reported abuse. These findings strongly contradict the fantasy model hypothesis that DID individuals fantasize their abuse. (Brand et al. 2016)

From its inception, attachment theory has been concerned with three key issues: 1.  Proximity seeking: for reasons of survival, we need the physical closeness and protection of others. 2.  Proximity maintaining: good or bad caregivers; a child then will attach to those he is familiar with. 3.  Proximity promoting: these are the defenses that we develop when the conditions for proximity seeking and proximity maintaining are not ideal or have failed altogether. When I asked K what kind of fantasies the previous therapy was referring to, she then started sucking her thumb and in a coy voice replied, “Sexual abuse, a lot of sexual abuse.” And before I could say anything, she lay on the floor complaining of an excruciating pain in her tummy, legs, head, and teeth: “It’s unbearable, ouch my tummy, my knees, I can’t take it.” I then covered her with a blanket and just repeatedly said, “Mm . . . oh . . . oh dear . . .” In mirroring her pain back to her with this basic form of preverbal sound and communication, what Beebe and Lachmann described as “implicit processing.” These are “procedural” processes, which they “use to refer to action sequences. These include attention processes, facial and vocal emotion (such as prosody, intensity, pitch), spatial orientation toward and away from the partner, and touch. This is Bucci’s (1997) realm of the subsymbolic. Procedural memory refers to skills or action sequences that are encoded nonsymbolically, and become quasi-automatic. Through repetition, these action sequences influence organizational processes and guide behaviour” (Beebe and Lachmann 2014, 24). K looked at me perplexed, as if not having expected this response. She then slowly gathered up her body and looked more collected in her posture as she sat back on the sofa. As Schore says, “These regulatory processes are precursors of psychological attachment and its associated emotions. An essential attachment function is “to promote the synchronicity or regulation of biological and behavioural systems on an organismic level” (Reite and Capitanio 1985, 235). Indeed, psychobiological attunement, interactive resonance, and the mutual synchronization and entrainment of physiological rhythms are fundamental processes that mediate attachment bond



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formation, and attachment can be defined as the interactive regulation of biological synchronicity between organisms” (Schore 2003, 39). He goes on: Regulation theory suggests that attachment is, in essence, the right-brain regulation of biological synchronicity between organisms. . . . These data bear upon Bowlby’s assertion, 30 years ago, that attachment behaviour is organized and regulated by means of a “control system” within the central nervous system. (Schore 2003, 41; italics in original)

K told me that this was a new experience for her. She went on to tell me that she spent seven years in and out of hospitals, feeling like climbing up the walls, feeling like she was going out of her mind. No one could understand what was wrong with her. Her mother would usually call her “hysterical” and constantly underplay each situation by saying: “Oh this must be your tonsillitis, constipation, too many antibiotics, glandular fever.” When she eventually collapsed with CFS (chronic fatigue syndrome) when she was twenty-four years old, her mother would visit her in hospital and assert that it was the Lariam (antimalarial tablets) that caused the collapse. Under such deprived conditions of proximity seeking and proximity maintaining, K’s highly down-regulated attachment system had to resort to dissociation as a form of proximity promotion. In their groundbreaking book, The Haunted Self, van der Hart, Nijenhuis, and Steel quote Marilyn Van Derbur, a survivor’s, testimony: “Without realizing it, I fought to keep my two worlds separated. Without ever knowing why, I made sure, whenever possible, that nothing passed between the compartmentalisation I had created between the day child and the night child” (2006, 1). During the following four years, as we gradually created a secure base for K, without much prompting, K arrived regularly to sessions, lay on the sofa or on a floor mat, and tucked herself under a blanket holding a teddy and a hot water bottle. Then she would go into “trauma time,” where slowly during each session more reports unfolded on a shocking scale about human atrocities visited on a young child. Attuning to K meant just going with the flow, listening and not saying very much. In Daniel Stern’s words: All the rich analogically nuanced, social and affective interactions that take place in the first 18 months of life occur, by default, in the implicit non-verbal domain. Also all the considerable knowledge that the baby acquires about what to expect from people, how to deal with them falls into this nonverbal domain. Nature was wise to not introduce babies to symbolic language until after 18 months so they would have enough time to learn how the human world really works without the distraction and complication of words—but with the help of the music of language. (Stern 2004, 113)

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This knowledge has made us sensitive, as Stern says, to the implicit domain, even when it is interwoven with the explicit world of language. I tended therefore to follow the implicit tunes that played in each session, gently streaming out into the space between us, while the horrors of her unbelievably depraved past slowly unfolded. So far, it appears that K has a most complicated system of dozens of internal parts, some of which are most collaborative and eager to share and recover their haunted nightmares and memories and some that are reluctant and hold in her words, “the wall which prevents more secrets from coming forward.” I consider Fogel’s (2002) concept of “participatory memory” to be most helpful in the understanding of traumatic memories. Participatory memories are lived reenactments of personally significant experiences that have not yet become organized into a verbal conceptual narrative. Participatory memories are conscious experiences in the present that are not about a past experience, meaning that the past experience is not represented as an image or concept divorced from emotional significance. Rather participatory memories are emotionally experienced as being with or reliving of past experiences (Braten 1998; Fogel 1993, 2001; Heshusius 1994). When experiencing a participatory memory, one is not thinking about the past. One is directly involved in a past experience as if were occurring in the present.” (Fogel 2002, 209–10, italics in original)

The study of attachment suggests that dissociation during personality development is primarily a failure in the integration into a unitary and meaningful structure of memories concerning attachment interactions with a particular caregiver. In addition, many EP (emotional parts) related to childhood abuse and neglect have insecure patterns of attachment that alternate with, or intrude upon, the attachment pattern of ANP (apparently normal personality), creating conflicting relational patterns, known as disorganized/disoriented attachment (e.g., Liotti, 1999a, 1999b; Main and Solomon 1986). This idea is compatible with Pierre Janet’s view, as dissociation originally referred to the division of the personality, which van der Hart et al. further developed as structural dissociation. “Structural dissociation involves hindrance or breakdown of a natural progression toward integration of psychobiological systems of the personality that have been described as discrete behavioral states” (Putnam 1997, 7). They note that “structural dissociation is a particular organization in which different psychobiological subsystems of the personality are unduly rigid and closed to each other. These features lead to lack of coherence and coordination within the survivor’s personality as a whole” (van der Hart et al. 2006, viii). Bowlby (1980) called dissociative parts “segregated systems of behaviour, thoughts, feelings and memory,” which occur in cases



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of pathologically unresolved grief. Van der Hart et al. described the division of the personality as divided to ANP and EP. “While ANPs typically function at a higher level than EPs, they sometimes may be overwhelmed by the intrusions of the EPs” (van der Hart et al. 2006, 16). Sexual assault, other forms of violence, and their psychological aftermath, cascade through the decades in different ways for every survivor. Each survivor with dissociative identity disorder (DID) that I have worked with comes with different manifestations that need to be attended to. Some survivors are co-conscious; some are affect phobic; some have clear memories of cult abuse; and some report their trauma through nightmares, flash backs, and bodily symptoms. In the case of K, what seems to be most unique to our work together is the countertransference. As each session progresses, the reporters in her system tell their horror stories of little K being regularly drugged, electric shocked, water boarded, raped, and endlessly experimented on. During these sessions, I find myself almost dozing off, and I can barely hold my eyelids open. It is as if we are both sedated into some trance state, as if someone inside her is making sure that her terror remains sealed by amnesiac barriers. Of this powerful trance-like countertransference Lowenstein (1991) writes: It is impossible to discuss fully here the impact of the Multiple Personality Disorder (MPD) patient on the clinician. The clinical field created by these patients may be quite intense. The interviewer may experience some of the auto hypnotic and dissociative experiences manifested by the patient, such as feeling depersonalized, “spaced out,” floating, confused, day-dreamy, sleepy, blocked in, forgetful or amnesiac during the interview. If these affects are noted and cannot be wholly accounted for on the basic of the clinician’s own difficulties (such as illness, being over tired, other problems), they may be indicators of a dissociative process in the patient. (Lowenstein 1991)

Later Lowenstein also wrote One complex MPD patient began to describe intense dissociative spells in which she would “float away” both in sessions and at other times. She related these events to abuse involving deliberate induction of intense hypnotic states and those who abused her. At other times, as she worked on abuse-related material, she would become uncontrollably sleepy. It eventually became a standing joke between us that episodes of my feeling sleepy, spacy or preoccupied in her sessions (or even on the phone) almost invariably were empathically in tune with her own experience. She said: “You didn’t know that dissociation is contagious.” At other times countertransferential sleepiness may be a response to covert conflict between different states: emergence and/or attempts by the patient to suppress painful material or unacceptable feelings in the transference. The

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therapist senses that his or her absent, blocked or slowed down affects which may also be an empathic response to similar processes in the patient. (Lowenstein 1993, 67–68)

The terror of speaking out is crippling for K. Often after revealing secrets of shocking torture and abuse, suicidal ideation, or more accurately the suicidal parts in their plea for protection, turn up and forcefully take over for a while until their attachment screams can be heard. K’s other parts will also insist that they are blocked by a huge concrete wall. For the first year, there was barely much affect going on between K and her system and between K and me. For most of the session, K would talk, and she reported feeling detached, in her words, “like a robot soldier.” She also has a sex slave part that occasionally acts out and has sex online with strangers. Irena Vogt, a therapist and survivor of mind control of the Stasi in East Germany, has written about similar encounters with her clients and with herself: Within the past ten years I have encountered quite a number of clients with life stories which include torture with electric shocks, infusions, hypnosis, sexual and other forms of physical abuse, in order to manipulate the subjects for political purposes when they were small children. In the light of these histories I cannot deny the reality of such experiments conducted by the Stasi. The incentive for the Stasi to do this, I am convinced, were reasons of competition with capitalist countries. The GDR was very keen to triumph over capitalism, and they worked hard on this in many realms—why not in the realm of scientific mind control as well? After all, the capitalist US was researching this with the MK-Ultra program at the same time! (Vogt 2013, 291)

K seems regularly to suffer from identity confusion, whereby she claims she cannot make decisions since she does not know who she is, and identity alteration, where different parts take control of her actions. Once K leaves the session, I then often sink into a deep sleep. After a half an hour nap, I then try to take notes, but to no avail. I can barely remember a thing she has told me. At this stage, it is still a struggle for me and K to have a shared mind, where her trauma of non-recognition (Bromberg, personal communication, 2016) can be fully comprehended and shared in an associated way between us. We have developed a way that has helped both me and K’s “reporters” to be more present and less sleepy in the room. I sit next to K and hold her hand with one hand, while with my other hand I take detailed notes. I have written a chapter in the book Talking Bodies on the different types of touch: Grounding or orienting touch: this form of touch is intended to help clients reduce anxiety or dissociation. By employing a touch to the arm or hand, it usually involves helping a client to be aware of his or her physical body. It can



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also be done by helping a client touch some fabric or by leading them to touch their own bodies, for example encouraging them to stroke their arm. (Badouk Epstein, Schwartz, and Schwartz, 2011, 113)

This has helped tremendously in keeping us grounded in the present, helping us create a cohesive narrative for what would be considered otherwise fantastical and unbelievable, and more importantly, to stay connected. The use of an empathic language that validates the client’s lack of recognition is also much needed in this process. In Bromberg’s words: “The analyst’s use of conflict language widens the dissociative gap both interpersonally and within self-state organisation of the patient” (Bromberg 2011, 76). He adds, “It is important therefore for us to use a non-conflict language which is empathic and non-shaming to the client who is already shame-ridden and may feel it’s simply too much for him or her to hold the shame experiences and represent it cognitively” (Bromberg 2011, 77). Slowly, as K’s body got stronger (she no longer uses crutches) and after different parts reported to us what took place in her early life, a coherent narrative has taken shape, and by now it seems like K has three different systems all running alongside each other, all of which get activated at different times of the day, week, or month: 1.  Attachment Bond: parts who report about her parent’s involvement in particular her mother’s involvement in the betrayal. 2.  Mind Control: according to K, these often take part on the left side of the head where different parts report on army based programming and torture. 3.  Ritual Abuse: this K describes as being subjected to rituals within the stepfamily, particularly triggered on Fridays, full moon, solstice dates, Christmas, Easter, and other anniversaries. For K, recognizing the term “gaslighting” has not only helped validate her reality and get her closer to her EPs (emotional parts), but has also enabled her to lift the veil of secrecy around her mother’s involvement in the abuse and to get in touch with grief about this horrific betrayal. In Janet’s words: “Realization implies the degree to which closure of an experience is achieved” (Janet 1935). Or, as van der Hart et al. have put it: “Both ANP and EPs lack full realization of the present, are unable to live fully in the present. They also lack complete realization of their traumatization, that it is over, and often have been unable to realize a multitude of other experiences, leaving much unfinished business” (van der Hart et al. 2006, 12). Attachment-based psychotherapy also means going through the painful stages of K’s failed grief, accepting the daunting reality of her past and the extent of her attachment betrayal. In her book Blind to Betrayal, Jennifer

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Freyed—the daughter of the people who started the False Memory Society (FMS) movement—writes: What should you do when the person perpetrating a betrayal is also a person you are dependent on? This is the core bind of a trauma victim. The standard response to betrayal—confrontation or withdrawal—might only make the situation worse for the person who depends on the perpetrator because confrontation and withdrawal are generally not good for inspiring attachment and care giving. In this case, the victim might be better off remaining unaware of the betrayal in order to protect the relationship. Indeed, this is what leads to betrayal blindness. (Frayed and Birrel 2013, 55)

Bowlby (1980) used the word “deactivation” to describe one of the psychological defenses against disorganization in the face of attachment loss. This deactivation involves the exclusion of all affect and thought that “might activate attachment behavior and feeling.” For K, facing the realization of her attachment betrayal and loss, she claims, is more painful than any of the abuse that took place. It is not only mourning of a childhood she never had, but more so, as each day passes, the facing up to the relentless shame and loss of a self that had been hijacked by her gaslighting mother. The depravity of her family has made her get in touch with the most shaming of internal working models: not feeling worthy, feeling like NO-Body. During such sessions K sometimes finds solace in the Mr. Men series, in particular Mr. Nobody, who is a comfort for her during this agonizing process. Dissociation for K and other survivors seems to conceal the painful aspect of shame, which is why they work in concrete ways to regulate affect. Lifting the veil of dissociation leads to a watershed of various strong affects, interspersed with shameful deflations. A victim-blaming culture tends to see the person who continues to live with a traumatically narcissistic partner or parent as passive and colluding; but they are fearful and shamed. Abusers systematically isolate victims from their community, where their reality is distorted and they cannot make healthy decisions. We now know that shame is one of the main factors in dissociative processes that may make many people come across as if they are living in denial, that they are colluding and behaving as passive bystanders. In his book The Shadow of the Tsunami Philip Bromberg writes, “To the degree the patient’s shame is indeed dissociated in the here and now, the analyst is highly unlikely to notice it, especially when he is attending mainly to the patient’s words. Thus, when working in areas where the reliving of trauma is taking place, the manifest absence of shame is a cue to search for its whereabouts” (Bromberg 2011, 23). He later writes:



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The longing is a “not-me” ghost that haunts her [the patient] because her own desire to communicate it to her therapist from her internal place of “illegitimacy” becomes a source of shame in itself. Thus, her sense of shame is compounded: The first source of shame comes from her belief that what she feels will not be real to the other. The second source of shame derives from her fear that she will lose the other’s attachment (and thus her core sense of self) because she believes that the therapist will not attribute validity to her desperation that he knows what she is feeling. This fear of attachment loss makes her even more desperate for evidence that the other has not indeed withdrawn his attachment, and the more evidence she seeks the greater is the shame she feels for seeking solace that is somehow tinged as illegitimate. (Bromberg 2011, 43–44)

For the dissociative client, for reason of safety, mainly, the shame of not feeling real is more pertinent than any other form of feelings, and this is what the client has had to dissociate from. This we know is due to the fact that for many people the abuse began at birth, and in some cases even in the womb. “[Daniel] Stern argues that processes of Affect Attunement are so powerful because they contribute to attachment security and the capacity for intimacy” (Beebe and Lachmann 2014, 28). “The present moment is the meeting ground between the past and the present” (Stern 2004, 197). I consider that K’s attachment system, when she suffered betrayal from her primary caregiver—her mother—is the one that deserves the most attention, in order that she may develop healthy relationships within herself and others. Once the process of what Lyons-Ruth terms “to know and be known” (Lyons-Ruth 1998, 1999) began, once her adult self-state, or what van der Hart et al. see as structural dissociation ANP (apparently normal personality) and some of her EPs (emotional parts), the young parts in particular began to feel more understood and regulated in therapy so that she had developed what Ainsworth calls having a reliable secure base, then K seemed less invested in proximity maintaining. She was then able to sever all contact with her birth family and other acquaintances from the past whom she suspects were involved in the abuse in one way or another. As with all individuals who come to therapy with a history of insecure attachment, the work with survivors of extreme abuse is similar, but clearly more demanding. Yet it can bear good fruit, in particular whenever we think creatively outside the constraints of traditional boundaries. While doctors give medication to their patients, expanding the boundaries of a secure base would mean using various methods of creative communications, such as drawings, sand trays, playing with gadgets, using scents, and giving the client transitional objects. These extras are mostly rewarding to the process, and tend not only to stabilize and ground the hyperarousal of a terrorized child’s self-state, but also to deepen the connection between therapist and client. For

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example, reading the old-time classic The Velveteen Rabbit by Margery Williams (1922) almost always seems to do the trick: “What is REAL?” asked the Rabbit one day, when they were lying side by side near the nursery fender. . . . “Real isn’t how you are made,” said the Skin Horse. “It’s a thing that happens to you. When a child loves you for a long, long time not just to play with, but REALLY loves you, then you become Real. . . . “It doesn’t happen all at once. . . . It takes a long time. Generally, by the time you are REAL, most of your hair has been loved off, and your eyes drop out and you get loose in the joints and very shabby. But these things don’t matter at all, because once you are REAL you can’t be ugly, except to people who don’t understand.”

My appreciation for the film Gaslight therefore is not only because of its advanced psychological thinking, but also for its contributions to the English lexicon, its cognitive resonance, and psycho-educational properties. Emotional literacy is a way of being, not just knowing or doing, that helps individuals differentiate, and enables people better to reach their feeling selves. When we finally find a word that accurately matches our experiences, whether internally or externally, something inside us shifts, since we feel we are being understood, and by way of doing so, we not only expand our awareness but better understand our rights as human beings. Trauma theory and the relational movement have greatly contributed to the shift in witnessing the client’s narrative. “Witnessing is an inherently relational process (Pizer 1998),” Schwartz says. It is impossible to treat survivors of severe childhood trauma and remain morally neutral. . . . Neutrality for clinicians is erroneous when it comes to child abuse, torture, child soldiering, and organized violence against innocents and can be considered a variety of denial (Simpson, 1996). . . . Simpson states: “No doctor feels bound to be neutral toward cancer. Why should we treat torture, the cancer of freedom any differently? (1996, 209). (Schwartz 2015, 162–63)

Harvey Schwartz goes on to assert that “all therapists treating trauma survivors with severe and complex needs should be well versed in the history of torture and perpetrations worldwide, so that they have a broad context within which to hold and contain the patient’s traumatic narratives” (Schwartz 2015, 164). Also, he continues, Both Ellen Lacter (2011) and Alison Miller (2012) question the potential pitfalls of therapist abdication under the guise of neutrality, for instance, by telling patients that whatever they conclude to be true “is entirely up to them.” Therapists



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should let patients know they are prepared to hear and believe whatever the patient tells them but that independence of thought and response are necessary preconditions for dialogue. (Schwartz 2015, 164)

Slowly and gently, as I empathically witness K’s bodily and mental pain, I understand that therapy for K is her secure base and source of safety. After four and a half years of twice-weekly therapy, K’s body is regaining its strength, and she has started taking rock-climbing lessons in her local gym. This, as well as her growing reflective functioning, in time, will help her differentiate her tendency to be frightened and confused and will hopefully protect her from ever being gaslighted in this horrific manner again. CONCLUSION The 1940s film Gaslight is a classic thriller and its strength lies in being a psychologically accurate storytelling ahead of its time. Recently, the term “gaslight” has come alive. Since emotional abuse and distortions of one’s reality has never received proper public recognition, the revival of the word and its modern interpretation is highly relevant to our work with clients who have been abused, in particular, clients with a poor sense of agency and those who have survived horrendous mind control, torture, and group abuse. From the personal to the societal, this chapter is about the various degrees of gaslighting, in particular with a client with DID (dissociative identity disorder) whose life has been marked by continuous and insidious emotional torment, and how the work and insight of attachment theory and a relational approach eventually helps the client shift her distorted internal working models and sense of selfhood. REFERENCES Badouk Epstein, Orit, Joseph Schwartz, and Rachel Schwartz. 2011. Ritual Abuse and-Mind Control. London: Karnac. Beebe, Beatrice, and Frank Lachmann. 2014. The Origins of Attachment. New York: Routledge. Bowlby, John. 1980. Attachment and Loss. London: Hogarth Press. ———. 1988. “On Knowing What You Are Not Supposed to Know and Feeling What You Are Not Supposed to Feel.” In A Secure Base: Clinical Applications of Attachment Theory, 99. London: Brunner-Routledge. Brand, Bethany, and Linda McEwen. 2016. “Ethical Standards, Truth, and Lies.” Journal of Trauma and Dissociation 17 (3): 259–66.

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Brand, Bethany, Vedat Sar, Pam Stavropoulos, Christa Krüger, Marilyn Korzekwa, Alfonso Martínez-Taboas et al. 2016. “Separating Fact from Fiction: An Empirical Examination of Six Myths About DID.” Harvard Review of Psychiatry 24 (4): 257–70. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959824/. Braten, S. 1998. “Infant Learning by Altercentric Participation: The Reverse of Ego Centric Observation in Autism.” In Intersubjective Communication and Emotion in Early Ontogeny, 105–24. New York: Cambridge University Press. Bromberg, Philip. 2011. The Shadow of the Tsunami. London: Routledge. Bucci, Wilma. 1997. Psychoanalysis and Cognitive Science: A Multiple Code Theory. New York: The Guilford Press. Cheit, Ross. 2014. The Witch-Hunt Narrative: Politics, Psychology and the Sexual Abuse of Children. New York: Oxford University Press. Cukor, George, dir. 1944. Gaslight. Los Angeles: Warner Home Video, 2006, DVD. Fogel, Alan. 1993. Developing Through Relationships. Chicago: University of Chicago Press. ———. 2001. Infancy: Infant, Family and Society. Fourth edition. Belmont, CA: Wadsworth. ———. 2002. “Remembering Infancy: Accessing our Earlier Experiences.” In Theories of Infant Development, edited by Gavin Bremener and Alan Slater. Cambridge: Blackwell. Fortun, C. 1990. “Psychoanalytic Champion of ‘Real Life Experience’: An Interview with J. Bowlby.” Melanie Klein and Object Relations 9 (December): 70–86. Frayed, Jennifer, and Pamela Birrel. 2013. Blind to Betrayal: Why We Fool Ourselves We Aren’t Being Fooled. Hoboken, NJ: Wiley and Sons. Heshusius, L. 1994. “Freeing Ourselves from Objectivity: Managing Subjectivity or Turning Toward a Participatory Mode of Consciousness?” Educational Researcher 23 (3): 15–22. Janet, Pierre. 1935. Les débats de l’intelligence. Paris: E. Flammarion. Lanthimos, Yorgos, dir. 2009. Dogtooth. Film. Athens, Greece: Boo Productions. Leve, Ariel. 2016. An Abbreviated Life: A Memoir. New York: HarperCollins. Liotti, G. 1999a. “Disorganization of Attachment as a Model for Understanding Dissociative Psychopathology.” In Attachment Disorganization, edited by Judith Solomon and Carol C. George, 297–317. New York: Guilford. ———. 1999b. “Understanding the Dissociative Process: The Contribution of Attachment Theory.” Psychoanalytic Inquiry 19: 757–83. Lowenstein, Richard. 1991. “An Office Mental Status Examination for Complex Chronic Dissociative Symptoms and Multiple Personality Disorder.” Psychiatric Clinic of North America 14 (3): 567–604. ———. 1993. “Posttraumatic and Dissociative Aspects of Transference and Countertransference in the Treatment of Multiple Personality Disorder.” In Clinical Perspective on Multiple Personality Disorder, edited by R. J. Kluft and C. G. Fine, 51–58. Washington, DC: American Psychiatric Association Press. Lyons-Ruth, K. 1998. “Implicit Relational Knowing: Its Role in Development and Psychoanalytic Treatment.” Infant Mental Health Journal 19: 282–91. ———. 1999. “The Two-Person Unconscious.” Psychoanalytic Inquiry 19: 576–617.



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Main, M., and J. Solomon. 1986. “Discovery of a New, Insecure-Disorganized/Disoriented Attachment Pattern.” In Affective Development in Infancy, edited by T. B. Brazelton and M. W. Yogman, 95–124. Norwood, NJ: Ablex. Nicolai, Nelleke. 2016. “Book Review of The Dissociative Mind in Psychoanalysis by Elizabeth Howell and Sheldon Itzkowitz.” ESTD Newsletter, June. Orwell, George. 1946. Politics and the English Language. London: Horizon. Pizer, John. 1998. Ego-Alter Ego. Chapel Hill: University of North Carolina Press. Putnam, Frank. 1997. Dissociation in Children and Adolescents. New York: Guilford Press. Reite, M. F., and J. P. Capitanio. 1985. “On the Nature of Social Separation and Attachment.” In The Psychobiology of Attachment and Separation, edited by M. Reite and T. Fields, 223–55. Orlando, FL: Academic Press. Ronson, Jon. 2016. “Ariel Leve: I Was the Parent and My Mother Was the Child.” Guardian, July 2. Schore, A. N. 2003. Affect Regulation and the Repair of Self. New York: Norton Books. Schwartz, Harvey. 2015. The Alchemy of Wolves and Sheep: A Relational Approach to Internalized Perpetration in Complex Trauma Survivors. London: Routledge. Simpson, M. A. 1996. “What Went Wrong? Diagnostic and Ethical Problems in Dealing with the Effects of Torture and Repression in South Africa.” In Beyond Trauma: Cultural and Societal Dynamics, edited by R. J. Kleber, C. R. Figlely, and B. P. R. Gersons, 187–212. New York: Plenum Press. Stern, Daniel. 2004. The Present Moment in Psychotherapy and Everyday Life. New York: W.W. Norton. van der Hart, Onno, Ellert R. S. Nijenhuis, and Kathy Steele. 2006. The Haunted Self. New York: Norton Books. Vogt, Irena. 2013. “Mind Control in the German Democratic Republic.” Attachment—New Direction in Psychoanalysis 7 (3): 287–97. Williams, Margery. 1922. The Velveteen Rabbit. London: Octopus Books.

VI ARTS THERAPIES

Chapters on music therapy by Jacqueline Robarts and play and drama therapy by Sue Jennings explain and illustrate the therapeutic effects of their trauma treatments.

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30 Embodied Mentalizing or “Meaning-Making” in Music Therapy with Traumatized Children Jacqueline Z. Robarts

Music is therapeutic because it attunes to the essential efforts that the mind makes to regulate the body, both in its inner processes and in its purposeful engagements with the objects of the world, and with other people. —Trevarthen 1999, 8

Since ancient times music has been recognized as having healing properties (Gouk 2000). Found in every culture music appears to be inborn in us; its universals and individuality of human expression forge the foundations of our first relating and of our social interaction throughout the life span (Blacking 1973; Daniel and Trevarthen 2017; Malloch 1999–2000; Stern 1985; Trevarthen 1999). Music therapy is an interdisciplinary profession, informed by a range of theoretical influences and therapeutic approaches, variously determined by client population, setting, ethos, therapists’ clinical experiences, and musicianship (Ansdell and Pavlicevic 2004; Baker and Wigram 2005; Bunt and Stige 2014; Darnley-Smith and Patey 2003; Edwards 2016; Nordoff and Robbins [1977] 2007; Odell-Miller 2014; Wigram and De Backer 1999a, 1999b). MUSIC THERAPY AND TRAUMATIZED PEOPLE Working with traumatized people is a major area of music therapy, both in individual and group therapy, using a range of approaches and techniques, across all age groups, client populations, and cultures (Amir, 2004, 2010; Austin 2008; Bruscia 1998; Loewy and Stewart 2004; Robarts 2003, 2009; Sutton 2002; Sutton and De Backer 2009, 2014). The profession of music 367

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therapy developed from working with traumatized people—veterans from World War II (Davis, Gfeller, and Thaut 2008)—and continues to be part of treatment programs helping those traumatized by mass conflict and violence (Bensimon, Amir, and Wolf 2008, 2012). The therapeutic role of music is also reported in the lives of people who have survived the Holocaust and its transgenerational impact (Fisher and Gilboa 2016). This chapter describes individual music therapy with particular reference to children with histories of early relational trauma and developmental posttraumatic stress disorder (PTSD). I describe music therapy from an integrated musical, developmental, and psychodynamic perspective, which I developed through three decades of clinical work, supervision, and independent study. It explores the clinically oriented use of music in music improvisation to form a therapeutic relationship from implicit to explicit levels of experiencing, where a core sense of self and capacity to mean are forged (Robarts 2003). When that self has been devastated or thwarted by early relational trauma, or not yet formed in any cohesive way, then a therapy is needed that attends finely, moment to moment, to the child’s experiences of being, sensing, taking in (i.e., introjecting), and emotionally self-regulating. Such fine attunement needs care, as it engages bodily and mental reexperiencing of self, which may trigger flashbacks and other symptoms of PTSD. Improvisational techniques in music therapy can work toward regulating emotions as they arise, including those of PTSD, while offering new experiences of self and other. In this way, the foundations of self may be helped to constellate and repair themselves, or be constructed for the first time (Robarts 2009, with reference to Siegel [1999] 2012; van der Kolk 2003). Music has many properties as a highly adaptable, resourceful medium to reach and support children who are “closed down,” “hard to reach,” and often presenting at varying developmental levels within and across therapy sessions (Birnbaum 2013; Cobbett 2007; Felsenstein 2014; Kim 2016; Robarts 1998, 2006, 2009, 2014; Strehlow 2009a, 2009b). The music therapist is trained to “perceive” or “read” the dynamic forms of the evolving sounded and unsounded phenomena arising “within” and “between” therapist and client (Pavlicevic 1997; Robarts 1998). If music is used with sensitivity and clinical perception, then fundamental self-experiences at the level of sensory, emotional, and motor actions can be regulated, organized—not as a “task,” but as part of evolving play and interplay, even if initially fragmented and hard to “read.” “Meaning-making” in therapy with traumatized children is the art of bringing fragments of intra- or interpersonal connectedness together in such a way as to be tolerable, if only momentarily, before they fall apart again. Such is the nature of working with people who carry trauma at the core of their being: dissociation and avoidance, falling



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apart, coming together, and falling apart again is part of the nature of this work, where overwhelming anxieties make thoughts unthinkable and feelings unfeelable. Music therapy is also the art of bringing new experiences of self and other, of expanding horizons and emotional landscapes, drawing known and unknown potential and the uniqueness of each child into play. EARLY RELATIONAL TRAUMA AND EMBODIED MENTALIZING IN MUSIC THERAPY When a child has experienced repeated relational trauma in early life, the child’s core experiences of being and relating are deeply, neurobiologically compromised. Trauma in early childhood disrupts the developing body-mind self, the basic sense of trust, especially when the abuse is perpetrated by a primary caregiver and is not an isolated event but persists over months and even years. The child may survive by coping mechanisms, such as dissociative states of mind, or “mindlessness.” The neurobiology of early relational trauma shows disorganized/disoriented attachment patterns, impairments of the regulatory system in the brain, and neurobiologically based dissociative defenses (Herman [1997] 2015; Perry 2006; Schore 2001a, 2001b; van der Kolk 2003). Neurobiological pathways that otherwise would have grown naturally in intersubjectivity are disrupted. Working with such children, the music therapist needs to use music carefully so that any heightened awareness of self and self-in-relation-to-another neither re-traumatizes the child, nor denies the reality of their experiences. The music therapist also needs to provide traumatized and abused children with a trustworthy sense of firm boundaries of self and other, physically, temporally, and spatially. In this way, new pathways of meaning in relationships and the capacity for healthy mentalizing can be built alongside a capacity for normal childhood experiences of play and fun. This can be a complex and heartrending therapeutic endeavor. Traumatized children are often unable to sustain coherence and continuity of self-awareness, being, and relating, the integrated and embodied experience of “going-on-being” (Winnicott 1971). They cannot sustain a feeling-thinking self in the course of exploration and discovery in play nor have any coherent self/self-other experiences in a sustained way that is basic to psychological well-being and growth. As child psychoanalytic psychotherapist Anne Alvarez points out: Where there is a real difficulty or deficit in making links, rather than an attack on a previously established link, the therapist may need to attend to certain temporal and dynamic features of the link which can enable sequentiality, ordinality, and twoness to be bearable and pleasurable. (Alvarez 1998, 213)

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In this regard, music therapy may support varied experiences of interaction, experiences flowing in a natural dynamic “to and fro,” carefully calibrated in ways that can be internalized, bypassing or modifying defense mechanisms (Robarts 2009). My years of working with children and adults who have a fragile foundation to their sense of self have helped my understanding of music as therapy. This understanding accumulates in a flow of experience and reflection, from practice into theory and from theory into practice. The music therapy process works with vital, “felt” experiences. Music can be used in ways that not only adjust in a split-second, but also provide a firm framework for building new pathways of relationship and self-experience in a practical ongoing process of enactment through movement and gesture that is sounded and re-sounded. It is those levels of self-experience that early trauma impacts so devastatingly at the core of self in intersubjectivity (Trevarthen 1993), where procedural levels of relating or “implicit relational knowing” (Lyons-Ruth 1998; Siegel 2012; Stern 2007) forge our fundamental experiencing of self and other. In cases of early relational trauma, these processes that are part of secure, healthy attachment go awry, put tragically off course invariably with long-lasting developmental-psychological consequences. Music’s properties regulate and engage people at sensorymotor-emotional levels and contain, transform, and develop mentalizing and symbolizing toward expressions of a coherent self. For traumatized people, Siegel (2003) highlights the importance of interpersonal sharing beyond words alone to facilitate integrative processes within the “holding environment” of a therapeutic relationship: The interpersonal sharing of the internal experience in words alone may not be the core curative feature within therapy. Such sharing may require a range of representational modalities, divided at the most basic level between the nonverbal and the verbal. (Siegel 2003, 29)

In work with “closed-down” or “hard-to-reach” children who do not make any sound or who find the experience too exposing or unpredictable, the therapeutic relationship or “alliance” may not begin with music, or even any form of sound making or play; rather, it is often a process of searching and gradually bringing the child into a state of play. Winnicott asserted that this process can come only from desultory formless functioning, or perhaps from rudimentary playing, as if in a neutral zone. It is only here, in this unintegrated state of the personality that that which we describe as creative can appear. This if reflected back, but only if reflected back, becomes part of the organized individual personality, and eventually this in summation makes the individual to be, to be



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found; and eventually enables himself or herself to postulate the existence of the self. (Winnicott 1971, 75)

In this endeavor, the music therapist’s silent yet attuned listening and attending—or, conversely, “switching off” attention that may be experienced as persecutory by the child—may offer a “potential space” or “intermediate area” for the emergence of play in the transformative sense Winnicott (1971) conceptualized, while maintaining a kind of suspended awareness, a listening in the present moment, without memory (from the past) or desire (anticipation for the future), as Bion (1962, 1967) suggests. In atypical development, particularly where there is early trauma, music therapy can offer a potentially constructive and transformative medium, shaping or reshaping intersubjective psychic structure. In the therapeutic relationship, this field of mutual influence affords the potential for “state transformation” (Beebe et al. 2000; Fosha 2000). The “tonal and rhythmic field of sympathetic resonance” (Robarts 2003, 2009) uses music’s intrinsic properties to impact “state transformation” through sensing and listening, as well as shaping and being responsive to aesthetic elements that arise both in overt and transferential phenomena of the therapeutic interaction. From this perspective, music therapy may be described as architectonic: the weaving of a tapestry, or, more appositely, an evolving composition of human feeling, spirit, inner and outer music, silence, time, and space. Many of the principles and processes of music therapy with children are applicable also in work with adult clients with traumatic early histories where there is a need to work at the very foundations of the self—the sensory, visceral, primordial self that is felt and that lies beyond words (Amir 2004; Austin 2008; Robarts 2006, 2009, 2014; Sutton 2002). Music therapy can offer an emotionally attuning and regulating medium as a catalyst to help build or rebuild normal social, developmental, and psychological growth. CLINICAL-THEORETICAL ORIENTATION AND INTERDISCIPLINARY INFLUENCES My clinical-theoretical orientation has developed over three decades of working as a music therapist. During that time, I worked in a large children’s hospital—in child development and child and adolescent mental health services—as well as in both mainstream and special schools, and a leading UK music therapy charity, the Nordoff Robbins Music Therapy Centre in London, where I also saw adults with mental health conditions. I developed an integrative creative music therapy approach from my clinical experiences, linking musical relational phenomena with perspectives from infant developmental

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psychology and object relations theory, my main influences being Trevarthen (1993, 1999), Stern (1977, 1985, 1995, 2007), Bion (1962, 1967), Winnicott (1971, 1990), and Alvarez (1992). Working in musical transference (see Bruscia 1998; Robarts 1994; Streeter 1999; Turry 1998) and understanding how to work at the metaphorical level in play, including the modalities of music, poetry, improvised song, and songwriting, was a further expansion of my approach to verbal and preverbal children and adolescents, many of whom did not play music spontaneously and were defensive/avoidant in their social interactions. They needed a range of ways to express themselves and share their feelings and internal worlds, ways of working and relating that could help lower or bypass defenses in other modalities that could lead into or combine with musical experience. Drawing, making things, and music form a natural part of children’s expression and play, no less in the music therapy room (Birnbaum 2013; Bruscia 2014; Cobbett 2007; Robarts 2014; Sekeles 2006). Young people who have had frightening experiences or are undergoing many changes in their lives often feel exposed and self-conscious when making sounds, or they need receptive, quiet ways of engaging in therapy, with a more tangible boundary and feeling of self-agency and control. For example, a piece of paper and colored pens can offer a safer starting point for some traumatized children than the immediacy of music or talking, or indeed, an empty silence. I now offer professional advanced training courses in working in music therapy with symbolic play, mixed media, and psychodynamic/ developmental approaches. However, early on in my career, there was no existing research to help me understand and work with all that was presenting in my therapy room. I was fortunate in being supervised by a leading child psychoanalytic psychotherapist and theoretician with a developmental approach and musical sensitivity. I was also guided in my reading of developmental psychology literature on intersubjectivity and attachment, which enabled me to make cogent links between these disciplines and music therapy, especially helpful with defensive/avoidant children with complex needs. My recorded clinical audio or video material (an intrinsic part of clinical music therapy practice where permitted and where not intrusive) provided a real-time, experiencenear basis for clinical and theoretical discussion, alongside any other arts materials generated in the music therapy sessions. This deepened my understanding not only of child development, but also of the meta-realms of human expression and relating and the development of mind and meaning. Nordoff and Robbins’s “Creative Music Therapy” (Nordoff and Robbins [1977] 2007) is an improvisational approach where the therapeutic relationship is developed through musical communication, interaction, and play. This approach also has a psychodynamic understanding implied in the concept of “resistive-



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ness,” which Nordoff and Robbins viewed as being a form of communication from the child and a corollary to “participation” (Nordoff and Robbins [1977] 2007, 373). In understanding the more complex nature(s) not only of defense but ego deficit, I found useful the developmentally informed psychoanalytic thinking of Anne Alvarez and her “theory of reclamation,” which illuminated the more primitive and subtle forms of communication that predominated both in play and in the transference, especially in defensive, “closed-down” and “undrawn” children (Alvarez 1992, 2012). The interdisciplinary confluence of developmental psychology, psychotherapy, and affective neuroscience, particularly in the field of early relational trauma and posttraumatic stress disorder (Schore 2001a, 2001b, 2003; Siegel [1999] 2012; van der Kolk 2003), has also informed my work. Interdisciplinary understanding of the essential functions of our inborn musicality has been led by infancy research documenting through microanalytic studies in the latter half of the twentieth century. Daniel Stern (1977) explained early emotional communication using musical terms to describe his concepts of “vitality affects” and “affect attunement” (Stern 1985)—later termed “forms of vitality” (Stern 2010)—that served to organize and regulate the self and self-in-relation-to-another in the development of a core sense of self, building meaning in relationships. Colwyn Trevarthen (1993, 1999) has also described the regulatory function of music and musicality underpinning human communication: “The essence of spontaneous musical expression is that it directly engages and activates the core of rhythmic and sympathetic impulses from which all human communication comes” (Trevarthen et al. 1998, 172). However, in working with traumatized, and indeed other clients, such as those with autism, that “core of rhythmic and sympathetic impulses” is no longer freely expressed, but possibly frozen or dissociated from, the child unable to take in experiences easily, or only in modified form. From the discipline of child psychoanalytic psychotherapy, Anne Alvarez (1998) suggests that, where there are significant deficits in a child’s capacity to make links (drawing from Bion’s theory of thinking), there is a need for the therapist to attend to dynamic and temporal forms in which experience is forged—essentially musical phenomena—to assist linking and thinking. As a music therapist, I have found distinct resonances between certain aspects of psychotherapy and music therapy, but I also recognize where our work diverges by its nature and training. At the root of both is the skill of listening, and noting the ways in which clients hear and take in experiences. The embodiment of feelings and expansion of meaning can be induced by the music in the words, just as words in music also play their vital part. Alvarez, in particular, has drawn attention to the use of tone of voice and inflection of phrase and has noted the musical or prosodic forms in which words

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become communicative, as well as interpretative, according to the level of the child’s growth and receptivity—words with accompanying attention, carefully crafted and timed, sensing the space and duration of phrase, and where the emphasis should best fall (Alvarez, 1992, 2012). I am stating this here because it is sometimes assumed that words are in opposition to music, or superfluous—this is not so, and both have their place in human expression and in qualities of listening. In her original concept of the “sound-object,” Maiello (2001, 2004) describes the beginnings of mind through the generating of shared meaning in relationships where “protoforms of an experience of relatedness may develop . . . at the auditory level.” She proposes that the rhythmical qualities of this “sound-object” may lie at the core of the infant’s developing basic trust. It is a concept particularly relevant to the field of early trauma, and it can help music therapists think about the ways in which music therapy may serve to help repair foundations of being and being-with. I have explored many of these ideas in my publications and presentations, illustrated by case studies. INNATE COMMUNICATIVE MUSICALITY Music therapy is based on the premise that human beings are innately musical, in the sense that music is intrinsic to our human functioning. We are tonal beings and rhythmic beings: there is tone in our voices whether laughing, crying, or speaking; there is rhythm in our bodily movements, gestures, breathing, and vocal expressions. Musical features are part of our human expression and identity. Music ethnologist John Blacking describes music as being deeply rooted within our feelings: “Its patterns are too often generated by surprising outbursts of unconscious celebration for it to be subject to arbitrary rules, like rules of games. . . . Many, if not all, of music’s essential processes can be found in the constitution of the human body and its patterns of interaction of human bodies in society” (Blacking 1973, x–xi). The temporal nature of musical experience is embodied, “lived” experience, as philosopher Susanne Langer describes: The elements of music are moving forms of sound; but in their motion nothing is removed. The realm in which tonal entities move is a realm of pure duration. . . . Musical duration is an image of what might be termed “lived” or “experienced” time—the passage of life that we feel as expectations become “now,” and “now” turns into unalterable fact. Such passage is measurable only in terms of sensibilities, tensions and emotions; and it has not merely a different measure, but an altogether different structure from practical or scientific time.” (Langer 1953, 109)



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Music therapy draws on this innate musicality, so robustly rooted within us that it survives despite neurological, sensory, and psychological trauma (Bunt and Stige 2014; Darnley-Smith and Patey 2003; Nordoff and Robbins [1977] 2007; Pavlicevic 1997;Wigram 2003; Wigram and De Backer 1999a). The range of music and musical expression across many genres and cultures provides rich “emotional landscapes” for use in music therapy transcending specific cultural applications (Nordoff and Robbins [1977] 2007; Robarts 2009; Sutton 2002). In music therapy, the properties of music and the artistry, clinical perception, and sensitivity of the musician-therapist may provide a containing-transformative-relational narrative in sound and in silence, as well as in words, and in metaphors of song, play, and other art forms (Baker and Wigram 2005; Birnbaum 2013; Edwards 2016; Hadley 2003; Robarts 2003, 2014), grounded in the use of clinical improvisation within a therapeutic relationship (Bruscia 2014; Nordoff and Robbins [1977] 2007; Pavlicevic 1997; Wigram 2003). Music literally moves us, while regulating our impulses at their emotional core. Music can both engage and contain our feelings. Music’s properties can be used to bring about emotional change and growth when used not merely as a receptive, passive experience, but in spontaneously developing play between people—a form of interpersonal communication that enlivens the preverbal area of experience where meaning is generated. Because of this it has enormous potential to galvanize consciousness of being an alive, sentient human being. Furthermore, music can activate and heighten this consciousness to a greater or lesser extent, even when considerable damage has been done to our neural-bodily-emotional-mental organisms that we call a “self.” Jaak Panksepp’s concept of SELF—an acronym for Self Ego-type Life Form—infers this model or schema of self that is fed by the sensory-perceptual system (Panksepp 1998). It is to the deepest part of the brain that we must refer, to embrace the areas that music reaches and from which it arises in us (Thaut 2005; Thaut and Hoemberg 2016). EMOTIONAL REGULATION Emotional regulation is often the first stage of the creation of meaning or mentalizing at an implicit relational level—akin to the “evoked response,” a term coined by Nordoff and Robbins ([1977] 2007)—whereby the child can reciprocate at an unconscious level and internalize/assimilate shared experiences, often bypassing cognitive or dissociative defenses. Emotional regulation may be effected by as little as the use of one tone pulsed gently, slowly or in double-time, or a two-note motif. A more direct shaping of shared experience can involve specific techniques to assist responsiveness, such as the use

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of an upbeat phrase or “anacrusis”—akin to Stern’s 1995 “temporal feeling shape” (Robarts 1998)—to invite, engage and help a child experience selfregulation in simple interaction, with anticipation for the next (possibly curtailed or elongated) anacrusis in sequence. Music therapists acquire a range of subtle and sophisticated musical techniques as they develop their skills. Paradoxically, emotional regulation can take place without any sound at all: through non-action, silence (Sutton 2006, 2007) and “active silences” (Nordoff and Robbins [1977] 2007). The music therapist’s intuition needs to be supported by careful listening, “reading” of the evolving clinical situation, both in its musical dynamic forms of the child’s expression, and in the context of the therapeutic relationship (De Backer and Sutton, 2014; Holck, 2004a, 2004b; Nordoff and Robbins [1997] 2007; Pavlicevic 1997). This dynamic relational process involves a body-feeling-mind experience across the dimensions of time and space. The German poet Heinrich Heine takes us some way to comprehending the existential dimensions, as well as paradoxes, that reside in music: Music is a strange thing . . . it stands half-way between thought and phenomenon, between spirit and matter, a sort of nebulous mediator, like and unlike each of the things it mediates—spirit that requires manifestation in time, and matter than can do without space. (Heine 1832)

This “nebulous mediator” is now being more roundly understood by interdisciplinary thinking on the complex yet elegant ways in which we embody music, just as it embodies us. Forms of Vitality, Attunement, and Meaning-Making in Communicative Musicality

The creation of meaning arises in interpersonal relations from the beginning of life, and its dynamic features are essentially musical. Meaning—as a verb and only then a noun—begins in the preverbal domain, the realm of “implicit relational knowing” (Stern 1995). The research of Stern, Beatrice Beebe, and Trevarthen, among others, contributed to raising awareness of temporality, timbre, tone, rhythm, and other aspects of musical form in emotional regulation and the organizing of the emergent sense of self. Infancy research has shown the sophistication of our inborn musicality from the beginnings of life. This field of enquiry has demonstrated that it is the musical features of emotional attunement that co-regulate our early emotional and psychological growth and continue throughout our life span (Stern 1977, 1985; Trevarthen 1993, 1999). It is these aesthetic, highly organized, and regulating experiences of self and self in relation to another that lie at



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the foundations of meaning-making and the development of mind (Fonagy et al. 2004; Schore 2001a, 2001b). The earliest emotional communication assumes autopoietic forms, and it is these forms that are directly involved in creating shared meaning in relationships (Trevarthen 1999). Trevarthen and Malloch’s research on communicative musicality showed not only duration, but also timing and intensity, to be basic parameters of musical expression and experience in early attachment or intersubjectivity (Malloch 1999–2000; Trevarthen and Malloch 2000). Musical receptivity and musical expression both emanate from felt experiences of the body-mind that we call “self,” “I,” or “me”-ness. In this way, musical expression is closely linked with a sense of identity (MacDonald, Hargreaves, and Miell 2009). At this visceral level, something of our essential being communicates directly through voice and movement, through involuntary fluctuations of emotional impulses. By its nature, music cannot articulate what words can—it reaches far beyond words to inexpressible, yet nonetheless felt, lived human experiences. Yet there are some overlaps between music therapy and psychotherapy in terms of the aesthetic listening to and feeling/thinking about the content and dynamics of the therapeutic relationship: its silences and transferential phenomena, where the therapist is in touch with the rhythms, tones, silences, and improvisational nature of the motifs, themes, and phrasing of the therapeutic encounter (Knoblauch 2000). From a psychodynamic and developmental perspective, music affords an experience of “going-on-being” (Winnicott 1971), in contrast with the falling forever, disintegrative catastrophe that characterizes the traumatized self, unable to feel “held” in time and space, with no sense of basic trust or safety. MUSICAL INSTRUMENTS AS EXTENSIONS OF OUR SENSE OF SELF AND SELF-EXPRESSION Music and musical instruments offer sensory experiences as events in the flow of time that may help a person make first connections with that “organized sense of self,” described by Daniel Stern as self-agency, selfaffectivity, self-cohesion, self-history. Stern observed that any one of the four senses of self were notably absent in psychosis (Stern 1985), and this is equally applicable to traumatized people with PTSD and dissociative disorders. Winnicott (1971) highlighted the “actual objects,” stating, now famously: “When a patient cannot play the therapist must attend to this major symptom before interpreting fragments of behaviour.” Touching and playing musical instruments in co-improvisation generates sensory self-experiences within the client’s own control, helping the unknown to become known in the

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simplest cause-and-effect yet dynamic ways, keeping the experience predictable yet fresh, with the slightest of variations in harmony or inversions of melodic motif (for example). Certain instruments may be used in symbolic play (for example, building a castle or a train), or clients may have particular associations or transferences (positive and negative) to certain instruments. The music therapist may provide a background accompaniment providing atmosphere to clients’ play (often expressing in music the transferential, unspoken feelings, rather like a film score), or equally the client or the therapist may reflect or introduce new ideas, musically or verbally. In this process, the regulating, organizing functions of music on the emotions become evident. For example, we naturally join the beat of the music (whether playing with the backbeat or syncopating the beat). It is quite hard, though all the more exciting, to experience oneself playing in different meters or contrapuntally with another person or persons, as, for example, in performing Steve Reich’s music. Equally, it is rare for two people to sing in a different key or style from one another. Rather, we are naturally drawn to the same fundamental: sooner or later, we will find ourselves on the same wavelength again. This is another manifestation of the “tonal-rhythmic field of sympathetic resonance” referred to earlier as the basis of empathy, not only in music and music therapy, but in everyday life as well: falling into step with, or being in harmony or in tune with another person or persons. Furthermore, if we consider the human brain as “a storehouse of emotionally toned, nonverbal, perceptual-motor memory structures, whose components are tightly integrated in associative ‘webs’ or ‘networks’” (Dissanayake 1992), then we can appreciate music as a direct link to that storehouse, and to another person’s patterns of empathy. In children who have suffered early relational trauma, this basic empathy, the emotional flow of connectedness between and within ourselves, is something that has to be reformed, or in the most severe cases, developed for the first time. For all the above to take place, a music therapy room is required: ideally, a well-contained and dedicated space, soundproofed, yet with a good acoustic (not too dry or too resonant), neither too large nor too small, without distracting wall decorations or extraneous equipment (Robarts 1998). A music therapy room needs to be equipped with a keyboard or piano, shelves and cupboards to house a good range of musical instruments, tuned and simple percussion (large and small, commercial and ethnic), suitable for different client populations in terms of chronological age and developmental age(s) that may present in the sessions; a mat or carpet, suitable seating (not a stack of chairs); above all, the room must meet health and safety regulations, as well as be inviting and accessible (Goditsch, Storz, and Stegemann 2017).



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MAPPING THE TERRITORY OF EMBODIED “MENTALIZING” IN MUSIC THERAPY Initially, I used the term “poietic processes,” derived from the Greek verb poiein and then “symbolization” (Robarts 2003, 2006, 2009) to denote the creation of meaning and the concomitant emergence of an organized sense of self. After much reflection and further study, I found that the theories of “mentalizing” as defined by Fonagy and associates (Allen and Fonagy 2006; Fonagy et al. 2004) in regard to music therapy (Hannibal 2014; Strehlow 2009a, 2009b; Strehlow and Piegler 2007) encompass the interplay of clinical phenomena at the core of self as embodied mentalizing: that of affect regulation; Stern’s sense of self (Stern, 1985) and forms of vitality (Stern 2010); Bion’s (1962) theory of thinking; and, in particular, his concept of alpha function and beta elements (Bion, 1967). As stated above, this and the work of Alvarez (1992, 1998, 2012) comprise the interdisciplinary thinking that informs my work. This composite map highlights some key layers of clinical phenomena that arise in music therapy. It is not a recipe or formula; the map is not the territory. Since every therapeutic journey is unique, and since every child and therapist form a unique relationship, the therapist needs always to be open and receptive to the child and the evolving relationship. This means being able to both witness and live in the experience without becoming consumed by it or overidentified in the transference to the detriment of helping the child. In the rich tapestry of music therapeutic processes with a wide range of children and adults, this map is intended to show the dynamic, multilayered continuum of phenomena, sensing the implicit and explicit levels of expression, however unconsciously or consciously or intentionally expressed; different developmental and musical forms of presentation; and much more besides—exploring and reflecting on these within the case material of many different children and adolescents. Figure 30.1 shows a bidirectional open channel of different aspects of embodied mentalizing and symbolizing processes from preverbal to verbal musical-emotional fields, indicating some phenomena of musical-aesthetic form in therapy (further described in figure 30.2). Preverbal levels continue to function within the verbal; verbal levels may need musical help to become rooted in the preverbal in order to reengage with the child’s spontaneity and authenticity. Levels of musical-emotional communication span three main fields: Field 1, the tonal-rhythmic field of sympathetic resonance; Field 2, emerging motives, shapes and patterns of musical-emotional communication; Field 3, autobiographical narratives arising from Fields 1 and 2.

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Figure 30.1.   Mentalizing or meaning-making in music therapy. Source: Robarts 2003, 141–82.

Figure 30.3 shows the dynamics of transference, affect regulation, and internalization in music therapy, following a model of Bion’s theory of thinking and the concept of the “container-contained” (Bion 1962). All the constructs of the phenomena of figures 30.1 and 30.2 are implicated within those of figure 30.3, showing some of the salient interweaving layers of music therapeutic clinical practice that may help embodied mentalizing and psychological integration in all client populations, but with special relevance for those whose foundations of self have been damaged by early relational trauma.

Figure 30.2.   Creative potential of music for embodied mentalizing or music making. Source: Robarts 2003, 141–82.

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Figure 30.3.   Embodied mentalizing or meaning-making in music therapy. Source: Robarts 2003, 2009.

NOTE I am grateful to Barcelona Publishers for their kind permission to include here figures 30.1, 30.2, and 30.3 updated from those first published in Jacqueline Z. Robarts, “The Healing Function of Improvised Songs with a Child Survivor of Early Trauma and Sexual Abuse,” in Psychodynamic Music Therapy: Case Studies, ed. Susan Hadley (Gilsum, NH: Barcelona Publishers, 2003), 141–82.

REFERENCES Allen, Jon G., and Peter Fonagy. 2006. Handbook of Mentalization-Based Treatment. Chichester, UK: John Wiley & Sons. Alvarez, Anne. 1992. Live Company: Psychoanalytic Psychotherapy with Autistic, Borderline, Deprived and Abused Children. London: Routledge. ———. 1998. “Failures to Link: Attacks or Defects? Some Questions Concerning the Thinkability of Oedipal and Pre-Oedipal Thoughts.” Journal of Child Psychotherapy 24 (2): 213–31. ———. 2012. The Thinking Heart: Three Levels of Psychoanalytic Therapy with Disturbed Children. London: Routledge. Amir, Dorit. 2004. “Giving Trauma a Voice: The Role of Improvisational Music Therapy in Exposing, Dealing with and Healing a Traumatic Experience of Sexual Abuse.” Music Therapy Perspectives 22 (2): 96–103. ———. 2010. “‘My Music Is Me’: Musical Presentation as a Way of Forming and Sharing Identity in Music Therapy Groups.” Nordic Journal of Music Therapy 21 (2): 176–93. Ansdell, Gary, and Mercédès Pavlicevic. 2004. Community Music Therapy. London: Jessica Kingsley.



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Austin, Diane. 2008. The Theory and Practice of Vocal Psychotherapy: Songs of the Self. London: Jessica Kingsley. Baker, Felicity, and Tony Wigram, eds. 2005. Songwriting: Methods Techniques and Clinical Applications for Music Therapy Clinicians, Educators and Students. London: Jessica Kingsley. Beebe, Beatrice, Joseph Jaffe, Stanley Feldstein, Cynthia L. Crown, and Michael D. Jasnow. 2000. Rhythms of Dialogue in Infancy: Coordinated Timing in Development. Boston, MA: Wiley-Blackwell. Bensimon, Moshe, Dorit Amir, and Yuval Wolf. 2008. “Drumming through Trauma: Music Therapy with Post-traumatic Soldiers.” The Arts in Psychotherapy 35 (1): 34–48. ———. 2012. “A Pendulum between Trauma and Life: Group Music Therapy with Post-traumatic Soldiers.” The Arts in Psychotherapy 39 (4): 223–33.  Bion, Wilfred R. 1962. “A Theory of Thinking.” International Journal of PsychoAnalysis 43: 306–10. ———. 1967. Second Thoughts. London: Heinemann Medical Books. Birnbaum, Jacqueline. 2013. Healing Childhood Trauma through Music and Play. EBook. Gilsum, NH: Barcelona Publishers. Blacking, John. 1973. How Musical Is Man? Seattle: University of Washington Press. Bruscia, Kenneth E. 1998. The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. ———. 2014. Defining Music Therapy. Third edition. Gilsum, NH: Barcelona Publishers. Bunt, Leslie, and Brynjulf Stige. 2014. Music Therapy: An Art beyond Words. Second edition. London: Routledge. Cobbett, Steve. 2007. “Playing at the Boundaries: Combining Music Therapy with Other Creative Therapies in Individual Work with Children with Emotional and Behavioural Difficulties.” British Journal of Music Therapy 21 (1): 3–11. Daniel, Stuart, and Colwyn Trevarthen. 2017. Rhythms of Relating in Children’s Therapies: Connecting Creatively with Vulnerable Children. London: Jessica Kingsley. Darnley-Smith, Rachel, and Helen Patey. 2003. Music Therapy. London: Sage. Davis, William, Kate Gfeller, and Michael Thaut. 2008. An Introduction to Music Therapy: Theory and Practice. Third edition. Silver Spring, MD: American Music Therapy Association. De Backer, Jos, and Julie Sutton, eds. 2014. The Music in Music Therapy: Psychodynamic Music Therapy in Europe: Clinical, Theoretical and Research Approaches. London: Jessica Kingsley. Dissanayake, Ellen. 1992. Homo Aestheticus: Where Art Comes from and Why. New York: The Free Press. Edwards, Jane, ed. 2016. The Oxford Handbook of Music Therapy. Oxford: Oxford University Press. Felsenstein, Rivka. 2014. “From Uprooting to Replanting: On Post-trauma Group Music Therapy for Pre-school Children.” Nordic Journal of Music Therapy 22 (1): 69–85.

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Fisher, Atarah, and Avi Gilboa. 2016. “The Roles of Music amongst Musician Holocaust Survivors before, during, and after the Holocaust.” Psychology of Music 44 (6): 1221–39. Fonagy, Peter, György Gergely, Eliot Jurist, and Mary Target. 2004. Affect Regulation, Mentalization, and the Development of the Self. London: Karnac. Fosha, Diana. 2000. The Transforming Power of Affect: A Model for Accelerated Change. New York: Basic Books. Goditsch, Manuel, Dorothee Storz, and Thomas Stegemann. 2017. “Opening the Door: First Insights into the Music Therapy Room’s Design.” Nordic Journal of Music Therapy 26 (5): 432–52. Gouk, Penelope, ed. 2000. Musical Healing in Cultural Contexts. Aldershot, UK: Ashgate. Hadley, Susan J., ed. 2003. Psychodynamic Music Therapy: Case Studies. Gilsum, NH: Barcelona Publishers. Hannibal, Niels. 2014. “Implicit and Explicit Mentalisation in Music Therapy in the Psychiatric Treatment of People with Borderline Personality Disorder.” In The Music in Music Therapy, edited by Jos De Backer and Julie Sutton. London: Jessica Kingsley. Heine, Heinrich. 1832. Uber die französische Bühne Neunter Brief. Herman, Judith. [1997] 2015. Trauma and Recovery: The Aftermath of Violence— from Domestic Abuse to Political Terror. New York: Basic Books. Holck, Ulla. 2004a. “Interaction Themes in Music Therapy: Definition and Delimitation.” Nordic Journal of Music Therapy 13 (1): 3–19. ———. 2004b. “Turn-Taking in Music Therapy with Children with Communication Disorders.” British Journal of Music Therapy 18 (2): 45–54. Kim, Jinah. 2016. “Psychodynamic Music Therapy.” Voices: A World Forum for Music Therapy 16 (2). https:/voice.no/index.php/voice/article/view/882/726. Knoblauch, Stephen H. 2000. The Musical Edge of Therapeutic Dialogue. Hillsdale, NJ: The Analytic Press. Langer, Susanne K. 1953. Feeling and Form: A Theory of Art. London: Routledge and Kegan Paul. Loewy, Joanne V., and K. Stewart. 2004. “Music Therapy to Help Traumatized Children and Caregivers.” In Mass Trauma and Violence: Helping Families and Children Cope, edited by Nancy Boyd Webb. New York: Guilford Press. Lyons-Ruth, Karlen. 1998. “Implicit Relational Knowing: its Role in Development and Psychoanalytic Treatment.” Infant Mental Health Journal 19 (3): 282–89. MacDonald, Raymond, David J. Hargreaves, and Dorothy Miell. 2009. “Musical Identities.” In The Oxford Handbook of Music Psychology, edited by Susan Hallam, Ian Cross, and Michael Thaut, 463–69. Oxford: Oxford University Press. Maiello, Suzanne. 2001. “On Temporal Shapes: The Relation between Primary Rhythmical Experience and the Quality of Mental Links.” In Being Alive: Building on the Work of Anne Alvarez, edited by Judith Edwards. London: BrunnerRoutledge. ———. 2004. “On the Meaning of Prenatal Auditory Perception and Memory for the Development of the Mind: A Psychoanalytic Perspective.” In Music Therapy for



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Premature and Newborn Infants, edited by Monika Nöcker-Ribaupierre. Gilsum, NH: Barcelona. Malloch, Stephen. 1999–2000. “Mothers and Infants and Communicative Musicality.” Musicæ Scientiæ, Special Issue: Rhythm, Musical Narrative, and the Origins of Human Communication, 29–57. Nordoff, Paul, and Clive Robbins. [1977] 2007. Creative Music Therapy: Fostering Clinical Musicianship. Second edition. Gilsum, NH: Barcelona Publishers. Odell-Miller, Helen. 2014. “The Development of Clinical Music Therapy in Adult Mental Health Practice: Music, Health and Therapy.” In Medicine, Health and the Arts: Approaches to the Medical Humanities, edited by Victoria Bates, Alan Bleakley and Sam Goodman. London: Routledge. Panksepp, Jaak. 1998. Affective Neuroscience: The Foundations of Human and Animal Emotions. New York: Oxford University Press. Pavlicevic, Mercèdes. 1997. Music Therapy in Context: Music, Meaning and Relationship. London: Jessica Kingsley. Perry, Bruce. 2006. “Applying Principles of Neurodevelopment to Clinical Work with Maltreated and Traumatized Children: The Neurosequential Model of Therapeutics.” In Working with Traumatized Youth in Child Welfare, edited by Nancy Webb Boyd. New York: The Guilford Press. Robarts, Jacqueline Z. 1994. “Towards Autonomy and a Sense of Self: Music Therapy with Children and Adolescents with Early Onset Anorexia Nervosa.” In Arts Therapies and Clients with Eating Disorders, edited by Ditty Dokter. London: Jessica Kingsley. ———. 1998. “Music Therapy and Children with Autism.” In Children with Autism: Diagnosis and Interventions to Meet their Needs, edited by Colwyn Trevarthen, Kenneth Aitken, Despina Papoudi, and Jacqueline Robarts. Second revised edition. London: Jessica Kingsley. ———. 2003. “The Healing Function of Improvised Songs with a Child Survivor of Early Trauma and Sexual Abuse.” In Psychodynamic Music Therapy: Case Studies, edited by Susan Hadley. Gilsum, NH: Barcelona Publishers. ———. 2006. “Music Therapy and Sexually Abused Children.” Clinical Child Psychology and Psychiatry, Special Issue: Theory of Change 11 (2): 249–69. ———. 2009. “Supporting the Development of Mindfulness and Meaning: Clinical Pathways in Music Therapy with a Sexually Abused Child.” In Communicative Musicality: Exploring the Basis of Human Companionship, edited by Stephen Malloch and Colwyn Trevarthen. Oxford: Oxford University Press. ———. 2014. “Music Therapy and Children with Developmental Trauma Disorder.” In Creative Arts and Play Therapy for Attachment Problems, edited by Cathy Malchiodi and David Crenshaw. New York: The Guilford Press. Schore, Allan N. 2001a. “The Effects of Early Relational Trauma on Right Brain Development, Affect Regulation, and Infant Mental Health.” Infant Mental Health 22 (1–2): 201–69. ———. 2001b. “Minds in the Making: Attachment, the Self-Organizing Brain, and Developmentally Oriented Psychoanalytic Psychotherapy.” British Journal of Psychotherapy 17 (1): 299–327.

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———. 2003. Affect Regulation and the Repair of the Self. London: W.W. Norton. Sekeles, Chava. 2006. “The Developmental Integrative Model in Music Therapy (D.I.M.T.).” Nordic Journal of Music Therapy 15 (1): 61–81. Siegel, Daniel J. 2003. “An Interpersonal Neurobiology of Psychotherapy: The Developing Mind and the Resolution of Trauma.” In Healing Trauma: Attachment, Mind, Body, and Brain, edited by Marion F. Solomon and Daniel J. Siegel. New York: W.W. Norton & Company. ———. [1999] 2012. The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. Second edition. New York: The Guilford Press. Stern, Daniel. 1977. The First Relationship: Infant and Mother. Cambridge, MA: Harvard University Press. ———. 1985. The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. New York: Basic Books. ———. 1995. The Motherhood Constellation: A Unified View of Parent-Infant Psychotherapy. New York: Basic Books. ———. 2007. The Present Moment in Psychotherapy and Everyday Life. New York: W.W. Norton. ———. 2010. Forms of Vitality: Exploring Dynamic Experience in Psychology, the Arts, Psychotherapy, and Development. Oxford: Oxford University Press. Streeter, Elaine. 1999. “Definition and Use of the Musical Transference Relationship.” In Clinical Applications of Music Therapy in Psychiatry, edited by Tony Wigram and Jos De Backer. London: Jessica Kingsley. Strehlow, Gitta. 2009a. “Mentalisierung und ihr Nutzen für die Musikterapie.” Musikterapeutische Umschau 30: 89–101. ———. 2009b. “The Use of Music Therapy in Treating Sexually Abused Children.” Nordic Journal of Music Therapy 18 (2): 167–83. Strehlow, Gitta, and Theo Piegler. 2007. “The Importance of Primary Non-verbal Therapy Procedures in Psychodynamic Psychiatry.” International Journal of Psychotherapy, EAP 11 (1): 25–35. Sutton, Julie P. 2002. Music, Music Therapy and Trauma: International Perspectives. London: Jessica Kingsley. ———. 2006. “Hidden Music: An Exploration of Silence in Music and Music Therapy.” In Musical Creativity: Multidisciplinary Research in Theory and Practice, edited by Irène Deliege and Geraint Wiggins. East Sussex, UK: Psychology Press. ———. 2007. “The Air between Two Hands: Silence, Music and Communication.” In Silence, Music, Silent Music, edited by Nicky Losseff and Jenny Doctor. Hampshire, UK: Ashgate Publishing. Sutton, Julie, and Jos De Backer. 2009. “Music, Trauma and Silence: The State of the Art.” The Arts in Psychotherapy 36 (2): 75–83. ———. 2014. The Music in Music Therapy: Psychodynamic Music Therapy in Europe: Clinical, Theoretical and Research Approaches. London: Jessica Kingsley. Thaut, Michael. 2005. Rhythm, Music and the Brain: Scientific Foundations and Clinical Applications. New York: Routledge. Thaut, Michael, and Volker Hoemberg. 2016. Handbook of Neurologic Music Therapy. Oxford: Oxford University Press.



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31 Trauma Work in Play and Drama Therapy The Importance of the Theatre of Resilience Sue Jennings

Theatre of Resilience is based on attachment-based playfulness during preg-

nancy and the first six months. It enables trauma recovery through sensory, rhythmic, and dramatic play and entranced theatre experience, and it facilitates the transformation of trauma symptoms into healthy creativity. THE BUILDING BLOCKS OF RECOVERY: THE BODY AND THE BRAIN This chapter concerns the application of Drama Therapy and Play Therapy in trauma recovery. In particular, it focuses on the essential stages of dramatic play and role development as shown by the direct application of Theatre of Resilience (ToR). Theatre of Resilience incorporates two developmental paradigms: the first is Neuro-Dramatic-Play (NDP) (Jennings 2011), the sensory, rhythmic, and dramatic play that occurs six months before birth until six months after birth; the second is Embodiment-Projection-Role (EPR) (Jennings 1990), which charts the dramatic development of infants from birth to seven years. This is underpinned by my theoretical approach derived from current research in theatre arts, neurobiology, social anthropology, and Theory of Mind. Theory of Mind (ToM) (Baron-Cohen 2008) is the capacity of people to attribute mental states to themselves and other people (also see Lahad et al. 2013; Rutter 1997). If we can express empathy, for example, we have some idea of how other people feel in a given situation, known as “putting oneself in someone else’s shoes.”

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The subject of attachment and trauma is documented elsewhere in this book—see chapter 2, by Bernd Huppertz; chapters 3 and 5, by Louise Newman; and chapter 31, by Nicolas Lorenzini, Chloe Campbell, and Peter Fonagy—however it is important to emphasize that in NDP, attachment is believed to start when the infant is conceived, or even thought about! This chapter will focus on (1) pre-birth and newborn attachment, (2) developmental role stages, and (3) the entranced experience. The forms of trauma that are particularly amenable to a Theatre of Resilience approach are reactive trauma, developmental trauma, and long-term childhood trauma in adults. The symptoms are many and varied and include: out-of-body experiences, self-harm, obsessive routines, blame, shame, and guilt. The two detailed case studies below discuss individuals who had been misdiagnosed as attention seeking, hyperactive, and neurotic. The detailed descriptions in the two examples (one child, one adult) describe the techniques applied and how they were chosen and adapted in an age-appropriate way. In neither situation had the underlying developmental trauma been recognized and named. Margot Sunderland points out that a baby’s emotional systems are already functioning at birth. She explains, There are several genetically ingrained emotional systems deep in the lower brain, and knowledge of these systems is a key to good parenting. The systems are Rage, Fear, Separation Distress, Seeking Care, Play. . . . The Rage, Fear and Separation Systems are already set up at birth to support a baby’s survival. They are designed to be so in order to save infants from being eaten by predators, and to keep them close to a parent. The potential dangers in a modern world are very different but nevertheless can easily trigger one or more of these systems in your baby’s brain. (Sunderland 2006, 24)

Gerhardt writes, Babies are like the raw material for a self. Each one comes with a genetic blueprint and a unique range of possibilities. There is a body programmed to develop in certain ways, but by no means on an automatic programme. The baby is an interactive project not a self-powered one. The baby human organism has various systems ready to go, but many more that are incomplete and will only develop through another human input. (Gerhardt 2004, 18)

Attachment is an “interactive project” and consists of the social playfulness between mother and new-born child from birth. If a primary attachment is not possible with the mother, then other significant adults can take on that role:



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dad, grandma, auntie and so on. The importance of consistency during the first twelve months or so of life cannot be overemphasized. In my attachmentbased therapeutic practice, I integrate a combination of body work (selfsoothing, massage, sensory play, messy play, movement, and relaxation); telling of personal stories through objects in the sand-tray; dramatic play, where metaphoric and symbolic scenes are represented through movement “body-sculpts”; and role play or drama. PRE-BIRTH AND NEWBORN ATTACHMENT Neuro-Dramatic-Play (NDP) emphasizes the importance of early sensory experience in trauma recovery; our sensory capability is our early survival system. NDP forms the basis of playful attachment between mother and unborn child and mother and newborn child. The important time frame is from six months before birth until six months after birth. NDP is unique in focusing on the playful nature of pregnancy and the dramatized and playful attachment after the birth (Jennings 2011). Through play and drama, NDP emphasizes a combination of basic trust (Erikson [1951] 1985), security, and ritual, together with sensory stimulation, messy play, physical movement, exploration, and risk (Jennings 2011, 2012). Ritual and risk form the basis of children feeling safe in the world, as well as a desire to explore the world. Infants during this time need to be able to experience a range of sensory stimuli, which gets them “in touch” with themselves and their environment. The birth itself is a very sensory experience, messy and slimy, and doctors are now being informed to delay the cutting of the cord as it can impede development and cause pain. Our early physical and bodily experience comes through our proximity to others: this is usually our mothers or carers, as we are rocked or stroked or cradled. The small infant has three “Circles of Security”; the first circle is within the womb, the second in the mother’s arms, and the third in the mother’s awareness as she is able to fine-tune her relationship (Jennings 2011). These help to create the experience of the “Safe Place,” which is essential when we practice trauma recovery. Rhythmic Play: The exchange of rhythms takes place at this time, and small infants will change their own heartbeat to the rhythm of their mother’s when they are held on the left shoulder. Chaotic and traumatized children and teenagers have often lost their ingrained “rhythm of life” and can regain it by participating in drumming; clapping; and rhythmic movement, games, and chants. For more about ingrained rhythm see Jennings (1995) on the ethnography of the Senoi Temiar people.

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Dramatic Play: This is inbuilt for most children, providing they are not ridiculed, put down, or laughed at. Mothers and other adults in the child’s early development need to interact in dramatic playfulness. We need to dramatize in order to understand other people. It is at the root of empathy, as we are able to gain insight into how other people are feeling or thinking. Within hours of being born, infants are trying to imitate the expression on their mother’s face; this starts the interactive imitation and echo play that characterizes dramatic play (Jennings 2011). Imitation of facial expressions and sounds, chanting nursery rhymes, and playing peekaboo are all examples of early dramatic play. Through dramatic play, children are learning about themselves and others, that different sounds carry different messages, that monsters can be pretend and not real. The child is responding “dramatically” to the individual adult and then groups. When children imitate their mother’s expression, they are beginning to respond as if they are the mother. Drama and dramatic play are the least understood of creative activities and processes. However, the enactment of a dialogue between Shakespearian characters can bring about an extraordinary insight and understanding of our own experience. The work of Kelly Hunter must also be mentioned (2015). She has pioneered using Shakespeare to work with children and teenagers on the autistic spectrum, and has shown that the rhythm of Shakespeare’s verse is the rhythm of the human heartbeat. The healing potential of theatre and drama therapy, has also been helped enormously by the contemporary research of Bessel van der Kolk (2015) in The Body Keeps the Score. Van der Kolk has demonstrated that we neglect the body at our peril when working with trauma. He is a very strong advocate of the arts as a means of healing for people who have been suffering from developmental trauma. He says: As a culture we are trained to cut ourselves off from the truth of what we are feeling. . . . Traumatized people are terrified to feel too deeply. They are afraid to experience their emotions, because emotions lead to loss of control. In contrast, theatre is about embodying emotions, giving voice to them, becoming rhythmically engaged, taking on and embodying different roles. (van der Kolk 2015, 335)

An understanding of the sensory, rhythmic, and dramatic play stages of Neuro-Dramatic-Play leads into a more detailed analysis of the developmental role stages.

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DEVELOPMENTAL ROLE STAGES: FROM BIRTH TO SEVEN YEARS Pre-birth Drama

The pre-birth stage involves a dramatic playfulness between mother and baby; a role reversal from the mother, who answers herself “as if” she is the baby; an awareness from the baby of sound, rhythm, light and dark, and the mother’s voice, as well as the beginning capacity to shape words. Stage One: “As If” or the “Dramatic Response”

This stage involves echo play and imitation, usually with the mother or carer, in which the adult echoes the child and the child echoes the adult. In this stage, new sounds can be introduced as well as facial expressions. This is a very important initial stage for the recognition of the self and other through expressions and sounds, and is the first step toward building empathy. Stage Two: My Body–Your Body

This stage involves physical play with an adult: up and down, flying “whee,” stretching arms and bending very tall and very small, bouncing and jogging on the lap. This “whole body” stage is very important for sensory integration and for the infant to experience the whole body as well as individual limbs. When the movement is accompanied by sounds, it further reinforces creativity and adaptability. Stage Three: “Peekaboo!”

During the “peekaboo” stage, adults put their hands over their face and then “appear” again. The infant enjoys the repetition, and the delay of the reappearance can be slowly increased. This game is a precursor to games of hideand-seek that are always popular. Many children who are in therapy wish to play hide and seek, repeatedly. The stage of being able to understand “disappearance and appearance” is an important step in developing “let’s pretend.” These first three stages of dramatic play are usually complete by the age of six months. Children who have been neglected or abused may need to replay these stages in order to build up confidence. Increasingly, the child is able to imitate others, especially family members, and take on roles and play through puppets that are a part of the following stages of dramatic play and role.

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Stage Four: Role Reversal

During this stage, the child talks to a special toy and then answers “as if” he or she is the toy; this occurs usually in solitary play as a relationship is played out between child and toy. This next step in dramatic development shows how the child is separating self and other, and then begins to take on the role of the other. Stage Five: Ordering and Reordering

During this stage, soft toy animals are assigned roles and lined up. They are often given voices or feelings or ideas of good or bad, or good or naughty. This is pre-narrative play where the child is experimenting with different ideas through the toys. It usually takes place before the creation of narrative and dramatic exploration. Stage Six: Creating Narratives

Whereas earlier play had the elements of narrative, during this stage, children are now putting things together into a story structure. It may be on an epic scale or a very simple conversation and outcome. Once a child creates a story and enacts it (either with other children or taking on the several roles themselves), they are integrating the several elements of role, scene, situation, and resolution. They have created an event that communicates. Stage Seven: Improvisation and Story

The child has previously engaged in random moments of improvisation, but now he or she is able to sustain an appreciable time in improvising an idea or scene. This stage leads to experimentation and choices and changes. It may then lead to a story based on the improvisation, showing an understanding of free flow and structure. This is the culminating stage of the child’s early dramatic development, where all aspects of previous dramatic play are integrated. It stimulates areas of the brain and assists both right and left hemispheres to function. THE ENTRANCED EXPERIENCE OF DRAMA AND THEATRE The entranced experience of another world is a means of healing. It is comparable to the specific trance-experience that I describe in my doctoral fieldwork with the Temiar people (Jennings 1995). When we witness great theatre



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or play important characters, we are transported to another world. The safe structure of the workshop or performance enables us to return to our everyday reality safely. However, the drama therapist will always do “grounding techniques” to make sure that people have come out of “dramatic reality” and returned to the everyday. An entranced session through rhythm, dance, music, and heightened sensory stimulation, within a cultural context, allows “other-world experience,” also referred to as “an altered state of consciousness.” This can happen through the arts and without recourse to drugs, alcohol, prescription medication, or shock treatment. Many people long for escapes from the dreary and the tedious: children, teenagers, homeless people, those surviving on charity. They are marginalized and scapegoated and feel confused about their roles and responsibilities. Theatre not only serves as an essential part of “prevention,” of promoting mental and physical health through other-world experience, it is also curative through healing theatre and drama therapy. Addiction is reduced where the arts can function at the core of social life (Jennings 1995). The following examples illustrate how the NDP and Role stages and “other-world” experience were important in the trauma recovery of both individuals. CASE STUDY ONE This is an example of an adult with long-term PTSD, which illustrates how childhood trauma can affect someone for life, unless there is recognition of the trauma and appropriate treatment put in place. In this situation, the traumatic events had taken place both at birth and during childhood, but the former did not emerge until several months into therapy. “Janice,” aged fifty-five, consulted about her dissociation or “out-of-body experiences” that would overwhelm her in many public places as well as home situations. She felt completely incapable of controlling her bodily reactions of tension, stomach cramps, and permanent frowns. She was unable to find the stressor that would provoke her to go out of her own body. She was frightened of sleeping because she would wake up in terror and out of control, and it affected her work and social life, as she was scared of unprovoked episodes. She attempted to impose total control over her body through diet, exercise, and cleanliness. She told me that I probably would not want to know about the beatings, as no other therapist had thought them important. She had been systematically beaten with a leather whip by her father, who had brutalized the whole family

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in drunken rages. There were many triggers for her dissociation; for example as a child, her family would sit waiting at the meal table for the father to return. They would know he was arriving when they heard the scrunch of gravel under his car tires, and then all the children would sit up straight, and fresh hot food was put on the table. The father would often turn the dining table over or take the food and throw it against the wall while shouting abuse, but sometimes he would just join the family for the evening meal. The sound of the gravel still caused her anxiety and could cause an out-of-body episode. Out-of-body experience is common when a person has been unable to escape a brutal or sexual assault; it is a freeze response that can later be triggered by any associated stimulus. When one cannot escape from the trauma, the brain’s coping mechanism enables one to “escape” from the body that is being assaulted, at least in consciousness. This is in contrast to the heightened experience of trance that is under ritualistic control. In Janice’s situation, falling asleep meant that she had lost control, and the proximity of people in public meant the possibility of stranger-danger. Basically, she needed to be vigilant at all times and in all places. However, when she was able to mother herself and create her own “safe-place,” she was able to develop greater “trust of the other.” Although we initially worked with her feelings about the beatings and the generalized fear in the family of unprovoked violent episodes, an early trauma was then remembered in a quite unexpected way. She brought in a newspaper article about a terrorist attack where a pregnant woman had been murdered. This reminded her of the stories surrounding her own birth, where the midwife, herself pregnant, had been murdered on her way to deliver Janice. It slowly emerged that she had literally been born into a “circle of fear,” as there were armed and ruthless terrorists surrounding the area where her family lived. She was often hidden in a cupboard in case there was a raid on the house. In Janice’s situation there seemed no basis for a trusting attachment with either of her parents, as her father beat her, and her mother did not protect her, but also the fear of attack rendered the whole family helpless, so she was unable even to trust her environment. Trust seemed a key theme for Janice in all of her work, even leading her to test me as her therapist, as she came to see me and then stopped and then came again. Time and again for Janice there would be images of total chaos and destruction, such as being swallowed up in the chaos and destruction, or destroyed by the power of the invaders. Much of the time there were accompanying feelings of shame, guilt, and blame. What was helpful was her developing a capacity to reflect in a mindful way on her own journey through the day and night, which slowly imparted a feeling of her own control; the following methods assisted her to move forward:



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a. Learning to self-soothe, and to care for herself in a nurturing way. b. Expressing her here-and-now feelings in the therapeutic sand tray with small toys and objects: in particular her country of origin and where she was now. c. Placing significant people on an empty chair and telling them what she had bottled up for so many years. d. Building larger than life “sculptures” of the destructive elements in her life, using giant puppets, stepladders, fabric, and masks. e. Recognizing her own journey through a variety of stories, especially the “Hero’s Journey” and “Sedna” (Jennings 2015). f. Finding ways to go beyond her body in creative ways such as joining a singing group and a dance class. CASE STUDY TWO “Maria,” aged nine, came to play therapy, as she was self-harming by pulling out her hair in clumps and biting her finger nails until they disappeared. She was the oldest child in a large family that seemed to be very chaotic and was blamed by her parents for causing disruption and not minding her younger six siblings. The theme of chaos was strangely contradicted by her orderly behavior in the play room. As a “follow the child” play therapist, this was fine with me, as she set the pace and content for time together. Having inspected the play room’s diverse materials, she chose to use pencil and paper and draw some very intricate patterns, slowly and painstakingly. After a few sessions, she asked if she could have something to eat, as she was always hungry. So drinks and snacks were available as she continued her drawings. She talked very little; then, one week she said, “That’s how it is inside my head, like a whirring machine.” We talked about mindfulness and how some gentle breathing exercises might slow down the whirring. The next session she said, “If someone has seen something illegal, should they tell if it gets someone in the family into trouble?” She had progressed from the drawings to the clay and was enjoying a first stage of messy play where she molded and squashed but did not make a particular object. In my mind was the basic maxim that mess eventually leads to form, and chaos to order (the basic principles of NDP). From a seemingly chaotic life outside the play room, she started by being as orderly as she could. She was now allowing herself to create some mess and seemed to daydream while she was doing it. She missed the next session without any message and returned with her mother the following week. She asked if her mother could stay in the session

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as she had something to tell me. It turned out that the maternal grandfather had been arrested with accusations of child sexual abuse. Tensions had built up in the house, with the parents arguing about the situation, and my client had overheard snippets of conversation. This was what she had referred to earlier about “something illegal.” She then asked if she could have some sessions with her mother so they could get to know each other again, which we all agreed was a positive step forward. REFLECTIONS In both these examples, the individuals concerned had either suffered or witnessed traumatic experiences within the family. These had made an impact that had caused physical responses, which had become repetitive and destructive. The therapeutic sessions had focused on sensory experience and the capacity to give up some control in order to experience the mess or chaos of the lived experience. This had enabled them to move on to a more positive experience in their lives. In particular with Maria, she was able to ask for a more meaningful relationship with her mother. For Janice, she could at last name all the terrors and externalize them and reclaim ownership of her body in a positive way. REFERENCES Baron-Cohen, Simon. 2008. Autism and Asperger Syndrome. Cambridge: Cambridge University Press. Erikson, Erik. (1951) 1985. Childhood and Society. London: Vintage. Gerhardt, Susan. 2004. Why Love Matters. London: Routledge. Hunter, Kelly. 2015. Shakespeare’s Heartbeat. London: Routledge. Jennings, Sue. 1990. Dramatherapy with Families, Groups and Individuals. London: Jessica Kingsley. ———. 1995. Theatre, Ritual and Transformation: The Senoi Temiars. London: Routledge. ———. 2011. Healthy Attachments and Neuro-Dramatic-Play. London: Jessica Kingsley. ———. 2012. Neuro-Dramatic-Play: A Play Book for Adults. Glastonbury: Healing Tree. ———. 2015. When the World Falls Apart: Working with the Effects of Trauma. Buckingham, UK: Hinton House. Lahad, Mooli, et al. 2013. The “BASIC Ph” Model of Coping and Resiliency. London: Jessica Kingsley.



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Rutter, Michael. 1997. Psychosocial Disturbances in Young People: Challenges for Prevention. Cambridge: Cambridge University Press. Sunderland, Margot. 2006. The Science of Parenting. London: Dorling Kindersley. van der Kolk, Bessel. 2015. The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma. London: Penguin.

VII OTHER TRAUMA TREATMENT APPROACHES

Here two recent forms of trauma treatment approaches are discussed. The

Mentalization approach described by Nicolas Lorenzini, Chloe Campbell, and Peter Fonagy is one of these. The second, “Take Two,” a therapeutic service, with its application of the core principles of the Child Trauma Academy’s Neurosequential Model of Therapeutics (NMT), is discussed by Annette Jackson, Margarita Frederico, Allison Cox, and Carlina Black.

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32 Mentalization and Its Role in Processing Trauma Nicolas Lorenzini, Chloe Campbell, and Peter Fonagy

The mentalizing approach to the understanding and treatment of trauma has

focused mainly on early attachment trauma (Fonagy, Luyten, and Campbell 2017). However, we suggest here that aspects of the theory and practice of mentalization-based interventions may be useful in shedding light on the subject of trauma caused by state violence and repression. Mentalizing—the capacity to understand other people and oneself in terms of possible thoughts, feelings, wishes, and desires—underpins all human interactions. The theory of mentalizing is embedded in attachment thinking, just as, heuristically, the development of mentalizing is embedded in attachment processes (Fonagy et al. 2002). Within this model, traumatic attachments in childhood are of particular significance because of their potentially cascading impact on subsequent development. This multilevel approach proposes that this process occurs via disturbances in the development of emergent mentalizing skills and the subsequent closing off of the mind to the possibility of accessing other people’s minds as safe and reliable sources of knowledge about how to navigate the social environment (Fonagy, Luyten, and Allison 2015). The openness to the communication of social knowledge from others is known as epistemic trust. Here, we will explore how recent developments in the theory of mentalizing and epistemic trust might be applied to thinking about the psychological implications of sources of trauma that originate beyond the caregiving environment—in particular, trauma arising from state repression and political violence.

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DEVELOPMENTAL ORIGINS OF THE CAPACITY TO MENTALIZE Mentalizing skills are developed in the context of attachment experiences. The earliest stage of this mentalizing development begins across marked mirroring interactions with the primary caregiver (Gergely and Watson 1996). Marked mirroring involves the caregiver reflecting back to the infant what the infant is feeling in a way that simultaneously registers or “marks” that the feelings being enacted by the adult are understood to be those of the infant. In reacting to the infant’s frustration, for example, the caregiver does not express frustration with the infant, but rather expresses the infant’s frustration for the infant (by intermingling an expression of frustration with an element of caring and concern) so that the infant sees it reflected back in expressions on the caregiver’s face (Fonagy et al. 2002). Good-enough mirroring relies on adequate mentalizing on the part of the caregiver—that is, being able to interpret the infant’s emotional state reasonably accurately—and it generates a sense in the infant that he/she is (a) an active agent in his/her own right, and (b) an active agent who is not alone. Later, in mentalizing interactions, the caregiver puts the child’s emotions (and the caregiver’s own feelings in response to the child’s emotions) into spoken words. Through these mentalizing narratives, the relationships surrounding and scaffolding the child’s emotional world are demonstrated to the child. In normal circumstances, secure attachment and mentalizing develop hand-in-hand (Fonagy, Gergely, and Target 2008). By virtue of being empathically thought about (or mentalized), children become better mentalizers themselves: they become more adept at inferring beliefs and more empathic with their peers (De Rosnay and Harris 2002). This is supported by a body of research on the intergenerational transmission of attachment patterns and the capacity to mentalize. Better mentalizing capacities measured by the Reflective Functioning Scale (Fonagy et al. 1998) in pregnant primiparous women predict secure attachment of the infant (Berthelot et al. 2015; Fonagy et al. 1991). Findings from earlier studies have shown that the combination of trauma and low mentalization abilities identified a group with borderline personality disorder (BPD) in a hospitalized sample of patients (Fonagy et al. 1996). THE CONSEQUENCES OF TRAUMA FROM THE MENTALIZATION PERSPECTIVE From a mentalizing perspective, it has been argued that adversity becomes traumatic when it is compounded by a sense that one’s mind is alone (Allen and Fonagy 2014): the presence of an accessible other mind provides the



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social referencing that enables us to frame a frightening and otherwise overwhelming experience. Without such referencing, it is harder to calibrate one’s own subjective experience in an accurate or proportionate way. Impaired mentalizing is a common developmental outcome of traumatic attachments, as typified most classically in cases of borderline personality disorder (Fonagy and Luyten 2016). Maltreatment thus not only disorganizes the attachment system (see Cyr et al. 2010, for a comprehensive review), it also appears to disrupt mentalization. Childhood maltreatment has a negative impact on several aspects of social-cognitive competencies in individuals who do not necessarily have a formal mental health diagnosis (Cicchetti et al. 2003; Pears and Fisher 2005; Smith and Walden 1999). That young maltreated children display mentalizing impairments is captured by various findings, for example as they engage in less symbolic and less child-initiated dyadic play (Alessandri 1991; Valentino et al. 2011). They may show less empathy when they view other children in distress (Klimes-Dougan and Kistner, 1990) and they may have poor affect regulation (Kim and Cicchetti 2010; Maughan and Cicchetti 2002; Robinson et al. 2009). Significantly, they tend to be less likely to make references to their internal states (Shipman and Zeman 1999) and might struggle to understand emotional expressions, particularly facial expressions (During and McMahon 1991), even when verbal IQ is controlled for (Camras et al. 1990; Shenk, Putnam, and Noll 2013). In particular, maltreated children can ascribe anger inaccurately (Camras, Sachs-Alter, and Ribordy 1996) and impute heightened event-related implications when exposed to angry faces (Cicchetti and Curtis 2005). There is a delayed understanding of Theory of Mind in maltreated children (the cognitive ability to attribute mental states to oneself and others and to understand that others have beliefs, desires, intentions, and perspectives that are different from one’s own; Cicchetti et al. 2003; Pears and Fisher 2005), and the capacity to describe complex and emotionally charged representations of the parent and the self may deteriorate with development (Toth et al. 2000). Differences were found between children who had experienced intra-familial and extra-familial sexual abuse. Those who had experienced intra-familial abuse had significantly lower mentalizing capacities in relation to the self and others than the extra-familial group, indicating that intra-familial abuse had a more severe impact on these children’s capacity to think about self and others in coherent mental-state terms. This is congruent with our developmental model, which argues that an early sense of self emerges in the context of interactions with the caregiver that mirror, reflect upon, and give agency to the infant’s mind (Fonagy and Target 2006). In particular, it may be the caregiver’s capacity to mentalize the trauma, rather than the caregiver’s mentalizing capacity in general, that determines the child’s attachment (Berthelot et al. 2015).

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In adults with a history of trauma, Stein et al. (2004) showed that mentalizing fully moderated the relationship between childhood maltreatment and impairment in adult romantic relationships. A comprehensive systematic review (Macintosh, 2013) identified five studies (Bouchard et al. 2008; Fonagy and Bateman 2006; Fossati et al. 2009, 2011; Stein and Allen 2007) providing support for the assumption that mentalizing mediates the relationship between attachment and/or adversity and adult functioning and distress. More recent studies have confirmed these findings in adolescents (Taubner and Curth 2013) and personality-disordered adults (Chiesa and Fonagy 2014). IMPACT OF TRAUMA ON COMMUNICATION A fundamental liability arising from attachment trauma is the closing of the mind to the communication of personally relevant knowledge about the social environment and how to function within it (Fonagy, Luyten, and Allison 2015). In other words, it erodes epistemic trust. This particular form of trust, or openness to social learning, is one of the mechanisms that power an important element of humanity’s most defining skill: our capacity to both teach and learn from each other. This human inclination to teach and learn new and relevant cultural information from one another has been termed natural pedagogy (Csibra and Gergely 2011). It is thought to be a key adaptation in enabling social complexity and cooperation (Gergely and Csibra 2005). As adults, we are far more likely to learn from and listen to someone else if we feel that that person has recognized our agency and subjectivity. We are more likely to adopt a position of epistemic trust toward someone who appears to be able to mentalize us. Particular signals—known as ostensive cues—trigger epistemic openness to the reception of new knowledge. Ostensive cues include eye contact, turn-taking, contingent reactivity, and so forth. The informant is thus signaling that he/she recognizes the separate individual subjectivity and intellectual agency of the recipient of the communication. The opening up of epistemic trust in this way is a necessary adaptation because indiscriminate openness to all forms of cultural communication would not be adaptive. It is possible that a communicator, whether motivated by a deliberate intention to mislead and cause harm, or simply as a result of ignorance, might misinform the listener. As protection against such scenarios, some form of epistemic vigilance is required. In the presence of trauma (which essentially disavows both subjectivity and agency—that is, the victim is not being mentalized), epistemic mistrust tends to crystallize, rendering the subject unable to learn from the social context, and this perpetuates maladaptive relationship patterns. The presentation of fresh information is of little



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value because although it may be understood at a superficial level, it cannot be internalized as being personally relevant or meaningful. USING MENTALIZING AND EPISTEMIC TRUST IN THINKING ABOUT POLITICAL VIOLENCE The evolutionary purpose of epistemic trust is to enable the individual to learn effectively about how best to navigate the particular social environment in which they are being raised. But as discussed above, having a mechanism for opening and closing epistemic trust is adaptive because there are situations in which a position of epistemic vigilance—or outright epistemic mistrust—might be the safer one to adopt. Within the existing literature on mentalizing, we have tended to understand this process via the dynamics of caregiving. But what if that family is operating within a wider social system characterized by high levels of violence and threat, particularly if the violence and threat emanate from entrenched social and political institutions? In such circumstances, it may not be possible to regard neighbors, schoolteachers, and even relatives as trustworthy. This presents the “good-enough” parent with a difficult dilemma: the consequence of mentalizing-rich parenting that stimulates epistemic trust, which might be adaptive in more benign circumstances, could potentially engender vulnerability in someone growing up in a more threatening milieu. We would suggest that one way in which a caregiver may seek to resolve this dilemma is by ring-fencing certain aspects of behavior and affect that are potentially dangerous, and excluding them from the usual repertoire of “marked mirroring” responses. For example, violent or aggressive behavior might not be responded to in a way that enables the infant to see the effects, implications, and ownership of their anger. Similarly, particularly expansive and open behaviors (i.e., very overt expressions of epistemic openness) might be responded to with a subduing blankness of parental responses: in other words, and perhaps paradoxically, the epistemic channel between caregiver and child might be used to communicate to the child a need for epistemic vigilance. Such paradoxical reactions are observed, notably, in the development of psycho-sexuality. While good parenting entails the marked mirroring of most of the infant’s mental states and their connection with physical arousal, states of sexual excitement in the infant are usually not mirrored by the parent (Fonagy 2008): most parents ignore or look away when young boys have an erection or young girls play with their genitals. Given that self-states that have not been adequately mirrored have the potential of remaining overwhelming, even in normally developed individuals the experience of sex

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is “madness” (19): it is accompanied by physical and mental phenomena that are felt with heightened intensity and are barely subject to regulation. More importantly, inadequate mirroring implies the internalization of a mismatched or amplified mental state as part of the self that encounters relief in projective identification, in an interpersonal situation. Those aspects of ourselves that have not been sufficiently mentalized are known as the alien self, which disrupts self-coherence. We find a similar description of the consequences of state violence in Michael Šebek’s work, crystallized around what he calls “totalitarian objects” (Šebek 1996). This describes an immature, schizo-paranoid internal object that takes the form of a mighty authority figure that requires total compliance and is indifferent to social and individual diversity. As with the alien self, the totalitarian object is not felt to be fully separated, so it cannot be possessed or manipulated, and it strives to control and own the other to impose a rigid ideology. Parallel to the alien self in situations of abuse, the totalitarian object can be idealized and identified with, because it is thought that this object is also a source of safety, self-importance, and (false) wholeness, particularly for immature individuals. Sexuality does reach “normality” in most people, despite the lack of early mirroring. This normalization has to do with both the repeated experience of having sex in adulthood and with the possibility of externalizing these unmirrored aspects in a secure interpersonal situation. An alien self that has taken the form of a totalitarian object does not go through this progressive de-escalation, because the social referencing aspect necessary to rectify it is carefully manipulated by totalitarian authorities through propaganda, persecution of creative endeavors, and the prohibition of assembly. The totalitarian object and the alien self thwart exploration and creativity, impede constructive dialogue and blur the borders between internal and external reality, in a state of “psychic equivalence” (Fonagy and Target 1996), where the totalitarian object represents a dogmatic truth. Once again we see how the totalitarian apparatus strives to isolate individual minds, because the mind left alone is incapable of working through abusive experiences, thus maintaining the effects of the totalitarian object. Another possibility is that secure attachment and mentalizing/epistemic trust become disengaged—entertaining the idea that certain circumstances might encourage the formation of secure attachment (in the form of sensitively interpreting and meeting the needs of the infant) but not result in a particularly mentalizing relationship. We conflate the developmental processes of attachment and mentalizing because they share the same evolutionary relational pipeline—that is, in normal circumstances, it is via the attachment relationship that mentalizing and the stimulation of epistemic trust is first



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experienced. However, it is worth considering whether in some social environments, a good-enough parent may provide secure attachment—they can recognize and meet the infants’ attachment needs—but they are more subdued when it comes to behaviors that might stimulate mentalizing, as happens when mothers have a poor use of language, referring to mental states known as maternal “mind-mindedness” (Meins and Fernyhough 1999; Meins et al. 2002, 2003). They respond to the child’s affects, but they do not mark them. It is a subject that would benefit further investigation. Certainly, we know that cross-culturally, there may be a greater emphasis on certain mentalizing styles. For example, more community-oriented cultures may have some bias toward mentalizing the other over the self, whereas more individualistic cultures may be slightly more skewed toward mentalizing the self; more visual cultures may put more emphasis on external over internal mentalizing, and so forth. And so an individual growing up in a threatening milieu may be better served by operating with a greater emphasis on automatic, affective, external mentalizing because the capacity to read quickly the likely immediate intentions and actions of others may be critically self-protective. We have an extensive body of research, undertaken by historians and criminologists, into the factors that relate to changing rates of interpersonal violence and in particular, homicide, across time and cultures. There are, of course, many factors at work in such fluctuations, but Cambridge criminologist Emanuel Eisner has rigorously analyzed the various factors connected with a decline in violence with the concept of the perceived legitimacy of the state. Rates of instrumental homicide, the kind that fluctuates the most historically, appear to be consistently influenced by whether societies are ruled by law, whether elites are trusted, whether corruption is under control, and whether services are provided. In short, they are shaped by social institutions and how they are perceived (Eisner 2013; Nivette and Eisner 2013): there is a powerful relationship between the ways that a society is governed and rates of individual acts of lethal interpersonal violence (see also Roth 2012, 2014). We would like to posit that the mechanism by which this relationship between state legitimacy and an individual act of violence may be regulated is epistemic trust. We are highly evolved to monitor ostensive or directly demonstrative cues and to raise our epistemic vigilance when these cues are absent or noncontingent with our needs. It is in our self-interest to behave in this way. A cultural milieu in which political authority and social institutions neglect or abuse its citizens’ needs closes down the channel of natural pedagogy. Cultural knowledge and expectations may be recognized and understood, but they are no longer experienced as relevant and generalizable to the individual concerned. In other words, they are stored as episodic rather than

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semantic memories. Social alienation is, in a sense, a systemic breakdown in epistemic trust directed toward the wider environment. However, when the state’s legitimacy is undermined—by corruption, repression, and political violence—not everyone becomes violent. We would suggest that one moderating factor that determines whether an individual is likely to act violently is their preexisting capacity for mentalizing. In a situation where epistemic trust has broken down, there is an increasing burden on the individual’s capacity to feel a sense of agency. This lack of agency creates a disconnect between internal experience and action. Ostensive cues are misread; other people’s attempts to mentalize are scotomized. Agency is highly dependent on the quality and reliability of internal representations of the mental states—just as ownership of action is linked to the mental state that initiated it. Individuals who are more prone to slip into non-mentalizing modes of subjectivity are more likely to act violently or become dysregulated. As suggested above, in a highly noncontingent, non-mentalizing social system, there may be advantages to operating in such non-mentalizing modes. However, restoring healthy mentalizing will depend on the pretraumatic capacity for mentalizing and, very importantly, the space to do so. That space, in which alternative perspectives can be referenced, is meticulously constrained by totalitarian governments, with their sanction or outright prohibition of even the most menial social exchanges that could imply intimacy and alternative thinking. Goldfarb (2005) calls this “The Politics of Small Things,” which is a space of everyday social interaction that is not necessarily political, but from where independent thought will slowly sprout, like social exchanges within the family where there is still some degree of security and intimacy. Therefore, the best prevention against the development of a personality structured by a totalitarian object consists of close, warm, and affectionate interpersonal relationships at home (Šebek 1998). These points can be illustrated by the experience of Dr. Juan Pablo Jiménez, a senior Chilean psychoanalyst who was illegally detained, tortured, and forced to leave his country under the violent dictatorship of Pinochet. He kindly shared these experiences and the learning obtained from them, decades after they occurred. Overcoming extreme situations like detainment and torture largely depends on the ability to cope with the ambiguity of the way we interpret the world. By ambiguity, I mean that to work though the position of victim, we inevitably find the aggressor within us. (Jiménez 2004, 6, our translation)

“Finding the aggressor within” is being able to elaborate the alien totalitarian object, to tolerate self-incoherence. In both traumatic child maltreatment and later trauma, elaboration is understood as the social referencing in a context of secure attachment. In Dr Jiménez’s case, the sense of security was his



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conviction of knowing himself enough, always in relation to his childhood family. It is what theorists of mentalization call “interpersonal regulation of stress”: anxiety can be controlled by recalling secure attachment relationships (Nolte et al. 2011). Dr. Jiménez relates dreams and memories he had during his detention, and they all referred to his parents and teachers. He describes singing in his cell to recall the artistic ambience of his maternal family, from which he always felt excluded, but not less loved. He dreamed of his paternal grandfather, whom he did not personally know, but who had a similar experience of detention. All these memories and dreams were accompanied by the question, what would my grandfather/mother/teacher do in this situation? Inevitably, we interpret external events from our internal world. The explanations and theories about ourselves and our behavior that we use to overcome situations that escape our immediate comprehension allow us to maintain our psychological coherence and fend off depression and anxiety. Thirty years on, I still understand my reaction to detention from the context of the relationships with my family. On the one hand as the realization of the paternal lineage, and on the other, the confirmation of the exclusion from my maternal family. (Jiménez 2004, 6, our translation)

The empirical literature supports these claims regarding the centrality of pretraumatic personality to the understanding of the effects of trauma and the possibilities for therapeutic work. Palestinian political prisoners with dismissive and preoccupied attachments had more PTSD symptoms than securely attached prisoners if they were victims of physical trauma. Conversely, if they had secure attachment, they showed increased PTSD severity if they had been victim of psychological torture (a complex form of interpersonal trauma that includes humiliation and threats; e.g., humiliating a family member) (Kanninen, Punamäki, and Qouta 2003). Positive posttraumatic growth—understood as personal strength, spiritual change, and affiliation to others—was predicted by attachment security (Salo, Qouta, and Punamäki 2005). If in treatment, these prisoners showed qualitatively different styles of therapeutic alliance (Kanninen, Salo, and Punamaki 2000). The erosion of epistemic trust (and the ensuing generalized mistrust), the thwarting of self-agency, and the lack of social referencing are in our view essential to recognize the effects of the trauma fostered by totalitarian governments. CLINICAL IMPLICATIONS The cognitive-psychodynamic model we have advanced has further farreaching clinical implications. Evolution has “prepared” all our brains for

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knowledge transfer by communication (i.e., psychological therapy); we are ready to learn from others about ourselves, just as we are ready to learn from them about the social world. As we find the meaning of our own subjective experience within the social world (within the other) and not simply in selfreflection, we are normally eager to learn about our own opaque mental world from those around us. However, the epistemic mistrust that follows social adversity, maltreatment, or abuse moderates this disposition to learn. A consequence of impaired epistemic trust, therefore, is that it serves to severely diminish the likelihood of responsiveness to any psychotherapeutic intervention (Fonagy, Luyten, and Allison 2015). If therapists are to work effectively with individuals with trauma, they must therefore consider not only the what but the how of “learning”—essentially, of becoming open to social communication. Before learning can begin, negative expectations about the trustworthiness or value of human communication must be radically shifted. To this end, the therapist must create a social situation whose aim is largely to open the person’s mind by establishing a relationship in which he/she feels his/her subjective experience is being thought about so that he/she can begin to trust the social world again. If an attachment relationship is the marker of trustworthiness, the establishment of an attachment relationship with the patient is a critical precondition for change, because it opens the patient up to therapeutic influence and, further, to the influence of the wider social network if this knowledge generalizes. The first stages of all psychotherapy, as we see below, imply the conveyance of information from the therapist to the patient about the patient’s mental state. But it is not what is “taught” in therapy that brings change; rather, in effective therapy an evolutionary capacity for learning from others is rekindled. Given the multiple sources, severities, and consequences of trauma, a person-centered approach to treatment is more promising than a disordercentered one (Luyten et al. 2008). Such an approach involves recognizing and responding to the patient’s mind in the context of a secure attachment relationship, enabling the therapeutic dyad to mentalize previously unbearable emotional states. This sets in motion two critical processes that relate to how we conceptualize the subjective experience of trauma. In the first process, the patient’s mind is no longer experienced as being alone, unable to access the relational referencing that can meaningfully frame adversity and make fear manageable. In the second, overlapping, process, the patient is able to become open to social communication through the reemergence of epistemic trust, which can enable him/her to further harness the human capital around him/her to create a sense of safety.



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COMMUNICATION SYSTEMS UNDERPINNING THE MECHANISM FOR CLINICAL CHANGE We suggest that effective treatments of trauma in cases where impaired mentalizing capacity and the loss of epistemic trust has led to considerable difficulties in personal functioning tend to work because they reopen epistemic trust through a process of careful modeling, scaffolding, and support of mentalizing in the patient (Fonagy, Luyten, and Allison 2015). This process can be broken down into three systems, which tend to follow linear but overlapping trajectories that have a cumulative effect. Communication System 1: The Teaching and Learning of Content

This first system encompasses all different effective therapeutic schools, including psychoanalysis. It entails the therapist conveying to the patient a model for understanding the mind that the patient can understand as involving a convincing recognition and identification of his/her own state (i.e., marked mirroring). This may, in itself, lower the patient’s epistemic vigilance. This process of locating the trauma and its effects within the therapeutic model is one that can be undertaken effectively and meaningfully only if the therapist is able to mentalize it with the patient. At the beginning of this chapter we defined trauma as arising from a sense of the mind being alone; through the therapist’s efforts to mentalize the patient, an attempt is made to markedly mirror the trauma for the patient in a way that indicates that another mind is able to tolerate and contain some of the patient’s unmanageable feelings of distress and isolation. Communication System 2: The Reemergence of Robust Mentalizing

Through the process of communicating to the patient, the therapist’s understanding and framing of trauma, the therapist is in effect recognizing the patient’s sense of agency and subjectivity. The therapist, through ostensive cueing in the form of careful mentalizing, is showing that he/she understands the patient’s perspective and is presenting to the patient information that is personally relevant and generalizable. This communication system constitutes a complex and ongoing process by which the therapist is modeling his/ her mentalizing in relation to the patient in a way that retains a sense of the patient’s own intentional agency in relation to how this knowledge might be relevant, comprehensible, and meaningful. This process is effective when it becomes a process of collaborative social communication that supports the

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patient’s attempts to mentalize in relation to the relationship with the therapist, and their shared thinking about the content discussed in the consulting room. This is a circular process: when the patient is once again open to social communication in interpersonal contexts previously blighted by epistemic hypervigilance, he/she shows increased interest in the therapist’s mind and the therapist’s use of thoughts and feelings, which stimulates and strengthens the patient’s capacity for mentalizing. Improvements in mentalizing or social cognition may thus be a common factor across different effective interventions: they share in common this benign virtuous cycle arising from the experience of two minds working together in a mutually mentalizing way. Communication System 3: The Reemergence of Social Learning

The relaxation of the patient’s hypervigilance via the first two systems of communication enables the patient to become open to social learning more widely. The third communication system stimulates another virtuous cycle, in which the patient applies his/her new mentalizing and communicative capabilities to wider social learning outside the consulting room. This final part of the process depends upon the patient having a sufficiently benign social environment to allow him/her to gain the necessary experiences to validate and bolster his/her mentalizing, and to continue to facilitate relaxation of epistemic mistrust, in the wider social world. MENTALIZATION-BASED TREATMENT Originally developed for the treatment of borderline personality disorder (BPD), mentalization-based treatment (MBT) has recently grown into a more comprehensive approach to the understanding and treatment of mental disorder in a range of settings, and mentalizing techniques are now being used for the treatment of drug addiction; eating disorders; personality disorder in adolescents, particularly those who self-harm; and in work with families in crisis (see Bateman and Fonagy 2012); it has also been applied in the treatment of posttraumatic stress disorder (PTSD). The aim of MBT is to work to improve the mentalizing capacity of the patient and to seek to increase the robustness of the individual’s ability to maintain more balanced mentalizing when confronted with challenges that might typically render mentalization less stable, for example in situations of raised interpersonal affect (Bateman and Fonagy 2012). The process by which this aim is approached is inevitably nonlinear, and the therapist’s mentalizing stance is crucial to this process. The work of mentalization-based therapy



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involves patient and clinician jointly engaging in scrutiny of the patient’s mental state (Bateman and Fonagy 2016). The clinician’s own mentalizing is an active part of this process: The clinician consistently seeks to build and, critically, to rebuild a perspective in his/her own mind of what might be happening in the patient’s mind. This rebuilding is crucial because, in this, the clinician is following the patient’s state of mind (rather than his/her behavior) in the here and now. This is the case even if the patient is discussing past events—the clinician’s concern is with the patient’s current experience when talking about these events. “In effect, the clinician moves from an interest in the events themselves, to the patient’s experience of the events at the time, to his reflection about the events, to his current feelings about talking about the events” (Bateman and Fonagy 2016, 182). The clinician’s mentalizing stance underpins this process. It is particularly relevant in the course of working with a patient who has experienced trauma arising from political violence or state repression, for whom there will often be a need to discuss events, actions, and behaviors both in the past and the present. The task of the clinician in the course of these conversations is to retain a focus on the patient’s current state of mind in relation to these events, while supporting the legitimacy of discussing them. In a dialogue about past events, the focus on mentalizing does not mean that no emphasis should be placed on establishing the facts surrounding events. Indeed, the therapist must alternate between eliciting narratives of actual events and the mental states surrounding those events at the time and, more importantly, the mental states elicited in therapy while remembering that event. Questions that elicit the details surrounding an experience may precede a process of rewinding in order to then discuss the patient’s state of mind in relation to those details, a common technique in mentalization-based treatment (Bateman and Fonagy 2016). According to our formulation of the nature of the traumatic effect arising from political violence and repression, as discussed above, the MBT therapeutic stance may constitute a relevant technique because of its emphasis on the social referencing of mental states, from which the patient in this context may have been systematically alienated. The technical manual of MBT summarizes the elements of the stance as one that strives for understanding and, as such, is based on a sense of “not knowing,” highlighting the opacity of mental states. This acknowledgment of human uncertainty in relation to mental states requires humility and authenticity from the therapist, recognizing his/her own mistakes and making their thought processes available to the patient (Bateman and Fonagy 2016). The mentalizing therapist is a curious therapist, whose major tool is active questioning. Interventions are straightforward and short. They are based in the current affect and aim at slowing down the patient in the face of emotional reactivity

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by encouraging explicit thinking about internal mental states, while shifting fluidly to maintain a balance of mentalizing in relation to self and to others. Although MBT has substantial roots in psychoanalysis, it strives to enhance mentalizing skills for the sake of effectiveness in interpersonal and intrapersonal problem-solving, rather than the attainment of insight. In that sense, MBT proscribes the use of phrasings like “what you mean is . . .” or “what you really feel is . . .” (Bateman and Fonagy 2016, 241). Those interventions are a sign of a therapist losing his or her own mentalizing capacity, perhaps even in the context of political trauma identifying with the totalitarian object, thwarting the patient’s agency. The focus on the unconscious is deemphasized in favor of near-conscious or conscious processes, closer to the experience of the patient. By the same logic, one of the most relevant interventions early in treatment is the validation of the subjective experience of the patient, regardless of its ideological foundation. This process of validation is the source of social referencing. It is more important to recognize the feeling of injustice (mental state) emanating from a patient when remembering a political detention than to recognize that the detention was unjust (an ideological position). With the use of ostensive cues, by authentically and explicitly validating the patient’s subjectivity and intellectual agency, the patient’s mind is no longer alone in approaching those (traumatic) mental states, and a process of working-through can start taking place. MBT uses transference and countertransference in a qualified sense (Bateman and Fonagy 2012): along with other relationships, the patient–therapist relationship is addressed in the service of improving mentalizing. The therapist and patient must discuss how they arrive at their current model of each other in their own minds, especially when those models are conflicting. This approach requires a high degree of transparency on the part of the therapist, which serves as a model of transparency for the patient—being able to speak directly and forthrightly about the experience of the relationship. It is not possible to provide a comprehensive guide to MBT within the confines of this chapter: more detailed accounts of MBT are available for the reader who might wish to learn more (Bateman and Fonagy 2012, 2016). Broadly, the ideal outcome of MBT is the patient’s internalizing of the mentalizing stance, the crux of which is an enduring inclination to explore and understand mental states with an open-minded and curious attitude. The sense that all subjective experiences can be thought about, questioned, and reappraised can rekindle the capacity to learn from the social world, making effective outcomes possible (this is Communication System 3 in the communication systems discussed above). The effectiveness of MBT for treating BPD has been examined in several randomized controlled trials, culminating in an eight-year follow-up study



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(Bateman and Fonagy 2008). In comparison to treatment as usual, MBT decreased suicide attempts, emergency-room visits, inpatient admissions, medication and outpatient treatment use, and impulsivity. Far fewer patients in the MBT group met criteria for BPD at the follow-up point (13 percent vs. 87 percent). Moreover, in addition to symptomatic improvement, patients in the MBT group showed greater improvement in interpersonal and occupational functioning. Similarly, the intensive outpatient program proved more effective than structured clinical management for BPD at the end of the eighteenmonth treatment period (Bateman and Fonagy 2009). Compared with the control group, the outpatient treatment resulted in lowered rates of suicidal behavior and non-suicidal self-injury, and fewer hospitalizations; in addition, the MBT group showed improved social adjustment coupled with diminished depression, symptom distress, and interpersonal distress. CONCLUSION Trauma, particularly attachment trauma, has been a central topic in the theory and practice of mentalizing. In this chapter, we have sought to apply this thinking to how we approach trauma arising from the experience of totalitarianism. As with early attachment trauma, the pathogenic element of state violence is its capacity to isolate individual minds through physical violence and psychological manipulation, making them incapable of social referencing. This provokes the shutting down of epistemic trust, rendering individuals incapable of trusting their social world, hindering in turn the capacity to understand and work through their position of victim (or perpetrator) of violence. Infants who are born amid political violence might find their parents unable to mirror constitutional states related to aggression, paving the way for dysregulation of aggressive tendencies. Together with other authors, we agree that the capacity for mentalizing previous to trauma constitutes an important protective factor, and that the best prevention for the harmful consequences of political trauma is maintaining secure, intimate, warm, and affectionate relationships. Regarding implications for treatment, we delineate our understanding of the way that working with mentalization strives to reestablish the opportunities for social referencing of mental life through the reopening of epistemic trust. This reopening is achieved by the patient’s repeated experience of a therapist striving to understand his or her mind in a secure therapeutic relationship. The rekindled capacity for epistemic trust allows the social referencing of mental states in the patient’s extra-therapeutic, wider social context.

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Despite the paucity of research and the limited experience of the mentalizing models in treatment of victims of political violence, we suggest that the potential of the concept to inform psychotherapeutic work with these patients might warrant further consideration. REFERENCES Alessandri, Steven. 1991. “Play and Social Behavior in Maltreated Pre-schoolers.” Development and Psychopathology 3: 191–206. doi: 10.1017/S0954579400000079. Allen, Jon G., and Peter Fonagy. 2014. “Mentalizing in Psychotherapy.” In Textbook of Psychiatry, edited by Robert Hales, Stuart Yudofsky, and Laura Weiss Roberts. Sixth edition. Washington, DC: American Psychiatric Publishing. Bateman, Anthony W., and Peter Fonagy. 2008. “8-Year Follow-up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment versus Treatment as Usual.” American Journal of Psychiatry 165: 631–38. doi: 10.1176/appi.ajp.2007.07040636. ———. 2009. “Randomized Controlled Trial of Outpatient Mentalization-Based Treatment versus Structured Clinical Management for Borderline Personality Disorder.” American Journal of Psychiatry 166: 1355–64. doi: 10.1176/appi .ajp.2009.09040539. ———, eds. 2012. Handbook of Mentalizing in Mental Health Practice. Washington, DC: American Psychiatric Publishing. ———. 2016. Mentalization-Based Treatment for Personality Disorder: A Practical Guide. Oxford: Oxford University Press. Berthelot, Nicolas, Karin Ensink, Odette Bernazzani, Lina Normandin, Patrick Luyten, and Peter Fonagy. 2015. “Intergenerational Transmission of Attachment in Abused and Neglected Mothers: The Role of Trauma-Specific Reflective Functioning.” Infant Mental Health Journal 36: 200–12. doi: 10.1002/imhj.21499. Bouchard, Marc-André, Mary Target, Serge Lecours, Peter Fonagy, Louis-Martin Tremblay, Abigail Schachter, et al. 2008. “Mentalization in Adult Attachment Narratives: Reflective Functioning, Mental States, and Affect Elaboration Compared.” Psychoanalytic Psychology 25: 47–66. doi: 10.1037/0736-9735.25.1.47. Camras, Linda A., Sheila Ribordy, Jean Hill, Steve Martino, Virginia Sachs, Steven Spaccarelli, et al. 1990. “Maternal Facial Behavior and the Recognition and Production of Emotional Expression by Maltreated and Nonmaltreated Children.” Developmental Psychology 26: 304–12. Camras, Linda A., Ellen Sachs-Alter, and Sheila Ribordy. 1996. “Emotion Understanding in Maltreated Children: Recognition of Facial Expressions and Integration with Other Emotion Cues.” In Emotional Development in Atypical Children, edited by Michael Lewis and Margaret Wolan Sullivan. Mahwah, NJ: Lawrence Erlbaum Associates. Chiesa, Marco, and Peter Fonagy. 2014. “Reflective Function as a Mediator between Childhood Adversity, Personality Disorder and Symptom Distress.” Personality and Mental Health 8: 52–66. doi: 10.1002/pmh.1245.



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33 The Treatment of Trauma The Neurosequential Model and “Take Two” Annette Jackson, Margarita Frederico, Allison Cox, and Carlina Black

This chapter describes the Berry Street Take Two program and its applica-

tion of the ChildTrauma Academy’s Neurosequential Model of Therapeutics (NMT). Take Two is a therapeutic service developed to assist children who are in recovery after experiencing abuse and neglect. NMT is a neurodevelopmental model that guides clinical practice when children have been exposed to trauma and deprivation, usually in the context of relational poverty. As such, this has been a beneficial pairing of service and model. Through discussion of the interrelationship of Take Two and NMT, we examine the developmental impacts of trauma and deprivation, recognizing that they can have lasting negative consequences for infants, children, and young people. Individually tailored therapeutic approaches, in concert with other rewarding experiences, can help children in their recovery and their move toward lasting positive changes. The power of culture is also explored: this helps explain the impact of separating children from their culture, and the healing power of cultural connection. We outline how the Take Two program and its application of NMT facilitate the application of such approaches. We conclude by discussing aspects of trauma and healing for Australian Aboriginal and Torres Strait Islander children and their communities, First Peoples who lived in Australia for over sixty thousand years prior to European invasion and colonization. Today, Aboriginal and Torres Strait Islander people make up 3 percent of Australia’s population (Australia Bureau of Statistics [ABS] 2011). The intergenerational and community-wide traumas they have suffered in the context of colonization are reflected in their overrepresentation in the child protection system. Similar patterns of disadvantage have been found in other Indigenous communities of other colonized countries. 423

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METHOD The data reported on in this chapter is from an analysis of the first ten years of the Take Two client group (2004–2013) (Berry Street Take Two 2016). Descriptive data from referral documentation and a de-identified case study are presented. Ethics approval was received from the Department of Human Services and La Trobe University. THE SERVICE AND MODEL Take Two

The Berry Street Take Two program is a statewide therapeutic service for child protection clients in Victoria, Australia. Victoria is the second most populous state in Australia, with approximately 5.9 million people, of whom approximately 1.3 million are children (ABS 2016). In 2016–2017, the Victorian child protection service substantiated 15,488 reports of children being at risk of significant harm due to child abuse and neglect (Australian Institute of Health and Welfare [AIHW] 2018). Take Two works with approximately 700 of these children a year. Established in 2004, Take Two is funded by the Victorian state government to provide a therapeutic service, with embedded research and training, and employs approximately ninety staff, located in fourteen offices throughout metropolitan and rural Victoria. Take Two is a program run by Berry Street, which is the largest child and family community service in Victoria, and one of the largest in Australia. It is a partnership with La Trobe University, Mindful Centre for Training and Research in Developmental Health, and the Victorian Aboriginal Child Care Agency (VACCA). Take Two works with children from infancy to seventeen years of age who are at risk of developing, or are already demonstrating, emotional and/or behavioral difficulties as a result of exposure to trauma and deprivation. Even when children are not yet showing difficulties, their experience of trauma suggests they are highly vulnerable. Whether or not they show particular mental health symptoms, and not all do (Perry et al. 1995), children with adverse experiences have significantly increased risk for poor life outcomes. These can include impoverished physical and mental health, and earlier mortality (Anda et al. 2006). The Take Two approach emphasizes the need to understand the children’s experience of trauma and disrupted attachment within their developmental, relational, cultural, and environmental context. Take Two intervenes at mul-



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tiple levels to harness resources available to the children and to build on their strengths (Jackson et al. 2009). The therapeutic response of Take Two is based on the primary understanding that the child has experienced trauma and has usually been denied important developmental and/or relational experiences, requiring opportunities for recovery and healing. The therapeutic response, which commonly involves direct therapy by a clinician, acknowledges there are a number of agents for change, especially those in the child’s day-to-day life (Griffin, Germain, and Wilkerson 2012). In its first ten years (2004–2013), Take Two worked with 2,473 children in 3,087 episodes of care. The gender distribution was 50.5 percent males and 49.5 percent females. At time of referral, 18 percent were less than six years of age, 30 percent were between the age of six and eleven years, and 52 percent were between twelve and eighteen years. There was an overrepresentation of Aboriginal children, with an increasing trend from 15 percent of the Take Two client group in 2004 to 25 percent in 2015. This is in contrast to the percentage of Aboriginal children in the general Victorian population (1.6 percent), and the percentage of Aboriginal children in Victoria where there was substantiation by abuse or neglect (12 percent) (AIHW 2017). Eighty percent of children referred to Take Two were in out-of-home care, such as foster care, residential care, and kinship care. There were 2,210 episodes relating to statewide provision of ongoing clinical work for children living with parents or in out-of-home care. Although NMT principles are applied throughout Take Two, it is this specific role where NMT tools are directly applied. Neurosequential Model of Therapeutics

NMT, developed by Dr. Bruce D. Perry from the ChildTrauma Academy, “helps match the nature and timing of specific therapeutic techniques to the developmental stage and brain region and neural networks mediating the neuropsychiatric problems” (Perry and Hambrick 2008, 38). NMT is not an intervention or technique. Rather, it provides a means of considering the best intervention “fit” for the child’s state and functioning (Perry 2009). NMT is described as a promising approach to working with children of different ages who have experienced trauma (Brandt et al. 2012; Twardosz and Lutzker 2010). NMT involves an intertwined neurodevelopmental and bio-ecological perspective. It applies neuroscience and other perspectives and frameworks, such as child development, trauma, and attachment, to understand the mechanisms for harm and the potential mechanisms for recovery. It encourages the

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enlistment of the child’s intimate and broader social world in a sequential approach to interventions. Although the model looks across the biopsychosocial continuum for gathering information and planning interventions, it is through understanding brain development in both healthy and toxic situations that NMT offers particularly valuable insights (Perry and Hambrick 2008). NMT provides an important perspective for understanding the interconnecting physical, sensory, psychological, and social implications of trauma and recovery for the child. NMT consists of a set of neurodevelopmental principles that have informed policy, programs, and practice. A number of these principles are described later in this chapter. An example of the interface between these principles and policy implications is that programs and practices that promote safe, predictable, nurturing and enriched intrauterine and early childhood experiences will be much more likely to promote optimal brain organisation and functioning than programs that seek to influence and change the brain later in life. That is not to say that trying to influence, modify and change the brain later in life is ineffective or a worthless activity—far from it. It is just that early life provides a unique, powerful, efficient and cost-effective opportunity to help children become healthy, creative, productive and humane. (Perry and Jackson 2014, 4)

Beyond these widely applicable principles, NMT constitutes heuristic semistructured tools imbedded within an overarching clinical practice tool available to those formally certified in the approach. These tools assist clinicians to complete the three steps of an NMT assessment: (1) assessment of the child’s history of adversity and relationships, (2) a review of the child’s current functioning (the brain map), and (3) recommendations to consider across a range of domains in the child’s world (Perry and Hambrick 2008). Becoming certified to apply the NMT tools involves a guided online and interactive theory and case-based training process of approximately ninety hours, access to trainers and mentors, participating in biannual fidelity checks, and access to a series of psychoeducation and other materials. NMT is overtly person centered, recognizing each child has traveled his or her own pathway. The intervention plans acknowledge that this individual path continues into the child’s future, and the aim is to tailor each child’s plan according to context and developmental readiness. The intervention plan involves a multidimensional approach that engages with elements such as school, community, and family, as well as the individual child, in order to address the complexity of the child’s experiences and current situation. “The power of relationships and the mediation of therapeutic experiences in culturally respectful relational interactions are core elements of NMT recommenda-



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tions” (Perry and Dobson 2013, 256). Thus, NMT recognizes the power of a child’s culture as part of the healing process. In particular, traditional healing practices in many Indigenous communities use elements that are necessary for therapeutic intervention, such as rhythm, relationship, and regulation (Gaskill and Perry 2014). THE FORMS OF TRAUMA WE TREAT Child abuse and neglect are often described as primary examples of complex trauma (Cook et al. 2005; Herman 1997) and developmental trauma (van der Kolk 2005). NMT is applicable to working with children who have experienced any type of trauma, but it is particularly suited for children who have suffered abuse and neglect. Children referred to Take Two have experienced abuse and/or neglect as substantiated by child protection services. Ninety-five percent of children referred had experienced multiple forms of extreme or serious maltreatment. Nearly all children (93 percent) had experienced emotional abuse, 81 percent had been exposed to abandonment/lack of supervision/parental incapacity, 80 percent had been physically abused, 60 percent had been exposed to developmental and medical harms, and 31 percent had experienced sexual abuse. Over two-thirds (69 percent) had been exposed to family violence. These multiple experiences of harm reflect the degree of complexity of the client group and the importance of an evidence-informed and flexible approach to intervention. SYMPTOMS AND PRESENTATION The Take Two referral documentation completed by child protection workers demonstrates that most referrals are for children already showing major difficulties. In the first ten years, according to referral information, these difficulties in presentation of the children included the following: • difficulties with attention/hyperactivity (81 percent) • attachment difficulties (78 percent) • lack of trust (72 percent) • lack of sense of belonging (64 percent) • changes in mood or affect (58 percent) • lack of sense of permanence (57 percent) • lack of sense of future (51 percent) • no or limited school attendance (51 percent)

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• poor or confused identity (46 percent) • conduct problems (45 percent) • violence to others (41 percent) • absconding/running away (41 percent) • no or minimal friendships (40 percent) • risk-taking behaviors (38 percent) • lack of sense of safety (37 percent) • substance abuse (34 percent) • anxiety (33 percent) • sexual violence toward others (32 percent) NMT is suitable for any presentation and provides the means of recording children’s current functioning in terms of both difficulties and strengths. It can also be applied with adults, such as adults who have experienced childhood trauma and parents or caregivers of children. THEORETICAL APPROACH AND CONCEPTUALIZATION OF THE APPROACH From the outset, Take Two has been developing and refining its conceptual framework and therapeutic interventions to best achieve positive outcomes for this heterogeneous and complex group of children and their families and caregivers. Drawing on Anglin’s (2002) criteria for therapeutic intervention, Take Two aimed to be guided by a research-informed theoretical and practice framework and a comprehensive assessment of the child’s history, current functioning, and situation. It also focused on bringing about directed change for a child and/or for those with a major influence on the child, and to do so through individualized and collective therapeutic and relational attention (Frederico, Jackson, and Black 2010). Through a continuous exploration of the literature we have concluded that to date, there is insufficient evidence to rely on any one approach for this diverse and vulnerable population (Fraser et al. 2013; Gillies et al. 2012). Consistent with Sackett and colleagues’ (1996) description of evidencebased practice, Take Two continues to review the research, utilize evidenceinformed practices when applicable, apply clinical wisdom and understanding of the client group, and ensure we take into account the child’s and family’s preferences.



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Take Two’s Theoretical Underpinnings

Given that Take Two clients have experienced multiple types of maltreatment, it is necessary to use a combination of theories to aid understanding of the effects of cumulative harm and to provide a basis for intervention (Jackson et al. 2009). The nature of the work is to promote opportunities for healing and recovery for children and families who have experienced trauma; hence, trauma theory is fundamental. A commonly understood and useful trauma-specific framework is the phased approach to treatment. This begins with safety and stabilization, including establishing self-regulation, followed by the creation of an opportunity for the person to integrate their experiences of trauma into a coherent narrative that no longer has the power to invoke fear. Finally, help is given in reintegration and reconnection with broader social supports (Ford and Cloitre 2009; Herman 1997). Take Two is a trauma-specific service, but it is not trauma limited: trauma theory is not the only theory that guides the program or interventions. “Trauma-specific” refers to therapeutic approaches that aim to help people manage and reduce trauma-related symptoms and integrate their experiences of trauma so that these no longer intrude on the present. It includes understanding that traumabased behaviors are best understood as efforts to survive an unsafe world (Fallot and Harris 2006). A bio-ecological approach (Bronfenbrenner 1979) offers a useful way of explaining the complex and systemic interactions within the child’s world. Developmental theories are also considered essential. This is particularly important when the experience of abuse and neglect can disrupt not only children’s current functioning, but also their developmental trajectory (Perry et al. 1995). Attachment theory (Bowlby 1969) provides insight regarding the vital role of relationships in children’s development and the effect of trauma on their view of themselves, their relationships, and the world around them. Thus, the four most influential and overlapping theories that anchor Take Two’s practice are bio-ecological, trauma, attachment, and developmental theories. Take Two’s framework is founded on a culturally respectful approach that “provides an encompassing lens with implications for how the other perspectives are applied in practice” (Jackson et al. 2009, 200). This has particular emphasis on Aboriginal children and families but is relevant to children from other cultures. Another tenet underlying Take Two’s work is that it is person centered. This necessitates ensuring that the voices of the child and family guide the goals, and that interventions are tailored to the individual and his or her context (Jackson and Waters 2015). These theories and other considerations emerging from practice continue to inform the Take Two theory of change. For example, neuroscience and

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psychology shed light on potential targets for change, such as how to increase physical and emotional regulation and how to build childrens’ and families’ resilience. Similarly, understanding the child’s social world is key to effecting and sustaining any change. A system’s understanding is highly relevant given the multiple formal and informal systems the children are engaged in, the experiences for many of multiple placements, and the common uncertainty of their future plans. Overall, Take Two employs a biopsychosocial approach to considering the range of potential mechanisms for harm and mechanisms for positive change. We developed a set of practice principles through consultation with stakeholders and informed by the literature. These principles continue to provide the foundation for Take Two’s practice (Frederico, Jackson, and Black 2005, 2010). Examples include the following: • Therapeutic intervention begins with establishing safety and reducing harm. If a child’s safety is not assured, this is the first target of intervention. • Engagement of clients is the responsibility of the service, not the client. A proactive, creative, and persistent approach is required to form meaningful therapeutic relationships with children, families, and carers. • Interventions should be informed by a holistic and comprehensive assessment of the child, child’s history, and current circumstances. • Interventions should consider a child’s developmental readiness and the capacity of parents or carers to provide consistent, nurturing care. • Therapy should be provided in the location most likely to facilitate engagement, including outreach to the home or school. (Downey 2004) The Take Two model privileges safety and healing in equal measure and both are ever-present considerations. Safety and stability do not have to be “established” for intervention to begin; indeed, a critical therapeutic intervention is the promotion of safety and reduction of harm during the first phase of intervention. As maltreated children are harmed within the context of relationships, their healing must occur within relationships. In many cases, these children are not living in safe or stable circumstances. Their needs are therefore not about protection alone, nor are they therapeutic alone. They require an approach that responds to both imperatives. Take Two’s overarching therapeutic model works in three overlapping but distinct ways to support recovery through relationships (see figure 33.1). These are described in order of the direct influence of the Take Two clinician. First, Take Two focuses on what happens in therapy between the clinician and the child and/or those in the child’s life, such as therapy with parents,



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Figure 33.1.   Three overlapping levels of focus for Take Two’s therapeutic work.

carers, and siblings. Second, Take Two focuses on facilitating what happens in the child’s social world to contribute therapeutically to the child’s recovery (Frederico et al. 2010). Perry (2006) describes this as the therapeutic web. Third, Take Two works at the system level, contributing to the system’s efforts to construct a world around the child that is therapeutic, but also to advocate and challenge when concerns are held regarding aspects of the system being detrimental to the child. Neurosequential Model of Therapeutics Approach

From the beginning of Take Two in 2004, it was informed in part through the publications from the ChildTrauma Academy. In 2008, Take Two decided to become formally certified in NMT. There are numerous overlapping neurodevelopmental principles associated with NMT, some of which are listed below. These are hallmarks of NMT, informed by research by the ChildTrauma Academy and other researchers. This research has direct relevance to the work of Take Two and informs its theory of change. NMT principles include the following: • The brain is organized hierarchically with sensory input entering through the lower parts of the brain. This includes sensory inputs that are pleasurable, such as the sound of the mother’s voice, the touch of her skin,

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the rhythm of her rocking. However, for children who have experienced abuse and neglect, these sensory inputs may represent threat rather than reward. • Although the brain is formed of interconnecting networks and systems, different functions are primarily mediated through specific areas. The lower parts of the brain mediate essential regulating functions, such as respiration and heartbeat. Higher parts of the brain mediate more complex functions, such as capacity for relationships and cognitive functions. • The stress response system involves multiple areas and networks in the brain. As parts of the stress response are mediated through the lower parts of the brain, they are pre-cortical and not directly available to conscious thought and control. • The brain makes associations with co-occurring sensory input. This is how we learn what a flower looks like, sounds like, tastes like, feels like, and smells like. This helps us know what a flower is. However, this developmental gift also means that if a child receives input that when she cries she hears yelling, experiences pain and numbness, and feels sick in her stomach, she learns that this is what parenting is, or what being a child is about. Such lessons of life may generalize to other situations, such as when she is in the presence of any adult or any time she cries. • Our brain changes in a use-dependent fashion. Children are born with more neurons than they need, and in the first few years, they develop a large number of synaptic connections. Over time a number of neurons die. Typically, synapses are re-absorbed when not sufficiently activated or used, described as the “use it or lose it” principle. For example, children are usually born with the potential to learn any language but will actually only learn the language they are exposed to. As such, some of the unused neurons and connections die or are re-absorbed in a normal neurodevelopmental process. We understand that if we want a child to learn to ride a bicycle, she needs to practice on a bicycle. If we want a child to show empathy, he needs to experience empathy and have opportunities to practice empathy. The child needs patterned repetitive activity in the specific area of development in order to change, grow, and develop in that area. • Certain parts of the brain develop at different rates at different ages. The brain develops sequentially and hierarchically, beginning with less complex areas, such as the brainstem, to more complex areas, such as the cortex. Optimal development of more complex brain systems requires the healthy development of less complex brain systems. Lower areas of the brain develop, organize, and become fully functional at an earlier age. • Although the brain continues to develop and organize throughout childhood and into adulthood, and has a number of key times of increased



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development, its most active development occurs in the early years. This means that although change is possible throughout life, early life trauma, such as through abuse and neglect, will most likely have a disproportionate impact on the child. • The area of the brain actively developing is the most receptive to the environment at the time. Thus, if we want to help the child develop in a certain area, learn a particular skill, or change a particular behavior or response, we need to activate that area in order for changes to occur (Perry 2006; Perry et al. 1995). There are many clinical implications for these and related NMT principles, such as those mentioned earlier regarding program and policy design, as well as the need to tailor interventions, not only to the children’s age, but also to their developmental readiness and recognizing their state-dependent functioning. A key assumption of NMT following from this understanding is the need to plan interventions recognizing the sequential nature of brain development. Another key assumption is that interventions “must provide adequate patterns and frequency of experiences that will activate and influence the areas of the brain that are mediating the dysfunction” (Barfield et al. 2012, 32). A primary application of these principles was the design and implementation by the ChildTrauma Academy of the NMT clinical practice tool. The NMT clinical practice tool is structured in four parts (see figure 33.2) with a series of Likert scale questions. Parts A and B have questions about the child’s history of adversity and relationships. The tool is based on the premise that we not only need to know what has happened to the child, but the child’s age when it occurred. This helps to consider the child’s developmental stage and resulting implications and provides a sense of the chronicity of adversity and the presence or absence of positive relationships. Part C of the NMT clinical practice tool is about the child’s current functioning. Questions are asked about certain physiological, sensorimotor, regulation, relational, emotional, and cognitive functions. Part C is often referred to as the brain map. Part D seeks information about the child’s current access to positive safe relationships, including the child’s immediate and extended family, carers, school, community, culture, and other potential sources of support. Although NMT is not an intervention in itself, the clinical practice tool provides recommendations from a suite of evidence-informed interventions and strategies depending on the focus and goals of intervention. Table 33.1 outlines the four possible foci of child-focused interventions, which are graphically presented in the clinical practice tool as functional domains. This table describes what such interventions would aim to target within the NMT

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Figure 33.2.   An overview of the NMT process.

approach and includes examples of interventions that may be recommended from the clinical practice tool (Perry and Dobson 2013). The NMT clinical practice tool also indicates which of these foci are essential, therapeutic, or enriching for each child. For example, one clinical practice tool may indicate that for one child all foci of intervention are essential, as the child is seriously developmentally and functionally compromised. In this situation, NMT would recommend beginning with interventions that target the lower areas of the brain in order to lay down foundations for subsequent interventions. This is based on the sequential nature of development



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Table 33.1.   Focus of NMT Interventions and Examples Focus / Functional Domains

Target of interventions

Sensory integration

Poorly organized somatosensory systems in the brain

Self-regulation

Poor capacity to selfregulate, such as poor stress response

Relational

Poor or underdeveloped capacity to form and sustain healthy relationships

Cognitive

Negative, unhelpful, delayed, or distorted thinking that contributes to other difficulties

Examples of child-focused interventions Patterned repetitive somatosensory activities such as: massage, music and movement, yoga, animal-assisted therapy Structure and predictability with consistent adults, and patterned repetitive activities, such as: occupational therapy activities, deep breathing exercises, music and movement, sports, nighttime routines, animalassisted therapy Predictable interactions with positive healthy adults who will not invade child’s sense of safety, psychotherapy, dyadic therapy, family therapy, animal-assisted therapy, cultural activities, group work, etc. Speech and language therapy, insight-oriented psychodynamic treatment, cognitive behavioral therapy, family therapy, lifestory work, cultural activities, etc.

and reflects the sequential nature of the model. Another child, on the other hand, may have a clinical practice tool that indicates that the only essential focus of intervention is the relational domain. For this child, interventions focusing on other areas are described as having either therapeutic or enriching value. In other words, they are useful but not as essential as interventions that target the child’s capacity to form and sustain relationships. NMT emphasizes the sequencing of interventions with lower areas of brain function targeted before higher areas of functioning. For example, if the child is already able to self-regulate, but is distressed by memories of traumatic events, the tool will likely suggest cognitive behavioral and insight-based interventions. However if the child is dysregulated both physically and emotionally, the tool will more likely suggest interventions focused on physical, sensory, and relational regulation before asking the child to delve into disruptive memories.

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INTERVENTIONS Intervening effectively with children who have experienced trauma is not a linear process. Thus, multiple modalities can be used concurrently to effect change with children, their families, and in the systems surrounding them. Take Two’s therapeutic approach includes individual work with the child, dyadic work with the child and parent(s) or carer(s), family work, and/or system work. Similarly, NMT makes recommendations for interventions at the child, family, and system level. Barfield and colleagues (2012) describe NMT’s six core elements of positive developmental, educational, and therapeutic experiences for children who have experienced trauma: • Relational—Providing positive, safe relational experiences for the child in a way that does not further increase their stress response or overwhelm their defenses. • Relevant—Ensuring that interventions and other approaches are developmentally matched to the child, not just by age, but also with an understanding of their developmental strengths and gaps. • Repetitive—Providing a level of repetition that is required by the brain to make and sustain changes. • Rewarding—Building on the child’s interests and what he or she find pleasurable so that the reward center of the brain receives positive stimuli, instead of just harmful stimuli, such as alcohol and other drugs. • Rhythmic—In order to resonate with the child’s neural patterns, providing rhythmic interventions and interventions in a rhythmic way. This is particularly important if they have had a neglectful and traumatized early childhood, which may have altered their rhythmic patterns and thus disrupted their ability to self soothe or be soothed and regulated by others. • Respectful—Ensuring practice genuinely respectful of the child, the family, carers, and culture. Table 33.2 outlines how each of the NMT core elements of intervention can be implemented at the bio-ecological, family, or individual level (Jackson 2014). This is not a complete description but illustrates how each NMT element of intervention can look in practice. Consistent with NMT, Take Two clinical practice identifies therapeutic interventions or techniques to enact the mechanisms of recovery for children, and develop a therapeutic plan (informed by assessment, the NMT clinical decision-making process, and client’s wishes) as to the sequence, timing, and frequency of interventions. Examples of interventions used by Take Two are:



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• Somatosensory activities to help regulate the child’s physical, emotional, or behavioral state in the home or school (e.g., Dunn 1999) • Attachment-informed interventions to help the parent or carer coregulate and be responsive to the child’s needs, such as Dyadic Developmental Psychotherapy (Hughes 2009) and Theraplay (Booth and Jernberg 2010) • Trauma-specific interventions when a child is ready to make sense of their experiences and develop a narrative about what occurred, such as Trauma Focused Cognitive Behavioral Therapy (Cohen et al. 2004), Therapeutic Life Story work (Rose 2012), and Eye Movement and Desensitization Reprocessing (EMDR) (Shapiro 2001) • Family sensitive practice, including therapy interventions, to strengthen communication, explore ways of problem solving, and increase capacity for reflection (Carr 2000) • Play therapy to help children explore their view of the world and express their emotional state (Gaskill and Perry 2014) • Take Two’s systems work includes advocacy, psycho-education, and/or family work. Take Two primarily works with the system through a care team. This is a group of professionals, parents, caregivers, and other significant adults in a child’s life with the responsibility of providing quality nurturing care and the coordination of service delivery (Miller 2012). Whatever the technique, the purpose is always to support those with direct contact with the child to be reflective, purposeful, and therapeutic in their day-to-day interactions with the child. Figure 33.3 provides an overview of the Take Two conceptual framework including the most common therapeutic interventions applied by this service. COMMON TREATMENT ELEMENTS The Take Two service model has interconnected phases and is a cyclical process (see figure 33.4). Each phase has specific yet interrelated functions. Each phase has therapeutic intent. The Take Two Outcomes Framework has four domains: (1) child safety; (2) child well-being; (3) stability, security, and connectedness; and (4) family and community support. The framework specifies certain outcome measures to measure aspects of these domains. These measures are completed at initial assessment, review, and closure. It is important to note that NMT does not aim to replace standardized measures or other assessment processes, nor

Provide psycho-education and support to carers, school, and others regarding child’s developmental history and current functioning and the implications for how to help child feel cared for, learn, and self-regulate over time Ensure predictability and continuity in child’s life. Provide access to recreational, creative, educational, and nurturing activities that sufficiently stimulate areas of the brain to help child’s cognitive, relational, sensory integration, and self-regulatory functioning

Relevant

Repetitive

Ensure child has access to healthy sustainable relationships with a network of people in placement, school, and other settings

Therapeutic web (Bio-ecological context)

Relational

Core elements

Relational work informed by assessment of child’s capacity to accept positive intimacy. Emphasis on engagement at child’s pace.

Work with family and others to increase positive relational experiences and to help child use relationships to help regulate their stress and reward systems Provide psycho-education and support to parents, siblings, and other family and informal relationships regarding child’s developmental history and current functioning and implications for helping child feel cared for, learn, and self-regulate over time Ensure predictability and continuity in child’s life. Educate and support key people as therapeutic agents to support child’s activities to sufficiently stimulate areas of the brain to help child’s cognitive, relational, sensory integration, and self-regulatory functioning

Assess child’s cognitive, relational, sensory integration, and selfregulation functioning and match therapeutic, educational, relational, and other responses to the child’s developmental age and current state–dependent functioning Ensure sufficient repetition of positive restorative experiences required to change and sustain changes in the brain and as informed by assessment

Individual work with child

Family/ relational

Table 33.2.   Core Elements of NMT Approach to Interventions at the Bio-ecological, Family, and Individual Level

Scan child’s environment for potential pull factors or attractions that are negative and harmful and reduce/cease child’s access to these. Increase positive, healthy opportunities in child’s life that they find rewarding and pleasurable

Ensure access to recreational, creative, educational, and nurturing activities that provide a predictable rhythm that the child finds comforting and calming to help sensory integration and selfregulatory functioning

Ensure that child has access to positive contacts with those who share beliefs, culture, and other interests. Ensure system demonstrates respect for child as an individual as well as the child’s human rights

Rewarding

Rhythmic

Respectful

Support and educate key people in child’s life regarding what is important to the child and how to strengthen child’s sense of personal identity and self-efficacy

Scan child’s family life and other relationships for potential pull factors or attractions that are negative and harmful and reduce/cease child’s access to these. Increase positive, healthy opportunities in child’s life that they find rewarding and pleasurable Educate and support key people to be involved with recreational, creative, educational, and nurturing activities that provide a predictable rhythm that child finds comforting and calming to help sensory integration and selfregulatory functioning Assess child’s self-regulatory and sensory functioning to determine baseline when apparently calm and when hyper-aroused. Ensure child has access to recreational, creative, educational, and nurturing activities that provide a predictable rhythm that child finds comforting and calming Understand and respect child’s beliefs, values, and cultural and other types of identity. Help child learn how it feels to be respected and to respect others.

Get to know child and what child’s interests are. Aim to replace negative rewards (e.g., drugs, selfharm) with positive rewards (e.g., relationships, doing something consistent with beliefs)

Figure 33.3.   An overview of Take Two’s therapeutic approach and theory of change. Source: Frederico, Jackson, and Black 2010, 83.



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Figure 33.4.   Take Two service model. Source: Downey 2004, 14.

does it dictate which measures should be used. Rather it aims to complement them and to integrate their findings into the NMT process (Perry and Dobson 2013). One of the measures used by Take Two is the Strengths and Difficulties Questionnaire (SDQ) (Goodman 1997). This is a brief standardized measure of positive and negative aspects of behavioral and psychological adjustment. There are versions completed by carers, parents, teachers, and young people aged eleven years and older. Other measures used are the Trauma Symptom Checklist for Children (TSCC) (Briere 1996) and the Trauma Symptom Checklist for Young Children (TSCYC) (Briere 2005). These are standardized measures of posttraumatic symptomatology in children. The TSCC is a self-report measure by children aged eight to sixteen years old. The TSCYC is completed by carers for children aged between three and twelve years old. Take Two also uses the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) (Gowers et al. 2000). This was developed for children (three to seventeen years) and is a clinician-rated outcome measure that assesses the behaviors, impairments, symptoms, and social functioning of children with mental health problems. Goals are planned and agreed upon through consultation with the child, the family, and carer. The goals are person centered and achievable and give the child and family/carer ownership of the plan. The NMT clinical practice tools provide recommendations to be included in the Take Two plan. On average, Take Two is involved with children for seventy-five weeks with a lot of variation.

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SPECIAL TREATMENT ELEMENTS OF THE APPROACH In 2015, Take Two established the Developmental Consultancies Team with the aim of integrating understanding of the impact of maltreatment on development in order to formulate specific targeted interventions that incorporated the findings from NMT and specialist assessment. The specialist assessments include neuropsychology and occupational therapy assessments, with an aim to increase this multidisciplinary team. Neuropsychology

The neuropsychologist provides trauma-informed neuropsychological assessment, feedback, consultation, and education. She may provide direct time-limited intervention as the primary focus of Take Two’s role, or she may work with another clinician as part of a more comprehensive collaborative approach. The inclusion of this service within Take Two was informed by the evidence regarding exposure to abusive and/or neglectful care environments associated with impaired brain development (De Brito et al. 2013; Nemeroff 2004) and impaired neuropsychological (cognitive) functioning (Kirke-Smith, Henry, and Messer 2014; Vasilevski and Tucker 2015). Neuropsychology assessment is helpful when there are unexplained concerns regarding the child’s thinking abilities (e.g., very poor attention, impulsivity, memory problems, poor planning and organization), academic skills or emotional and behavioral regulation, in the context of prenatal adversity, developmental delay, recurrent early life exposure to abuse and neglect, or acquired brain injury. Occupational Therapy

Sensory processing capacities are profoundly affected by the absence of primary nourishment and nurturing, and lack of vital sensory-motor and relational developmental experiences necessary for optimal development (Cermak 2009a, 2009b; Lin et al. 2005; Miller 2012). This can result in children seeking key sensory inputs they have missed out on. These may include sufficient and age-appropriate opportunities to move, play, touch, hear, see, smell, and explore a range of sensory-motor experiences. Such sensory-seeking tendencies can have marked consequences on a child’s behavior, including attention and concentration difficulties, fidgetiness, disruptive behavior, and impacts on learning. It can also involve children avoiding certain sensory experiences that evoke powerful emotions that they may not be able to put into words. The Occupational Therapy Consultancy role focuses on improvement



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in self-regulation during the initial phase of treatment. It assists clinicians in individualizing the suite of somatosensory interventions, often recommended through NMT, through alignment of clients’ sensory preferences, specific environments, individual interests, and personal strengths. This significantly augments and strengthens the existing trauma-and-recovery-focused interventions of Take Two. HISTORICAL CONTEXT OF TRAUMA AND ITS CONSEQUENCES It is well recorded that when traumatic events are experienced by a particular person or generation of people, there can be ongoing effects in subsequent generations, even when they do not experience the trauma directly—that is, the trauma can be “passed down” (Friend 2012; Giladi and Bell 2013). Within Child Protection services, many families are at risk of, or are displaying the effects of intergenerational trauma. The Aboriginal and Torres Strait Islander population of Australia has been affected by generations of disadvantage and trauma, including invasion, colonization and massacres, displacement from land, being forced on to missions, the Stolen Generations, banned from practicing their culture and speaking their languages, stolen wages, slavery, and other racist government policies (for instance, not counting the Aboriginal and Torres Strait Islander Indigenous people as a part of the human population until 1967). Stolen Generations refers to when Aboriginal children were forcibly removed from their families by the State, which occurred in Australia largely between 1910 and 1970. They were not removed due to concerns of maltreatment but as part of a strategy to assimilate them into “white” society. During this time, Aboriginal people were also denied citizenship in Australia and were under the power of the Aborigines Protection Boards. As a result of Aboriginal children being taken from their families to be placed with “white” families or in institutions, Aboriginal families were torn apart, with major consequences to family life (Human Rights and Equal Opportunities Commission [HREOC] 1997). The myriad of government reports that outline the need to “close the gap” between Indigenous and non-Indigenous people in terms of life span, economic security, housing quality, educational achievement, and health outcomes shows clearly the immense level of disadvantage that continues today. Given Australia’s shameful history and the resulting vast disproportion of Aboriginal and Torres Strait Islander children in the Child Protection and Youth Justice systems, and in the Take Two population, understanding and responding to these multigenerational injustices is a crucial component of our service response across the service system and with individual children

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and families. Intergenerational issues are not limited to Aboriginal and Torres Strait Islander peoples, and research, theory, and practice focused on this topic spans many populations—such as holocaust survivors, descendants of those who were enslaved, refugee and war survivors, and clients of the Child Protection system. Theories of the “transmission” of trauma through the generations are varied, and Kellerman (2001) recommends an integrated understanding of the various theories to allow the best chance of understanding the person’s experience. Some of the biopsychosocial and structural mechanisms believed to account for the phenomenon of trauma being “passed” from one generation to the next (Friend 2012) include the following: • Epigenetics: external (environmental) factors that either inhibit or activate our genes. Epigenetic processes are strongly influenced by environment factors such as diet, exercise, stress, drugs and chemicals, and living conditions (Mansuy and Mohanna 2011). • Psychodynamic theory contends that trauma is passed to the child through the unconscious absorption of repressed and unintegrated trauma experiences. • Sociocultural models focus on the direct impact parents and social environment have on the child as the child learns vicariously through observation. Family systems theory can be particularly helpful to understand this, in considering the communication patterns, roles, and rules of families (Giladi and Bell 2013). • Structural barriers that perpetuate trauma (e.g., poverty and education cycle, racism, dispossession, marginalization, homelessness, unemployment); these can be understood through theories such as ecological and feminist perspectives. The research findings about the effects of intergenerational trauma are mixed, with some families and children building and drawing on their own resilience, shaped/reinforced by the resilience provided by their community and culture, and other families’ lives significantly impacted by the ongoing effects of historical trauma. There are, however, many who are resilient in the face of the ongoing effects of trauma. Clinicians need to be aware of the complexity the situation encompasses. Parents with ongoing effects from their own trauma (and possibly transgenerational trauma) may be impacted in their ability to parent well and safely. In addition to the potential consequences of trauma described earlier, some additional potential negative outcomes when considering intergenerational and cultural trauma include:



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• Interpersonal difficulties: inability to communicate feelings, impaired parental functioning, separation anxiety, and disconnection and isolation from supports; • Incomplete or fractured knowledge and understanding of family history and cultural identity, including the existence of siblings; cycles of violence and abuse; impoverished communication within the family, which may include secrecy, silence and shame; • Socio-legal difficulties: poor access to health care, education systems that are unresponsive to the child’s particular needs, poor portrayal in the media, overrepresentation in child protection and corrective services, continuing racism; • Community-level difficulties: internal conflicts; drug and alcohol abuse (at a community level, as a subculture); high levels of poverty, incarceration, disrupted relationships within the community. Children living in traumatized communities, while often surrounded by love, warmth, and humor, may be affected by the suffering of the community. However, it is critical to note that not everyone who has experienced trauma as a child has poor outcomes or goes on to maltreat others. Where families have coped and thrived, this too can be transmitted through the generations. One of the greatest buffers against intergenerational trauma is being connected to a “familiar group” or having a connection to a positive and sustaining culture. Traumatized communities may also have strengths, such as intensive support for one another, humor, courage, will to survive, resilience, desire for the next generation to do well, adaptability to new environments and capacity to straddle two different cultures and worldviews (Landau and Saul 2004). Healing from intergenerational trauma can take many forms and not all require mental health or therapeutic services. When they are presenting to a therapeutic service there are several points of intervention for the clinician and the client to consider. There is strong evidence about the role of connection to a positive culture in the healing process. Connection to culture fulfills a basic human need—to belong. Having interactions with people of similar values, history, and experience is recognized as a rewarding experience for the brain (Gaskill and Perry 2014). In understanding—and sometimes reinstating—cultural practices of healing, clinicians are able to work in a way that is congruent with the client’s understanding of the world. Cultural healing practices such as listening, storytelling, and sharing also strengthen the community, as well as the individual, and create a positive spiral of healing, connection, and resilience.

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Across cultures and circumstances, the need for a consistent narrative (a family’s life story) that allows children and families to know, work with, grieve, accept, and celebrate their past, is essential to healing—to putting the past in its place. Where a family (or community) shows resilience, trauma narratives convey strength, optimism, and coping strategies that children can incorporate into their own life story (Neimeyer and Stewart 1996). Specifically, the work involves transmitting cultural and family identity, restoring a fragmented or misunderstood past to give a complete story, and connecting the process of listening and learning to culminate in shared wisdom (Braga, Mello, and Fiks 2012). CASE STUDY This anonymized case study illustrates the way in which Take Two works with highly traumatized children and how NMT contributes to the way we work. Matthew’s History

Matthew is a nine-year-old Aboriginal boy who has lived in foster care for most of his life. Both of his parents are Aboriginal with their own history of being raised in the child protection and care system, and experiencing significant loss and trauma. Matthew’s maternal family were Stolen Generations. As adults, Matthew’s parents struggled with the trio of mental illness, drug abuse, and family violence built on a foundation of poverty and intergenerational trauma. This is a common experience for Stolen Generations and their children. In his first two years, Matthew experienced severe neglect by his parents and frequent exposure to his father’s extreme violence toward his mother and verbal abuse toward him. This included yelling at Matthew to go outside unsupervised when he was getting in the way. At the age of two years old, Matthew witnessed his father murdering a stranger. His father has since been in prison. At the time of this murder, Matthew came to the attention of child protection services and was placed in care. Over the next three years he had four different placements. He was further neglected and emotionally and physically abused in the first of these placements. Matthew’s mother lived a highly transient life. At one time she took Matthew when she believed he was unsafe in his placement. However, while in his mother’s care he was subjected to physical abuse, sexual abuse, and neglect. One incident included his mother holding him under water.



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Things Start to Get Better

When Matthew was five years old, he was placed with his current carers, who have provided consistent nurture and responsive caring. This was also when he was referred to the Take Two program. He was allocated to a general clinical team, which sought consultation with the Take Two Aboriginal team. Matthew was physically small in stature, compared with other family members. He was slow to eat and dress himself. When he first arrived at the foster care placement, his carer described him as “hyper-aroused,” unable to settle, soothe or co-regulate, and very hypervigilant. He would only eat soft and easy to eat foods. A speech assessment showed that he scored poorly on recalling information and expressive language and demonstrated articulation difficulties. He rarely initiated verbal communication. His school was more concerned about his speech and language than was reflected in these speech assessment results. According to the school, Matthew was generally delayed academically and the teacher reported that he fidgeted a lot, would act without thinking, and had poor concentration. Matthew was very quiet and withdrawn and often described as a “daydreamer.” The school reported he would be “in his own world.” He had occasional behavioral outbursts at school, whereas at home he was more frequently hyperaroused, having tantrums that lasted a long time. In the early stages of the placement, the tantrums reportedly went on for an hour or more. He would lie on his bed and kick his wall, throw things around his room, scream as loud as he could, and then burst into tears. He would cry for half an hour or more, inconsolable. He would not put his head under water and had a fear of water on his face. Often, he had nightmares and associated sleep disturbance. At this age, Matthew appeared indiscriminate in his attachments and relationships with others. He showed anxiety in play with other children and needed reassurance. During his play therapy sessions with Take Two he would play with sticks (representing a knife), trying to cut people’s heads off. This was a similar picture to what occurred in the murder he witnessed. Take Two analyzed a carer-completed SDQ that placed him in the clinical range for all scales. This related to emotional problems, conduct problems, hyperactivity problems, and peer problems and insufficient pro-social skills. The SDQ completed by the school placed him in the typical range for all these scales. Matthew Aged Seven

When Matthew was seven years old, the school described his development as having improved considerably, although they still considered him to be

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approximately twelve months behind in most areas. A neuropsychology assessment by Take Two found weaknesses in areas of attention and working memory. He was hypervigilant for parts of the day and would be startled easily. This could not always be aided by co-regulation strategies, which would sometimes trigger a freeze or flight response. At other times, Matthew was able to be co-regulated by an adult. Matthew was having weekly therapy sessions with Take Two and showed a reduction in emotional distress both in placement and at school. His carer reported a noticeable improvement following sessions as evidenced by his calmer presence, lower tone of voice, and slower speech. He did, however, continue to have behavioral outbursts on occasions, particularly around access with an uncle who had previously exposed him to violence. He showed signs of regression prior to and following each access, such as talking like a baby, wanting to be rocked by the carer, sucking his thumb, and crawling on the floor. Matthew continued to have limited ability to talk about his feelings. Take Two analyzed a review carer SDQ that continued to place him in the clinical range for emotional problems, conduct problems, and hyperactivity, but now with only some minor difficulties with peers. Matthew’s carer also completed the TSCYC. He was rated as having significant symptomatology in relation to depression and anger symptoms. High depression scores such as those found in Matthew’s TSCYC are likely to be associated with feelings of sadness, unhappiness, or depression observed in his behavior. Significantly, elevated scores can also be related to grief associated with loss or trauma. The scores in relation to Matthew’s anger scale reflect the extent of anger and aggressive behavior observed by his carer. Matthew Aged Nine

Matthew had made major gains in the prior two years but still experienced problems with sensory processing. For example, he was calmer and more settled but could be startled by loud noises. His food preferences had not changed a great deal; however, he was more willing to explore other foods suggested by the carer, with a remaining preference for soft foods. Matthew continued to be hyper-aroused but was beginning to display an ability to communicate his emotions verbally to his carers. His sleep had improved, he was more easily settled, and he no longer experienced nightmares. When he became anxious about access, he was more able to use his carers for comfort and reassurance. He showed a secure attachment to his carers. He was able to express his fears and his wishes more readily, including when he stated that he did not wish to visit his father in prison. Matthew’s class teacher reported a great improvement in his reading and academic learning and described him



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as being within the low-average range of what would be expected of children his age. Take Two completed analysis of the carer-completed SDQ at this time, which noted that Matthew had minor emotional difficulties, though still significant conduct problems. The Teacher SDQ noted no or only minor difficulties. The TSCYC completed by his carer showed that Matthew no longer had elevated scores on any of the clinical sub-scales. Another tool completed by Take Two was the Aboriginal Cultural Connection Assessment Tool. This is a tool to guide assessment of each Aboriginal child by ensuring attention is given to the child’s cultural belonging, identity, and community. This tool highlighted that Matthew had increasing contact with the Aboriginal community, for instance, through the local Aboriginal Community Controlled Organization and through an Aboriginal school liaison worker. This involved increased connection with his culture and community through school-based activities so that he could learn more about his heritage. His carers attended cultural awareness training and were committed to his engaging more with the Aboriginal community. An Aboriginal Elder had begun to attend Matthew’s care team meetings, which met regularly to assist in the planning and implementation of case management and care decisions. Take Two’s Role

Take Two clinicians have worked with Matthew in a number of ways, guided by assessments and reviews, including the use of standardized outcome measures as well as the NMT clinical practice tool. Whether it was in direct therapy, psycho-education with the carers and the school, or advocacy for Matthew’s needs with the broader system, NMT has been a key informing set of principles and applied tools. The primary backdrop for intervention with Matthew has been nondirective child-centered play therapy that enabled him to explore his world and his thoughts and feelings at his own pace. Given Matthew’s presentation of low self-esteem, underdeveloped social skills, hypervigilance, sleep difficulties, moods ranging from withdrawn to hyperaroused, and an inability to communicate his emotions, this type of play therapy was considered appropriate. In the sessions, the play included sand and sensory-based activities such as stress balls, playdough, gooey slime, drawing, and painting, which provided repetition and soothing experiences in the context of a consistent relationship. In therapy, Matthew initially struggled to use language to communicate his thoughts and feelings and would often grunt in response or cry if he was emotionally overwhelmed. He would also present like a baby following difficult experiences, such as access visits with his father at the prison. Play

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therapy was a way for Matthew to use toys, art materials, and other activities to express his thoughts and feelings and to explore relationships and share experiences. The development of a safe place and a trusting relationship, along with the use of limits being set when needed to support the play therapy process in an empathic and respectful way, helped Matthew make choices and develop confidence as he was gaining mastery over developmental tasks. Individual therapy was a way Matthew was able to work through emotional, psychosocial, developmental, and behavioral difficulties, thus supporting his innate capacity for inner growth, development, and healing. This supported the longevity of his home-based care placement. Culturally specific work was undertaken through the involvement of the Take Two Aboriginal team. This included using a narrative approach called “Tree of Life” to help Matthew make sense of his relationships, culture, and history (Denborough 2008). The Aboriginal team also provided consultation to the ongoing Take Two clinician. Another key aspect of Take Two intervention was psycho-education with the carers. The clinician often met with them to help make sense of Matthew’s behaviors and to consider how to respond. This included helping the carers to self-regulate their own stress levels. There were regular care team meetings at the school with the teachers and the carer. A number of the psycho-education materials provided by the ChildTrauma Academy were instrumental in helping the carer understand a number of Matthew’s reactions, such as why he was initially not always responsive to touch as a positive experience, and the range of ways he responded to threat and stress. Similar materials and concepts were also provided for the school. For example, the NMT tools were used directly to assist the school to work with his developmental age rather than his chronological age. The visual representation of the tools was helpful to assist them to see that Matthew has been making steady sequential developmental gains through a planned and purposeful approach. In terms of calming, soothing activities, the carer started with a swing and trampoline in the backyard. She would let Matthew jump on the trampoline until he wished to stop, then get him to lie down and she would gently bounce it for him with her hand with this rhythmic motion soothing him. Over time, swimming was added to his weekly routine. This helped him to regulate, after school on hot days in particular, when his behaviors were most difficult. More recently, when Take Two had access to the internal occupational therapist role, a Sensory Profile was completed for Matthew with his carer’s input. The results showed that he detects sensory cues much more than others (but tends to miss other cues) and is more likely to be overwhelmed. He responds to auditory, tactile, oral, and visual input much more than other children do. Additional intervention strategies were recommended, such



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as practical ideas for the carers regarding each of the senses. In relation to sound, suggestions included limiting the amount of auditory information at any one time, reducing volume of auditory stimuli, and creating “white noise” or calming repetitious sounds to drown out distracting noises. In relation to touch, suggestions began with providing Matthew with opportunities to desensitize his touch system through self-directed firm touch. The carer and Matthew were encouraged to be sensory detectives and identify the textures they like or do not like on their skin. In terms of taste and smell, suggestions included introducing new foods and smells gradually and identifying flavors and scents that he likes and using them consistently, while naming them. Gradually increasing Matthew’s tolerance of texture across food types was also considered important. This was done by involving him in meal preparation, encouraging him to become comfortable with handling fruit and vegetables, tasting vegetables as he goes along, and grading textures through food preparation. The following diagrams in figure 33.5 are Part C (brain maps) of the three NMT clinical practice tools completed about Matthew approximately two years apart. These represent his current functioning compared to the age typical child, beginning with the map on the right when he was five years old. Each square represents certain functional capacities: adult functioning, moderate functioning, and underdeveloped or disorganized functioning. The lower three maps in figure 33.5 show that an age-typical child would develop and become more organized in a number of these functions over this time period. The top three maps demonstrate Matthew’s progression, which, while still not age typical, reflects major developmental growth.

Figure 33.5.   NMT clinical practice tools in relation to the anonymized case study of Matthew over three time periods. Source: All rights reserved @Bruce D. Perry MD, PhD, and The Child Trauma Academy 2009–2013.

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CONCLUSION The application of NMT and its core principles within the Take Two program has had a significant influence on the choice and use of interventions for children traumatized by abuse and neglect. As discussed in this chapter, NMT principles provide a framework for understanding the neurodevelopmental impact of trauma and guides approaches to therapeutic interventions. These interventions not only focus on what the clinician may use in a therapeutic session, but also how to support the child’s family, carers, school, and others to bring therapeutic intent throughout the child’s day. The essential role of relationships required for addressing the consequences of trauma is a core element of the NMT approach. The case study of Matthew provides an example of the Take Two therapeutic process from assessment to intervention and the outcomes that can follow. This chapter has also explored the importance of culture. We have described how denial of culture has been a hallmark of the intergenerational and community trauma experienced by many Aboriginal children and families and, conversely, how building cultural connection and cultural safety has a key role in healing for this and future generations. REFERENCES Anda, Robert, Vincent Felitti, Douglas Bremner, John Walker, Charles Whitfield, Bruce Perry, et al. 2006. “The Enduring Effects of Abuse and Related Adverse Experiences in Childhood.” European Archives of Psychiatry and Clinical Neuroscience 256 (3): 174–86. Anglin, James. 2002. Pain, Normality, and the Struggle for Congruence. New York: Haworth Press. Australia Bureau of Statistics (ABS). 2016. “Census QuickStats.” Canberra: Australian Bureau of Statistics. http://quickstats.censusdata.abs.gov.au/census_services/ getproduct/census/2016/quickstat/036 Australian Institute of Health and Welfare (AIHW). 2018. “Child Protection Australia 2016–2017.” Child Welfare Series, Number 68. Canberra: AIHW. Barfield, Sharon, Christine Dobson, Rick Gaskill, and Bruce D. Perry. 2012. “Neurosequential Model of Therapeutics in a Therapeutic Preschool: Implications for Work with Children with Complex Neuropsychiatric Problems.” International Journal of Play Therapy 21 (1): 30–44, doi: 10.1037/a0025955. Berry Street Take Two. 2016. “Analysis of Client Group: The First 10 Years.” East Melbourne: Berry Street Take Two. Unpublished. Booth, Phyllis, and Ann Jernberg. 2010. Theraplay: Helping Parents and Children Build Better Relationships through Attachment-Based Play. Third edition. San Francisco: John Wiley & Sons.



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Bowlby, John. 1969. Attachment and Loss, Vol. 1: Attachment. Harmonsworth, UK: Penguin. Braga, Luciana Lorens, Marcelo Feijó Mello, and José Paulo Fiks. 2012. “Transgenerational Transmission of Trauma and Resilience: A Qualitative Study with Brazilian Offspring of Holocaust Survivors.” BMC Psychiatry 12 (1): 134–45. Brandt, Kristie, James Diel, Joshua Feder, and Connie Lillas. 2012. “A Problem in Our Field: Making Distinctions between Evidence-Based Treatment and EvidenceBased Practice as a Decision-Making Practice.” Zero to Three 32 (4): 42–45. Briere, John. 1996. “Trauma Symptom Checklist for Children.” Odessa, FL: Psychological Assessment Resources. ———. 2005. “Trauma Symptom Checklist for Young Children.” Odessa, FL: Psychological Assessment Resources. Bronfenbrenner, Urie. 1979. “Contexts of Child Rearing: Problems and Prospects.” American Psychologist 34 (10): 844. Carr, Alan. 2000. “Evidence-Based Practice in Family Therapy and Systemic Consultation.” Journal of Family Therapy 22 (1): 29–60. Cermak, Sharon. 2009a. “Deprivation and Sensory Processing in Institutionalized and Post-Institutionalized Children: Part 1.” Sensory Integration, Special Interest Section Quarterly 2 (2). http://www.researchgate.net/publication/230788554. ———. 2009b. “Deprivation and Sensory Processing in Institutionalized and PostInstitutionalized Children: Part 11.” Sensory Integration, Special Interest Section Quarterly 32 (3). http://www.researchgate.net/publication/230788557. Cohen, Judith, Esther Deblinger, Anthony Mannarino, and Robert Steer. 2004. A Multisite, Randomized Controlled Trial for Children with Sexual Abuse–Related PTSD Symptoms.” Journal of the American Academy of Child and Adolescent Psychiatry 43 (4): 393–402. Cook, Alexandra, Joseph Spinazzola, Julian Ford, Cheryle Lanktree, Margaret Blaustein, Marylene Cloitre, et al. 2005. “Complex Trauma.” Psychiatric Annals 35 (5): 390–98. De Brito, Stéphane, Essi Viding, Catherine Sebastian, Phillip Kelly, Andrea Mechelli, Helen Maris, et al. 2013. “Reduced Orbitofrontal and Temporal Grey Matter in a Community Sample of Maltreated Children.” Journal of Child Psychology and Psychiatry 54 (1): 105–12. Denborough, David. 2008. Collective Narrative Practice: Responding to Individuals, Groups, and Communities Who Have Experienced Trauma. Adelaide: Dulwich Centre Publications. Downey, Laurel. 2004. “The Take Two Practice Framework.” Unpublished document. Dunn, Winnie. 1999. Sensory Profile: User’s Manual. San Antonio, TX: Psychological Corporation. Fallot, Roger, and Maxine Harris. 2006. Trauma-Informed Services: A Self-Assessment and Planning Protocol. http://smchealth.org/sites/default/files/docs/tisap protocol.pdf. Ford, Julian, and Marylene Cloitre. 2009. “Best Practices in Psychotherapy for Children and Adolescents.” In Treating Complex Traumatic Stress Disorders: An

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Evidence-Based Guide, edited by Christine Courtois and Julian Ford. New York: Guilford Press. Fraser, Jenifer G., Stacey Lloyd, Robert Murphy, Mary Crowson, Cecilia Casanueva, Adam Zolotor, et al. 2013. “Child Exposure to Trauma: Comparative Effectiveness of Interventions Addressing Maltreatment.” Agency for Healthcare Research and Quality Comparative Effectiveness Review, no. 89. http://citeseerx.ist.psu.edu/ viewdoc/download?doi=10.1.1.394.2733&rep=rep1&type=pdf. Frederico, Margarita, Annette Jackson, and Carly Black. 2005. Reflections on Complexity: Take Two First Evaluation Report. Bundoora, Australia: La Trobe University. ———. 2010 More than Words: The Language of Relationships. The Third Evaluation of the Take Two Program. Bundoora, Australia: La Trobe University. Friend, Jai. 2012. “Mitigating Intergenerational Trauma within the Parent-Child Attachment.” The Australian and New Zealand Journal of Family Therapy 33 (2): 114–27. Gaskill, Rick, and Bruce D. Perry. 2014. “The Neurobiology of Play: Using the Neurosequential Model of Therapeutics to Guide Play in the Healing Process.” In Creative Arts and Play Therapy for Attachment Problems, edited by Cathy Malchiodi and David A. Crenshaw. New York: The Guilford Press. Giladi, Lotem, and Terece Bell. 2013. “Protective Factors for Intergenerational Transmission of Trauma among Second and Third Generation Holocaust Survivors.” Psychological Trauma: Theory, Research, Practice, and Policy 5 (4): 384–91. Gillies, Donna, Fiona Taylor, Carl Gray, Louise O’Brien, and Natalie D’Abrew. 2012. “Psychological Therapies for the Treatment of Post-traumatic Stress Disorder in Children and Adolescents.” Cochrane Database of Systematic Reviews 12: CD006726. DOI: 10.1002/14651858.CD006726.pub2. Goodman, Robert. 1997. “The Strengths and Difficulties Questionnaire: A Research Note.” Journal of Child Psychology and Psychiatry 38 (5): 581–86. Gowers, Simon, Sarah Bailey-Rogers, Alison Shore, and Warren Levine. 2000. “The Health of the Nation Outcome Scales for Child & Adolescent Mental Health (HONOSCA).” Child Psychology and Psychiatry Review 5 (2): 50–56. Griffin, Gene, Edward Germain, and Raymond Wilkerson. 2012. “Using a TraumaInformed Approach in Juvenile Justice Institutions.” Journal of Child and Adolescent Trauma 5 (3): 271–83. Herman, Judith. 1997. Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. New York: Basic Books. Hughes, Daniel. 2009. Attachment-Focused Parenting: Effective Strategies to Care for Children. New York: W. W. Norton & Company. Human Rights and Equal Opportunities Commission (HREOC). 1997. “Bringing Them Home: Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families.” Sydney: HREOC. Jackson, Annette. 2014. Literature Review: Young People at High Risk of Sexual Exploitation, Absconding, and Other Significant Harms. Melbourne: Berry Street Childhood Institute. www.childhoodinstitute.org.au/Reports.



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Jackson, Annette, Margarita Frederico, Chris Tanti, and Carly Black. 2009. “Exploring Outcomes in a Therapeutic Service Response to the Emotional and Mental Health Needs of Children Who Have Experienced Abuse and Neglect in Victoria.” Australia Child and Family Social Work 14: 198–212. doi:10.1111/ j.13652206.2009.00624.x. Jackson, Annette, and Sarah Waters. 2015. Taking Time: A Trauma-Informed Framework for Supporting People with Intellectual Disability. Richmond, Australia: Berry Street. www.childhoodinstitute.org.au/Reports. Kellerman, Natan. 2001. “Psychopathology in Children of Holocaust Survivors: A Review of the Research Literature.” The Israel Journal of Psychiatry and Related Sciences 38 (1): 36. Kirke-Smith, Mimi, Lucy Henry, and David Messer. 2014. “Executive Functioning: Developmental Consequences on Adolescents with Histories of Maltreatment.” British Journal of Developmental Psychology 32 (3): 305–19. Landau, Judith, and Jack Saul. 2004. “Facilitating Family and Community Resilience in Response to Major Disaster.” In Living beyond Loss: Death in the Family, edited by Froma Walsh and Monica McGoldrick. New York: W.W. Norton. Lin, Susan, Sharon Cermak, Wendy Coster, and Laurie Miller. 2005. “The Relation between Length of Institutionalization and Sensory Integration in Children Adopted from Eastern Europe.” American Journal of Occupational Therapy 59 (2): 139–47. Mansuy, Isabelle, and Safa Mohanna. 2011. “Epigenetics and the Human Brain: Where Nurture Meets Nature.” Cerebrum: The Dana Forum on Brain Science (May). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3574773/pdf/cere brum-08-11.pdf. Miller, Christine. 2012. “The Care Team Approach to Helping Troubled Children.” InPsych 34 (3). https://www.psychology.org.au/inpsych/2012/june/miller/. Neimeyer, Robert, and Alan Stewart. 1996. “Trauma, Healing, and the Narrative Employment of Loss.” Families in Society: The Journal of Contemporary Social Services 77 (6): 360–75. Nemeroff, Charles. 2004. “Neurobiological Consequences of Childhood Trauma.” The Journal of Clinical Psychiatry 65 (1): 18–28. Perry, Bruce D. 2006. “Applying Principles of Neurodevelopment to Clinical Work with Maltreated and Traumatized Children.” In Working with Traumatized Youth in Child Welfare, edited by Nancy Boyd Webb. New York: Guilford Press. ———. 2009. “Examining Child Maltreatment through a Neurodevelopmental Lens: Clinical Applications of the Neurosequential Model of Therapeutics.” Journal of Loss and Trauma 14: 240–55. Perry, Bruce D., and Chris L. Dobson. 2013. “The Neurosequential Model of Therapeutics.” In Treating Complex Stress Disorders in Children and Adolescents, edited by John Ford and Christine Courtois. New York: Guilford Press. Perry, Bruce, and Erin Hambrick. 2008. “The Neurosequential Model of Therapeutics.” Reclaiming Children and Youth 17 (3): 38–43. Perry, Bruce D., and Annette Jackson. 2014. “Long and Winding Road: From Neuroscience to Policy, Program, Practice.” Insight 9: 4–7.

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Perry, Bruce, Ronnie Pollard, Toi Blakley, William Baker, and Domenico Vigilante. 1995. “Childhood Trauma, the Neurobiology of Adaptation and ‘Use-Dependent’ Development of the Brain: How ‘States’ Become ‘Traits.’” Infant Mental Health Journal 16 (4): 271–91. Rose, Richard. 2012. Life Story Therapy with Traumatized Children: A Model for Practice. London: Jessica Kingsley Publishers. Sackett, David, William Rosenberg, J. A. Muir Gray, R. Brian Haynes, and W. Scott Richardson. 1996. “Evidence Based Medicine: What It Is and What It Isn’t.” BMJ 312 (7023): 71–72. Shapiro, Francine. 2001. Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. Second edition. New York: Guilford Press. Twardosz, Sandra, and John Lutzker. 2010. “Child Maltreatment and the Developing Brain: A Review of Neuroscience Perspectives.” Aggression and Violent Behavior 15: 59–68. van der Kolk, Bessel A. 2005. “Developmental Trauma Disorder: A New, Rational Diagnosis for Children with Complex Trauma Histories.” Psychiatric Annals 35 (5): 401–8. Vasilevski, Vidanka, and Alan Tucker. 2015. “Wide-Ranging Cognitive Deficits in Adolescents Following Early Life Maltreatment.” Neuropsychology 30 (2): 239.s

VIII SUMMARY AND OUTLOOK

After first focusing on the progressive refinements in the Diagnostic and Statistical Manual, this section, again by me, summarizes the findings from the work of a variety of trauma therapists, exploring risk factors, different ways of reacting to a trauma, and recent developments in the identification of trauma-related symptoms. This summary offers a distillation of certain common elements of trauma treatment.

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In this book, I have tried to offer some clarification of the nature of trauma and of the developments in its conceptualization. Included have been issues such as the neurobiology of trauma, the meaning of intergenerational trauma, massive trauma, and micro-trauma. We have gone on to examine the influence of the elements of trauma on development and the importance of resilience. In addition, I have tried to illustrate the powerful effects of historical processes and to put the whole subject into a cultural context, addressing the way in which a totalitarian state may inflict traumatic experiences on its subjects. There is discussion of the consequences of totalitarian Communist systems for individuals and groups, the development of a false self, of totalitarian and post-totalitarian matrixes, the collective false self, and the collective disorders of totalitarian groups. I have given a social-historic overview of Germany in the particular context of the two totalitarian systems that lay behind the case histories presented here. The reader will find a variety of treatment methods: several psychodynamic-psychoanalytic approaches, certain arts-based treatment approaches, as well as the mentalization-based treatment approach and the neuro-sequential model. In this summary, I would like to take us back to the issue of the identification, diagnosis, and clarification of the nature of the condition. I shall start with the description of the way in which the Diagnostic and Statistical Manual of Mental Disorders identifies the causes and symptoms of trauma.

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THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS With the varied consequences of the wars in Vietnam, the Persian Gulf, Iraq, and Afghanistan—and the large number of those affected—the treatment of acute trauma, such as PTSD arising from combat trauma, became the focus of research and clinical studies. This is also reflected in the advances in the development of the DSM, in which over the decades new findings, studies, discussions, and opinions have been incorporated and taken into account. This has resulted in changes to the criteria for the diagnosis of PTSD, as well as other related diagnoses (Briere and Scott 2014). In the current DSM-5 (American Psychiatric Association 2013), the effects of trauma are listed, most notably in the chapter entitled “Trauma- and Stressor-Related Disorders” as described below. POSTTRAUMATIC STRESS DISORDER IN DSM-5 According to DSM-5, the diagnosis for posttraumatic stress disorder (PTSD) now requires the following diagnostic criteria: exposure to the risk of death or impending death, serious personal injury, or sexual assault, either through direct personal experience, witnessing the experience of afflicted family members or friends, or the repeated experience of negative effects (for example, in the case of rescue workers). Symptoms associated with the traumatic event and beginning after the traumatic event are divided into different categories: intrusive symptoms, such as sudden memories of the traumatic event or recurring dreams with reference to the event; dissociative reactions, for example, flashbacks; avoidance of stimuli associated with the trauma; negative changes in cognition and mood, for instance, inability to remember trauma issues (dissociative amnesia); and arousal alterations, for example, overexcitement or sleep disorders, excitability, or excessive alertness. The presence of these complaints must have lasted longer than a month and be associated with suffering or impairment in important areas of everyday function, rather than being due to any other cause. In addition to these symptoms of PTSD, dissociative symptoms may also occur, such as depersonalization or derealization. If the beginning of the symptoms began more than six months after the event, this is described as an occurrence of PTSD with delayed onset. These criteria of the DSM-5 for PTSD apply to persons over six years old. For children of six years and under, similar as well as different criteria for the diagnosis were identified. The symptoms for children are similar to those of adults and also include the categories of intrusive symptoms, for example



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dissociative reactions, avoidance symptoms, negative alteration in cognition, and changes in arousal. For children, the symptoms must have lasted for longer than a month, be connected to the trauma, and cause suffering or impairments in important relationships, for example, with parents or siblings. In addition to these symptoms of PTSD, dissociative symptoms should be differentiated as depersonalization or derealization. If the symptoms began more than six months after the event, it is, as with adults, deemed a case of PTSD with delayed onset. It is quite common for PTSD to exist comorbidly alongside other classic psychiatric disorders, substance abuse disorders, and personality disorders. Throughout history, psychiatric diseases that afflict children and young adults have not been rare. The most common comorbidities are major depressive disorder, panic disorder, and substance abuse disorder (Briere and Scott 2014). ACUTE STRESS DISORDER In the same chapter, DSM-5 identified a condition termed “Acute Stress Disorder” (ASD), previously described in DSM-IV, which is differentiated from PTSD by the requirement of its occurring between three days and a month after the traumatic event. The diagnostic criteria for this event include: exposure to the risk of death or impending death, direct experience of serious personal injury or sexual assault, bearing witness to such events and experiencing severe distress, experiencing such events when family members or friends are afflicted, or having repeated experience of negative effects focusing on the terrible details of such traumatic events, as in the case of rescue workers. The criteria for the symptomatology require at least nine complaints after a possible traumatic event, taken from the categories of intrusive symptoms, negative mood, dissociative symptoms, and avoidance and arousal symptoms. These complaints should be connected to relevant impairments in important areas of functioning and not due to another cause. ADJUSTMENT DISORDERS “Adjustment Disorders” (ADs) can occur after the surfacing of a specific, identifiable stressor and may be associated with emotional and behavioral symptoms, which are seen as a response to this stressor. The adjustment disorder symptoms must occur within three months after the start of the occurrence of the stressor and be associated with marked distress and significant

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impairment of important functional areas of everyday life. These may also be associated with depression, anxiety, or a combination of both, with conduct disturbance, a mixture of emotional and behavioral disturbance, or the appearance of other unspecified reactions. OTHER TRAUMA- AND STRESSOR-RELATED DISORDERS The diagnosis of “other specified trauma- and stressor-related disorders” can be used in cases in which not all criteria for the usual disorders are met, but the specific reason is known, which can then be named at the conclusion of the diagnosis. If the cause for such complaints is not known, or cannot be ascertained, then it may be diagnosed as “unspecified trauma- and stressorrelated disorder.” In addition to these diagnoses, the chapter on “Traumaand Stressor-Related Disorders” presents additional diagnoses that relate to traumatic disorders relative to children: “reactive attachment disorder” and a “disinhibited social engagement disorder” both resulting from a lack of care involving neglect or deprivation. OTHER CONDITIONS: TRAUMA-RELATED DISEASES IN DSM-5 In addition to the stress disorders, which are often triggered after severe trauma such as PTSD or ASD, there is still a further third important traumaspecific disorder, the “brief psychotic disorder with marked stressor(s)” (BPDMS), which was at first called “brief reactive psychosis” in DSM III-R. Brief Psychotic Disorder with Marked Stressor(s)

The diagnostic criteria required for BPDMS include one or more symptoms, such as, for example, hallucinations or abnormal psychomotor behavior. The duration of such symptoms must range from a day to less than one month, and the complaints should not be attributable to any other illness, such as, for example, drug abuse or other diseases. The symptoms should be the result of one or more stress-laden events. If the symptoms arise without reference to an event, it is an occurrence of a brief psychotic disorder (without marked stressor[s]). The severity of psychotic symptoms must be rated. Additional Diseases Belonging to the Trauma Spectrum

Additional diseases that belong to the trauma spectrum and/or can belong to the trauma spectrum of disorders can be found under the chapter heading



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“Dissociative Disorders,” with the diseases dissociative identity disorder, dissociative amnesia, with or without dissociative fugue, depersonalizationderealization disorder, other specified dissociative disorder, or unspecified dissociative disorder. Other diseases that have been identified by many authors as also related to trauma, and comorbidities consequent upon trauma include depressive disorders, anxiety disorders, somatic symptom and related disorders, substancerelated and addictive disorders, personality disorders, or “other conditions that may be a focus of clinical attention” (Briere and Scott 2014). FURTHER DEVELOPMENTS AND OUTLOOK It is clear that the subject of trauma has been receiving increasing attention from both practitioners and researchers. The new developments in neuroscience, attachment, mentalization, and transgenerational research have had a big influence in this regard (Courtois and Ford 2009; Foa et al. 2010; Kirmayer, Lemelson, and Barad 2007; Ringel and Brandell 2012; van der Kolk 2014). There are now many psychotherapeutic schools and directions, each of which have a variety of tools for trauma treatment. However, each method tends to be described by its own proponents. DEVELOPMENTS IN THE DEFINITION OF TRAUMA EMERGING FROM THE FINDINGS OF TRAUMA THERAPISTS The definition of trauma depends, on the one hand, on the respective definition of the term in the DSM or ICD, which is always changing, and, on the other hand, on the respective models and conceptualizations arising from different directions taken in the trauma therapies. At first the processing of trauma and discomfort in connection with events of war (later called PTSD) was foregrounded, and early childhood developmental disorders as a result of maltreatment, sexual or physical abuse, or neglect found no consideration. This imbalance has now been corrected. However, several studies concerning other causes and symptoms, such as everyday psychosocial stressors, still await further consideration (Briere and Scott 2014). A uniform definition does not exist so far, and seems also impossible under the present circumstances. However, the possible traumatic situation is usually connected with a direct or indirect threat to life or to physical integrity. Furthermore, an emerging definition is that the trauma is not the result of an inevitable traumatic experience but of one that overwhelms the coping mechanisms of particular individuals, thus leading to traumatic stress responses

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(van der Kolk 1995). The reactions vary from individual to individual, and the posttraumatic outcome depends upon several factors. The respective individual resilience of an affected person and other protective factors can prevent a strong manifestation of symptoms, just as the presence of a high degree of vulnerability in the person affected could favor the occurrence of a more severe traumatic reaction. The best-known type is acute trauma, which emerges from a single traumatic event that was both unpredictable and emotionally overwhelming (Boulanger 2007; Levine 2010; Litz et al. 2016). Such events may lead to a “frozen trauma” response such as PTSD. Trauma therapists are suggesting that for recovery to proceed, the new information concerning the traumatic event needs to be integrated. If it cannot be integrated, it will be stored and eventually lead to disturbances. The concept of PTSD has been expanded to identify a condition of Complex PTSD as a reaction to trauma-inducing stressors that have a repeated or prolonged and sustained effect on the afflicted party at times of vulnerable psychological states. The complex psychological trauma may have, depending on the respective damages to the developmental processes of those affected, psychological, emotional, and/or social consequences (Briere and Scott 2014; Courtois and Ford 2009; van der Kolk et al. 1996). Developmental trauma is the name given by some workers to a condition of traumatization identified in childhood. Developmental trauma as a result of child abuse or neglect may compromise and influence the development of a child and may lead to disorders of neurological, cognitive, mental, and attachment functions and the child may develop corresponding behavioral, emotional, cognitive, and interpersonal disturbances (Briere and Scott 2014; Schupp 2015; van der Kolk 2005). RISK FACTORS FOR TRAUMATIC STRESS AND TRAUMATIC REACTIONS The risk factors for traumatic stress have been identified as arising from three different sources: stressor-related, individual, and social factors (Briere and Scott 2014). Among the stress-related factors are, for example, life threats or physical injuries. Among the individual factors are, for example, the genetic disposition or socioeconomic conditions. Social or relational factors imply, for example, the extent of support by family members or other existing resources. Culturally specific stress responses must also not be forgotten. Different cultures are suggested to have different stress responses.



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POSSIBLE WAYS OF REACTING TO A TRAUMA As has been noted, potential traumatic events, which may vary in nature, frequency, and intensity, depend on individual, victim-specific, and social/ cultural factors in their development, and in their respective posttraumatic response. It has been found that only a small amount of people exposed to a traumatic event may respond with more serious symptoms and diseases. A large number of symptoms and disorders are possible. In addition to general psycho-traumatic syndromes, it is also possible, depending on the traumatic situation, to differentiate even more specifically the symptoms that may appear after rape, for example, from symptoms after attempted murder. A very good overview of possible common complaints is given by Briere and Scott (2014). DEVELOPMENTS IN THE IDENTIFICATION OF TRAUMA-RELATED SYMPTOMS Specific symptom responses to a traumatic experience have been divided by Briere and Scott (2014) into different groups. The most important complaints are distinguished as intrusive, avoidant, hyperaroused, and dissociative responses/reactions. There may also be, for example, symptoms of substance abuse and somatic disturbances with physical or bodily symptoms, or of sexual disturbances and of cognitive disturbances. After a trauma, psychotic reactions and symptoms may temporarily occur, such as trauma-induced hallucinations or delusions. Unusual behavior such as self-harm or impulsive behavior can occur as a way of dissipation of tension. Respective culturespecific trauma responses must be considered when sufferers are from other cultures (Briere and Scott 2014). If the patient cannot develop the ability to manage his symptoms and dysfunctions, and remains at a stage of pseudoadaptation, various posttraumatic syndromes and diseases may develop. TYPES OF OTHER POSTTRAUMATIC REACTIONS, SYNDROMES, OR DISEASES Briere and Scott add to the list of the DSM-5 trauma-related syndromes or diseases (whereby the three important trauma-specific disorders are ASD, PTSD, and BPDMS) various other types of reactions related to a possible traumatic event. These are associated with possible traumatic events: depressive symptoms and depression-related disturbances such as complicated or

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traumatic grief, major depression, or psychotic depression. Symptoms of anxiety and anxiety disorders may include generalized anxiety, panic or phobic anxiety, and dissociative symptoms, as well as dissociation disorders such as depersonalization-derealization disorder, dissociative amnesia, or dissociative identity disorder (DID). Also in the list are somatic symptoms and related disorders, such as somatic symptom disorder or conversion (functional neurological symptom disorder). Psychosis disorders include psychotic symptoms, such as delusions or hallucinations. Brief psychotic disorders with marked stressors (BPDMS) may occur, as may substance abuse disorders and physical health complications, such as for example hypertension, back pain, chronic pain, and certain other diseases. PROCESS RESPONSES TO TRAUMA Briere and Scott differentiate various types of “process” responses to trauma. If posttraumatic stress increases after a trauma, posttraumatic symptoms (memories, thoughts, and/or emotions) may suddenly occur in sufferers. These can be viewed as signs of trauma response, and can occur in everyday life, during medical consultations, or during therapy when talking about traumatic material, or at any other time when a sufferer is reminded of the trauma. Activation and avoidance responses, affect dysregulation, and relational disturbances are different types of process response (Briere and Scott 2014). DIFFERING AND COMMON ELEMENTS OF TRAUMA TREATMENT Differing elements of the treatment are within each methodology but these arrive partly in response to different conceptualizations and to different forms of traumatization and its effects (van der Kolk 2014; van der Kolk, Macfarlane, and Weisaeth 1996). A variety of types of trauma are included under one umbrella term “trauma,” which may be considered to cover a variety of different causes and a variety of different effects (Allen and Fonagy 2015). Two main categories of trauma have been distinguished: acute versus chronic and complex trauma. That is, the traumatic experiences are distinguished on the basis of duration, intensity, and frequency. These are referred to as Type I trauma (acute, mono trauma) or Type II trauma (multiple, repeated, chronic trauma) (Terr 1991). Despite the many differences shown by these various perspectives, I would like to give a more general short overview about what is commonly accepted by many of the trauma therapists.



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A DISTILLATION OF THE TREATMENTS OF THE DIFFERENT TYPES OF TRAUMA 1.  Trauma as an interactional event between victim and environment or external agents: 1.1 Acute trauma leading to ASD or PTSD. After a treatment stage of stabilization (for example, the question of medication, provision of external security, resource orientation, psycho-education, and development of coping strategies), treatments of varying duration such as EMDR, trauma yoga, emotional freedom techniques, energy tapping for trauma, or other forms may follow (Emerson and Hopper 2011; Gallo 2007; Levine 1997, 2015; Shapiro 2001, 2002). 1.2. A repeated trauma of any kind may turn PTSD into complex trauma (CPTSD) with different levels of severity. Complex trauma with different levels of severity may need a trauma treatment over some years by psychodynamic and other forms of psychotherapeutic treatment and therapy. 1.2.1. Developmental trauma often results in CPTSD or other severe conditions such as, for example, borderline personality disorder. Stage-specific trauma treatment taking place over some years is needed using psychodynamic or other forms of psychotherapeutic treatment as well as art therapies. 1.2.2.  Combined developmental traumas and acute traumas throughout childhood, adolescence, and/or adulthood also need the stage-specific trauma treatment over some years. The work described in this book concerns mostly psychodynamic or other forms of psychotherapeutic treatment and therapies. 1.3. Trans- or intergenerational trauma is described, where a traumatic event or events took place in previous generations, but its lack of contemporary resolution, like a previous resolution, affects future lives. Two of the clinical cases described by the author received psychotherapy. 2.  Internal trauma due to psychological or constitutional sensitivity, which leads to intra-psychic disturbance and the development of neurotic traits or psychopathology. This type is not illustrated in the book, but may need treatment nevertheless. Thus it has been interesting to discover how much the various treatment approaches have in common. Perhaps this is because the effects of trauma have

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a way of focusing clinicians’ minds in particular ways. Here are some of the common features in the treatments described in this book: 1.  The dangers of exposing patients to retraumatization with premature integrations. 2.  The corresponding need to go slowly in approaching traumatic material. 3.  The need to facilitate the building up of the non-traumatized part of the personality (secure base, good objects, self-respect, containment, selfregulation, not becoming flooded by emotions). CONCLUSION Most of the methodologies differentiate levels of mind/body involvement and note that the results of trauma are at first more bodily implemented in a fragmented way. The embodied complaints and symptoms reduce with the respective degree of integration of the traumatic experience and memory into the self and its biography. The terror of trauma may be allowed to become more conscious over time and treatment. As I have pointed out above, acutely traumatized patients respond better to treatments that access and seek to alter bodily responses, whereas the complex PTSD patient needs the more long-term and wide-ranging approach of psychodynamic or other forms of psychotherapy and therapy. However, this does not imply a simple division between body and mind. The Complex PTSD patient, whose original trauma has become so repeated that it has invaded the construction of personality and the whole developmental trajectory, does need the multilayered approach of psychotherapy, but this is not to say that the bodily reactions to trauma triggers are absent. Indeed, these patients may also be helped by some of the bodily based treatments. Thus, it may be seen from the clinical illustrations and the description of the various methods that the treatment of severe cases may need to be multipronged, as outcome studies indicate. With the level of terrible events, incidents, violence, and conflict still so evident throughout the world, it is vital for clinicians of all theoretical persuasions to be competent to help people so damaged by trauma past or present. REFERENCES Allen, Jon, and Peter Fonagy. 2015. “Trauma.” In Handbook of Psychodynamic Approaches to Psychopathology, edited by Patrick Luyton, Linda Mayes, Peter Fonagy, Mary Target, and Sidney Blatt. New York: The Guilford Press.



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American Psychiatric Association. 2013. Desk Reference to the Diagnostic Criteria from DSM-5. Arlington, VA: American Psychiatric Association. Boulanger, Ghislaine. 2007. Wounded by Reality: Understanding and Treating Adult Onset Trauma. Mahwah, NJ: The Analytic Press. Briere, John, and Catherine Scott. 2014. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. Second edition. Thousand Oaks, CA: Sage. Courtois, Christine, and Judith Ford, eds. 2009. Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press. Emerson, David, and Elizabeth Hopper. 2011. Overcoming Trauma through Yoga: Reclaiming Your Body. Berkeley, CA, and Boston: North Atlantic Books and The Trauma Center at Justice Resource Institute, Inc. Foa, Edna, Terence Keane, Matthew Friedman, and Judith Cohen. 2010. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. Second edition. New York: The Guilford Press. Gallo, Fred. 2007. Energy Tapping for Trauma: Rapid Relief from Post-Traumatic Stress Using Energy Psychology. Oakland, CA: New Harbinger Publications. Kirmayer, Laurence J., Robert Lemelson, and Mark Barad, eds. 2007. Understanding Trauma: Integrating Biological, Clinical, and Cultural Perspectives. Cambridge: Cambridge University Press. Levine, Peter. 1997. Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences. Berkeley, CA: North Atlantic Books. ———. 2010. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, CA: North Atlantic Books. ———. 2015. Trauma and Memory: Brain and Body in Search for the Living Past. Berkeley, CA: North Atlantic Books. Litz, Brett, Leslie Lebowitz, Matt Gray, and William Nash. 2016. Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury. New York: Guilford Press. Ringel, Shoshana, and Jerrold Brandell, eds. 2012. Trauma: Contemporary Directions in Theory, Practice and Research. Thousand Oaks, CA: Sage Publications. Schupp, Linda. 2015. Assessing and Treating Trauma and PTSD. Second edition. Eau Claire, WI: PESI Healthcare Inc. Shapiro, Francine. 2001. Eye Movement Desensitization and Reprocessing (EMDR): Basic Principles, Protocols, and Procedures, Second edition. New York: Guilford Press. ———, ed. 2002. EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. Washington, DC: American Psychological Association. Terr, Lenore. 1991. “Childhood Trauma: an Outline and Overview.” American Journal of Psychiatry 148 (1): 10–20. van der Kolk, Bessel. 1995. “Dissociation and the Fragmented Nature of Traumatic Memories: Overview and Exploratory Study.” Journal of Traumatic Stress 9: 505–25. ———. 2005. “Developmental Trauma Disorder: Toward a Rational Diagnosis for Children with Complex Trauma Histories.” Psychiatric Annals 35 (5): 401–8.

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———. 2014. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking Penguin. van der Kolk, Bessel, Alexander McFarlane, and Lars Weisaeth, eds. 1996. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: The Guilford Press. van der Kolk, Bessel, David Pelcovitz, Susan Roth, Francine Mandel, and Alexander McFarlane. 1996. “Dissociation, Affect Dysregulation and Somatization: The Complex Nature of Adaptation to Trauma.” American Journal of Psychiatry 153, 7th Festschrift Supplement: 83–93.

Index

An Abbreviated Life (Leve), 349 Aboriginal Community Controlled Organization, 449 Abraham, Nicolas, 338–39 absence, 333 abusive father, 202 ACTH. See adrenocorticotropic hormone acting out, of patients, 313 active silences, 376 actual objects, 377 acute depression, 256 acute stress disorder (ASD), 4, 18, 25, 461 acute trauma, 283–84, 301, 464, 467 adjustment disorders (ADs), 18, 461–62 adolescence: difficulties during, 291; False Self challenged by, 283–84; frightening experiences of, 372 adrenocorticotropic hormone (ACTH), 24 adults, 20, 380–81 adversity, 350 affective attunement, 45, 359, 373 affective responses, 29 Age of Totalitarianism, 160 aggression, 73, 190–91, 272; finding the aggressor within and, 410; of

husband, 226; identification with aggressor, 63, 179, 311, 335–36; microaggressions, 79; original aggressor, 182; passive-aggressive, 317 agricultural factories, 136–37 Agricultural Production Cooperatives, 132 AIDS-related death, 284–85 Ainsworth, Mary, 7, 359 airbrushing, psychic, 78, 81 alien self, 408 altered state of consciousness, 395 Alvarez, Anne, 369, 372–73, 379 ambiguous loss, 91–92, 410; ambivalence and, 94; both-and thinking in, 98; defining, 94; depression and, 95–96; family and, 96–97, 99–100; family therapy guidelines for, 102; individual symptoms of, 96; interventions for, 99–100; perspectives of, 95; psychological family and, 94–95; PTSD and, 93–94; relational assessment of, 97–99; relational therapy for, 99–100; resilience building for, 98–99; self-blame and, 93; treatment guidelines for, 471

472

Index

100–102; treatment perspectives of, 97; types of, 93–94 ambivalence, 94 American Psychiatric Association (APA), 17, 351 amygdala, 23–28 analysts. See therapists anger, self-righteous, 82 Anglin, James, 428 annihilation anxieties, 164 anorexia nervosa, 290 ANP. See apparently normal personality ANS. See autonomic nervous system anti-Communist revolution, 170 antisocial elements, 124 antisocial tendencies, 148, 285–86, 291 anti-totalitarianism, 161 anxieties: annihilation, 164; collective, 109; of Daniel, 328; dependency, 243; of infant, 45; infants-parents relationship with, 69; of Mrs. M, 236; posttraumatic, 310; primitive existential, 63; secure attachments controlling, 411; separation, 231, 236; social systems, 109; from traumatic experiences, 254–55; unspeakable, 63 anxiousness, 225–26 APA. See American Psychiatric Association apathy, of infants, 269 apparently normal personality (ANP), 359 apprentices, 118 Apprey, Maurice, 338–39, 342 Arendt, Hanna, 172–73 ASD. See acute stress disorder atrocities, 307 attachment, secure, 408, 411, 448 attachment-based psychotherapy, 357–58 attachment bond, 357 attachment disruptions, 46–48, 101, 354 attachment-informed interventions, 437 attachment system, 359

attachment theory: anxieties and, 411; Bowlby developing, 7, 39; child development in, 429; childhood trauma and, 66; children and, 22; disorganization in, 350, 354; disorganized infant and, 68; in infancy, 40; insecure, 74, 195–96; issues of, 352; parents with unresolved trauma and, 45–46; regulation theory and, 353; therapists and, 49 attachment trauma, 337 Auerhan, Nanette, 255 Auschwitz, 53, 64 Australia, 423–24, 443–44 authenticity of oneself, 151 authority figures, 299, 408 autistic monstrosity, 163 autonomic nervous system (ANS), 23 autonomic sympathetic nervous system, 24 autonomy: abuse as attacks on, 288; child issues of, 287–88; phase, 317; spontaneity and, 287–90; True Self expressions of, 287 Auxiliary Labor Law, 122 back pain, 318 bad-me, 84–85 bad other, 84 Badouk-Epstein, Orit, 350 Balint, Michael, 7, 151, 262 Bamberg, Helen, 341 Banja Luka Reflective Citizens, 170–72 Barfield, Sharon, 436 basic law (Grundgesetz), 127 Basic Trust, 148 Bateman, Anthony W., 48 Beat Demonstration, 132 Beebe, Beatrice, 352, 376 behavior-related stress response, 25 being human at risk, 329 Berlin Ultimatum, 132 Beyond the Pleasure Principle (Freud, S.), 257



Index

bilingual therapy, 327–28 Binder, Elisabeth, 183–84 bio-ecological approach, 429 Bion, W. R., 163–64, 267, 372, 379; container-contained from, 381; infantile unconscious from, 60; notion of containment from, 49; selfdevelopment disruptions and, 47; theory of thinking from, 381 biopsychosocial approach, 426, 430 birth, premature, 224 Bismarck, 120–21 Blacking, John, 374 Blind to Betrayal (Freyed), 357–58 The Body Keeps the Score (van der Kolk), 392 Bollas, Christopher, 336 Bonomi, Carlo, 333–34 borderline personality disorder (BPD), 69–70, 302; adults with, 20; attachment disruptions and, 46–48; mentalization-based treatment and, 414–17; mentalizing and, 404–5 Bosnia, 170 Boss, Pauline, 94, 101 both-and thinking, 98 Boulanger, Ghislaine, 340 boundaries, 185 bourgeois class, 119, 121–23, 137 Bowlby, John M., 336–37; adversity observed by, 350; attachment theory of, 7, 39; deactivation and, 358; dissociative parts comments of, 354–55 BPD. See borderline personality disorder BPDMS. See brief psychotic disorder with marked stressor(s) brain: co-occurring sensory input and, 432; emotional systems in, 390; empathy and, 378; functions of, 432; infant’s developing, 70; posttraumatic vulnerability of, 30; sequential development of, 432–33; use-dependent functioning of, 432

473

brainwashing, 107, 349 Brand, Bethany, 351 Brandchaft, Bernard, 325 Bremner, James Douglas, 29 Breuer, Joseph, 5 Brezhnev, Leonid, 133 brief psychotic disorder with marked stressor(s) (BPDMS), 4, 18, 462, 466 Briere, John, 465–66 broad-brush psychodynamics, 75 Bromberg, Phillip, 7, 83, 86; conflict language comments of, 357; dissociation from, 336–37; The Shadow of the Tsunami by, 358 Bucci, Wilma, 352 Bunt, Leslie, 375 Caloz-Tshopp, Marie-Claire, 56 Campbell, Chloe, 390 cancer diagnosis, 198 Cannon, Walter B., 24 caregivers: attachment and betrayal by, 359; child abuse by, 19; good-enough actions of, 149; infant’s relatedness with, 337–38; mentalization by, 404 case studies: of Anna, 268–72; antisocial tendencies in, 285–86; autonomy and spontaneity in, 287– 90; child imprisonment in, 314–15; chronic and acute trauma in, 283–84; developmental perspective in, 284– 85; of Janice, 395–97; of K, 56–57, 60; of Lorenza, 274–77; of Maria, 397–98; Matthew age nine in, 448– 49; Matthew age seven in, 447–48; Matthew analyzed in, 447; Matthew and Take Two in, 447, 449–51; Matthew’s background in, 446; of Miyuki, 327; of Mr. Q, 195–96, 205–10; of Mr. R, 197–98, 217–22; of Mrs. B, 203, 245–49; of Mrs. M, 200–201, 233–37; of Mrs. N, 201–3, 239–43; of Mrs. O, 198–99, 223–27; of Mrs. P, 199–200, 229–32; of Mrs.

474

Index

U, 196–97, 211–15; parenthood challenges in, 290–92; of Roy and Lynn, 272–73; of Sarah, 57 Center for Early Childhood Mental Health Consultation, 21 Center for Prevention and Early Intervention Policy, 21 Charcot, Jean-Martin, 8–9 Cheit, Ross E., 351 Chernobyl nuclear power disaster, 53–54 child abuse: autonomy attacks in, 288; by caregivers, 19; by father, 287–88; sexual, 338 Child and Family Psychiatry Service, 290 child-centered play therapy, 449 child development: in attachment theory, 429; complex trauma symptoms in, 22; infantile omnipotence and, 6–7; traumatic experiences in, 6, 8 childhood: attachment theory and, 66; maltreatment during, 405–6; of Mrs. B, 246; of Mrs. P, 229–30; rape, 335; tormented in, 256–57 childhood trauma: attachment theory and, 66; contextualizing fears from, 318; of Mrs. O, 223–24; of Mrs. U, 212; permissive social structures in, 20 child-parent relationship, 267–68 child pornography, 341 children: attachment theory and, 22; autonomy issues of, 287–88; closeddown, 370, 373; coping mechanisms of, 369; cumulative psychic damage and, 86–87; dangerous authority figures of, 299; developmental stages of, 393–94; dramatic play inbuilt for, 392; from East Germany, 300; emotional connections of, 325–26; family and role of, 119–20; father fear of, 288; father violent with, 298–99, 446; feeling-thinking self

of, 369–70; imprisoned father and, 272–73; internal object attack on, 60; internal world expression of, 273; mother feeding, 84–85; music therapy for, 368–69, 371, 380–81; NMT and Take Two symptoms of, 427–28; parent’s maladaptation to, 83; in psychoanalysis, 273; psychopathologies and, 58; psychophysiological development of, 28; sexual abuse of, 338, 398; stress regulatory mechanisms of, 65–66; Take Two protection of, 424–25; time tunnel entered by, 59; trauma interventions for, 436–37; traumarelated symptoms of, 21–22; unwanted, 234 ChildTrauma Academy, 450 chosen glory, 184 chosen trauma, 184 chronic ambiance, 87n2 chronic entrenchment, 78, 81–82 chronic stress, 25–27 chronic trauma, 283–84, 299–300 circle of fear, 396 Circles of Security, 391 citizenship, mature, 173 civilian trauma, 10, 295–96 classless society, 130 class structure, 133–41 clinical implications, 411–12 clinical practice tools, 433–35, 449, 451 clinical technique, 301–5 clinical-theoretical orientation, 371–74 closed-down children, 370, 373 cognitive-affect stress response, 25 cognitive-psychodynamic model, 411–12 collective anxieties, 109 collective consciousness, 112 collective false self concept, 182 collective trauma, 21 communication: bypassing consciousness, 342; innate, 374–75;



Index

intergenerational, 20–21; learning and, 412; mentalization in, 413–14; patient learning and understanding for, 413; social learning and, 414; trauma impacting, 406–7 communism, 110; classless society of, xxii–xxiii, 130; utopian, 111, 138; in Yugoslavia, 168–69 Communist dictatorships, xix–xx Communist Party, 111, 128, 163, 181 community-level difficulties, 445 community support, 99 compensatory reactions, 277 Complex Posttraumatic Stress Disorder (CPTSD), 18–19, 467 complex psychological trauma, 464 complex trauma symptoms, 22 concentration, 223 concrete fusion, 311 conflict, avoiding, 242 conflicted feelings, 276 conflict language, 357 Confusion of Tongues, 335 connoisseurship gone awry, 78–80 consciousness, 342, 395 container-contained, 381 containment, notion of, 49 control, loss of, 303 control system, 353 co-occurring sensory input, 432 cooperative farmers, 136 coping mechanisms, 369 coping strategies, 301 corticotropin-releasing hormone (CRH), 24 countertransference, 355–56; in clinical environment, 302–3; enactment, 313; Lorenza and, 276; MBT using, 416; of micro-trauma, 272; Mr. Q and, 209–10; Mr. R and, 222; Mrs. B and, 248–49; Mrs. M and, 237; Mrs. N and, 243; Mrs. O and, 227; Mrs. U and, 215; of patients, 266; in treatment process, 317–19 Courtois, Christine, 18, 21

475

CPTSD. See Complex Posttraumatic Stress Disorder craftsmen, 118–19 creative exploration, 292n2 creative imagination, 209 Creative Music Therapy: Fostering Clinical Musicianship (Nordoff and Robbins), 372 CRH. See corticotropin-releasing hormone criminals, war, 130 cultural healing, 445–46 cultural identity, 445 culturally respectful approach, 429 Cultural Revolution, 310 cultural trauma, 111–12 culture, victim-blaming, 358 cumulative psychic damage, 86–87 cumulative trauma, 83 Czechoslovakia, 177, 182–83, 206; deposited image in, 186; groupanalytic attention in, 189–90; Mr. R from, 217–18; reformation movement in, 186 Dalenberg, 351 daughter, puerperal psychosis and, 292 Davies, Jody, 7, 337, 341 Davoine, Françoise, 340 Day of German Unity, 141 DDR. See German Democratic Republic deactivation, 358 Death of a Salesman (play), 82 defensive aspects, 304 defensive reactions, 255 delayed nation, 120–21 democracy, 130 democratic centralism, 130–31 de-Nazification, 130 dependency, 215, 243 deposited images, 183–86 depression: acute, 256; ADs and, 461–62; ambiguous loss and, 95–96; of Daniel, 328; high-risk parents and, 69; of Matthew, 448; MBT and, 417;

476

Index

of Mr. Q, 195, 205–7; of Mr. R., 218–19, 221–22; of Mrs. M, 233–35; of Mrs. N, 201–3, 241–42; of Mrs. O, 198–99, 223; of Mrs. P, 199–200, 229–30; of Mrs. U, 196, 211–14; phobic symptoms from, 200–201; PTSD and, 94; rapprochement phase and, 317; relational trauma and, 42; trauma-related syndromes and, 465–66; from traumatic experiences, 21–22, 198–99; traumatization and, 308; zero process and, 298 depressive-anxious symptoms, 200, 231, 235 DESNOS. See disorders of extreme stress not otherwise specified despotism (Willkürstaat), 139 de-Stalinization, 132 destructive radioactive transmission, 56–57 detainment, 410 Developmental Consultancies Team, 442 developmental origins, to mentalization, 404 developmental perspective, 284–85 developmental psychology, 372 developmental stages, 393–94 developmental trauma, 64–65, 464, 467–68 Developmental Trauma Disorder, 19–20 Diagnostic and Statistical Manual of Mental Disorders (DSM), 17–18, 459–60 dialectical thinking, 98 Dickens, Charles, 143–44, 148 dictatorships, xix–xx, 130–31, 137–39 DID. See Dissociative Identity Disorder diseases, trauma related, 462–63 disorder-centered approach, 412 disorder of the self, 323 disorders: ADs, 18, 461–62; ASD, 4, 18, 25, 461; BPD, 20, 46–48, 69–70, 302, 404–5, 414–17; BPDMS, 4, 18, 462, 466; CPTSD, 18–19, 467;

Developmental Trauma, 19–20; DID, 348, 351–52, 355, 361, 466; DSM, 17–18, 459–60; mental, 3–4, 66, 85, 412; MPD, 355; relational, 91–92; severe personality, 67; stress related, 462. See also Posttraumatic Stress Disorder disorders of extreme stress not otherwise specified (DESNOS), 18 disorganized attachment, 350, 354 disorganized infant, 68 dissociation, 240, 328, 350; from Bromberg, 336–37; out-of-body experiences and, 395–97; of patient K, 358; persistent, 301; structural, 354, 359; trauma correlations with, 352 Dissociative Identity Disorder (DID): gaslighting and, 348, 361; as iatrogenically created, 351–52; trauma-related syndromes and, 466; violence and, 355 dissociative parts, 354–55 dissociative states, of patients, 258 distorting influences, 83 divorce, of parents, 198, 218–19 Dog Tooth (film), 349 double bind, 74 dramatic play, 392 dramatic reality, 395 dramatic response stage, 393 drama-triangle, 190–91 DSM. See Diagnostic and Statistical Manual of Mental Disorders DSM-5, 460–61; trauma-related diseases in, 462–63; trauma-related syndromes in, 465–66 dynamism, 85 dystopian fascism, 110 East Germany, 138, 300 echo play, 393 economic miracle, 139 egalitarianism, 135 ego equilibrium disruption, 6



Index

ego psychology, 5–6, 301 ego regression, 297 ego shutdown, 296, 298, 300 Einheitsgewerkschaft (trade union), 129 Eisner, Emanuel, 409 elections, in totalitarian system, 183 Elias, Norbert, 161 Elzinga, Bernet M., 29 Embodiment-Projection-Role (EPR), 389 EMDR. See Eye Movement and Desensitization Reprocessing emergent self, 65–71 emotion: abuse of, 240, 246; child connections to, 325–26; dependence on, 202; deprivation of, 220; landscape of, 375; life of, 41; movements of, 266; music therapy and, 375–77; primary and secondary, 29; regulation, 30; seduction of, 80; systems with, 390; traumatization and, 308–9 emotional attunement, 376–77 emotional parts (EPs), 359 empathic attention, 266 empathic internal other, 311 empathic language, 357 empathy, 330n3, 378 employment, 220 enactments, 313 enduring personality traits, xxi engagement, 430 entranced experience, 394–95 entrenchment, chronic, 78, 81–82 environmental impingement, 295–97, 300 epigenetic inheritance, 184, 444 epinephrine, 24 epistemic trust, 407–11 epistemic vigilance, 406 EPR. See Embodiment-Projection-Role EPs. See emotional parts Das Es (The It), 144 “Ethical Standard: Truth and Lies” (Brand and McEwen), 351

477

etiology, of False Self, 143, 146–47 evoked responses, 375 excessive niceness, 78, 81 existential trauma, 325, 330 exploitation, 146, 148 expression imitation, 392 external events, 411 external witnessing function, 308 external world, 77 eye contact, 271 Eye Movement and Desensitization Reprocessing (EMDR), 437 failed dependency, 164 failure, fear of, 241 Faimberg, Haydee, 338, 342 Fairbairn, William R. D., 6, 83–84, 342 Fairfield, Susan, 340 falling forever, 342 false collective self, 180, 187 false memories, 253, 257–58, 348 False Memory Archive: Crudely Erased Adults (photo exhibition), 348 False Memory Society (FMS), 358 falseness, 146 False Self, 107; adolescence challenge to, 283–84; collective concept of, 182; encapsulated, 150–51; etiology of, 143, 146–47; healing process for, 179, 182; implications of, 147; individual, 180; manifestations of, 147–48; moving towards health and, 148–50; totalitarian system and, 152–53; trauma as origin of, 152–53, 178; from Winnicott, 143, 146–50 family: ambiguous loss and, 96–97, 99–100; ambiguous loss and therapy for, 102; children’s role in, 119–20; history, 445; of Mrs. U, 212; psychological, 94–95; psychotherapy and, 92; sensitive practice, 437; system effects, 96–97; traumatic experiences within, 398 fantasy world, 221, 301, 313, 352 farmers, 117–18, 122, 136

478

Index

father: abusive, 202; AIDS death of, 284–85; child abuse by, 287–88; child’s fear of, 288; child with imprisoned, 272–73; mother killed by, 283; Mrs. N death of, 242; violence of, 298–99, 446 fault line, 156n4 FDGB. See Free Trade Union Federation FDJ. See Free German Youth fears, past and present, 318 Federal Republic of Germany (FRC or BRD), 127–33, 139 feeding difficulties, 268, 291 feeling-thinking self, 369–70 Feiffer, Jules, 83 felt experiences, 370 Ferda Mravenec (fictional character), 190 Ferenczi, Sándor, 5, 262; communication bypassing consciousness and, 342; identification with aggressor from, 335–36; introjection from, 335; Thalassa by, 335; trauma reality from, 333; war trauma work of, 339; witnessing element from, 336 finding the aggressor within, 410 first-order construction, 296–97 First World War, 121–22, 218, 335 fixed-wage policy, 124 Flipper (television), 248 fMRI. See functional magnetic resonance imaging FMS. See False Memory Society Fogel, Alan, 354 Fonagy, P., 390; mentalizing from, 379; parent mental state and, 42; parent reflection from, 44–45, 48; reflective functioning and, 40 Ford, Julian, 21 foreign workers, 125 forms of vitality, 373 Fortun, C., 350 Foulkes, S. H., 161

foundational development period, 41 Fraiberg, Selma H., 43, 65 Franco-Prussian war, 120 Frawley, Mary, 7, 337, 341 free association, 215 Free German Youth (Freie Deutsche Jugend, FDJ), 129, 134 Free Trade Union Federation (FDGB), 134 Freie Deutsche Jugend (Free German Youth - FDJ), 129, 134 Fresco, Nadine, 58 Freud, Anna, 173; ego psychology from, 5–6; identification with aggressor from, 311; vegetative excitation from, 144 Freud, Sigmund, 5, 74, 265; earliest relationships described by, 39; Inhibitions, Symptoms and Anxiety by, 255; Beyond the Pleasure Principle by, 257; relational theory and, 334; sexual trauma and, 333–34; trauma/affect theory of, 350; traumatic experiences recreation and, 257; zero process and, 298 Freudian taboo, 328 Freyed, Jennifer, 357–58 Frie, Roger, 330 friendless state, 230 Fritzl, Josef, 349 functional magnetic resonance imaging (fMRI), 26 Gales, Mary, 7 Gaslight (film), 347–48, 360–61 gaslighting: defining, 349; DID and, 348, 361; by mother, 349; public, 351; reality distorted in, 75, 347–48; reality validation and, 357 Gaudillière, Jean-Max, 340 GDR. See German Democratic Republic generations, telescoping of, 338 genocide, 310, 325, 343 Gerhardt, Susan, 390



Index

German Democratic Republic (GDR or DDR), xix–xx; breakdown of, 139–41; class structure changes in, 133–41; development of, 127–33; totalitarian system of, 115–16 German Labor Front, 124 Germany: Day of German Unity, 141; East, 138, 300; Federal Republic of, 127–33, 139; First World War and, 121–22; Imperial, 122; middle class in, 119–20; Nazi, xx, 59–60, 115, 328; Nazi dictatorship in, 123–25; New Era of, 117–20; People’s Council of, 129; political parties in, 127; reunification of, 140; Second World War and, 125–27; Social Democratic Party of, 121; social history of, 116–41; Soviet Union withdrawing troops from, 140–41; unification of, 120– 21; Weimar Republic in, 122–24; West, 133 Gershwin, George, 171 Gerson, Sam, 333, 336, 341 Ghent, Emmanuel, 340 ghosts in the nursery, 43, 65 Glasnost (openness), 133 Goldfarb, Jeffrey, 410 good-enough actions, 149, 407 good-enough self, 81 good-me, 84–85 Gorbachev, Mikhail, 133, 140 grandparents, 245–46, 261 Greenberg, Jay, 334 Groddeck, Georg, 144 Grotewohl, Otto, 129 Grotstein, James, 67 grounding, 356, 395 group-analytic attention, 189–90 group culture, 189, 191–92 group dynamics, 109 group identity, 185 group individuation, 192 group matrix, 160 Grundgesetz (basic law), 115, 127

479

Habsburg monarchy, 186 The Haunted Self (van der Hart, Nijenhuis and Steele), 353 healing process: cultural, 445–46; entranced experience in, 394–95; for False Self, 179, 182 health: as compromise, 152; insurance, 120; mental, 64–65; more toward, 151; moving toward, 148–50; safety regulations and, 378 Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), 441 Heine, Heinrich, 376 here-and-now feelings, 397 Herman, Judith, 18 heroes, 187–89 Herrenrasse (Master Race), 125 Herzegovina, 170 heteronormativity, 334 hippocampus, 26, 28–30 Hiroshima, 53 historical trauma, 65, 443–46 Hitler, Adolf, 125 Hitler-Stalin pact, 125 holding environment, 370 Holmes, Jeremy, 40 Holocaust, 342–43. See also Shoah Honecker, 132–33, 138 HoNOSCA. See Health of the Nation Outcome Scales for Children and Adolescents Hopper, Earl, 107, 164, 177–78 Hopwood, A. R., 348 Horowitz, Mardi, 9 housing settlements, 125 Howell, Elizabeth, 337 HPA. See hypothalamic-pituitaryadrenal human rights, 153–55 human right suppression, 138 Hungary, 139 Hunter, Kelly, 392 Huppertz, Bernd, 112, 301, 305, 390 Hus, Jan, 186

480

Index

husband, aggressive, 226 Huston, John, 340 hypothalamic-pituitary-adrenal (HPA), 24 hysteria, 348–49 iatrogenically created, 351–52 identification with aggressor, 63, 179, 311, 335–36 identity: alteration, 356; confusion, 356; cultural, 445; group, 185; search for, 222. See also Dissociative Identity Disorder Iliad, 9–10 imaginative life, 236 imaging techniques, 26 Imperial Germany, 122 implicit processing, 352 implicit relational knowing, 370, 376 imprisonment, child, 314–15 improvisation and stories stage, 394 indigenous people, 443–44 Indignation (Roth), 82 individuals: ambiguous loss and symptoms of, 96; in Communist society, xxii–xxiii; False Self of, 180; trauma of, 64, 465; zero process structures of, 305 industrialization, 120 infants: anxieties of, 45, 69; apathy of, 269; attachment disruptions of, 46–48; attachment theory of, 40; brain development of, 70; caregivers relatedness with, 337–38; Circles of Security of, 391; disorganized, 68; emotional systems of, 390; experience of, 40–42, 46–48; expression imitation by, 392; feeding difficulties of, 268; foundational development period of, 41; hidden trauma of, 41–42, 267–68; intergenerational relationships of, 47–48; maltreatment of, 71; mental health, 64–65; mother and, 154; nonverbal domain of, 353; not-

good-enough experiences of, 155; omnipotence, 6–7; parent interaction with, 43–45; parent reflection and, 44–45; parents anxiety-provoking relationship with, 69; possibility range of, 390; psychoanalysis of, 67; self-development of, 47; sexuality and, 338; trauma to, 48–50; unconscious of, 60; Winnicott and anxieties of, 45; Winnicott and development of, 70; Winnicott and gaze of, 42, 46–48 Inhibitions, Symptoms and Anxiety (Freud, S.), 255 innate communication, 374–75 inner configurations, 266 inner confusion, 73 inner disposition, 181 inner witnessing function, 308 insecure attachment, 74, 195–96 insomnia, 211 intentional choice, 92 interactive object, 390 interdisciplinary influences, 371–74 intergenerational communication, 20–21 intergenerational relationships, 47–48 intergenerational transmission, 338–39, 444–46 intergenerational trauma, 196, 467–68; Mr. R and, 217–18; parents and, 444–46; severe, 197–98 internal object-relations, 310–11 internal objects, 60, 339, 343, 408 internal protection, 311 internal representations, 277 internal world: child’s expression of, 273; external events and, 411; of patients, 278 internment camp, 218 interpersonal difficulties, 445 interpersonal regulation of stress, 411 interpersonal violence, 409–10 intersubjective taboo, 328–29 interventions: for ambiguous loss, 99–100; attachment-informed, 437;



Index

children with trauma, 436–37; NMT core elements for, 438–39; NMT focus in, 435, 435; psychoanalysis, 278; theoretical, 429–31; therapeutic, 430 intra-familial abuse, 405 intrapsychic process, 295 introjection, 335 Iron Curtain, 141 The It (Das Es), 144 Itzkowitz, Shelley, 337 Jackson, Jeffrey B., 94 Janet, Pierre M. F., 5 Jára Cimrman (fictional character), 187–89, 191 Jennings, Sue, 391 Jiménez, Juan Pablo, 410–11 Kaplan, Lori, 94 Keats, John, 99, 152 Keilson, Hans, 307 Kelava, Vera, 170 Kellerman, Natan, 444 Kestenberg, Judith, 59 Khan, Masud, 7, 82–83 Klein, Melanie, 39, 84, 265–67 Klímová, Helena, 107 Kohut, Heinz, 7, 330n2; empathy and, 330n3; psychology of self from, 323 Krteček (fictional character), 190–91 Ku Klux Klan, 165 labor camp, in Russia, 212 Lacan, Jacques, 47 Lachmann, Frank, 352 Lacter, Ellen, 360 Laing, R. D., 74 land reform, 128 Landwirtschaftliche Produktionsgenossenschaften (LPG), 136 Langer, Susanne K., 374 Laplanche, Jean, 76, 338

481

Lassie (television), 248 Laub, Dori, 255, 343 law enforcement, 341 learning, communication and, 412 Lenkung (guidance), 115 Lerner, Alan J., 80 let’s pretend, 393 Let There Be Light (film), 340 Leve, Ariel, 349 Levi, Primo, 64 liberal cultures, 166 liberation, 182 libidinal ego, 84 Likert scale, 433 Little Mouse Girl, 190 little murders, 78, 82–83 lived experiences, 374–75 living unaliveness, 151 Loewe, Frederick, 80 Loftus, Elizabeth, 351 loneliness, 219, 231 Lorenza (patient): case study of, 274–77; conflicted feelings of, 276; countertransference and, 276; therapy session with, 274–77 Lorenzini, Nicolas, 390 losses, fear from, 200–201 Lowenstein, Richard, 355–56 LPG (Landwirtschaftliche Produktionsgenossenschaften), 136 Lyons-Ruth, Karlen, 8, 359 macro-political evolution, 110–11 magical thinking, 260 Maiello, Suzanne, 374 Main, Mary, 7 malignant regression, 151 Malloch, Stephen, 377 maltreatment, 71, 405–6 marked mirroring, 404, 407–8, 413 Marshall Plan of 1947, 127 mass murder, 54 mass trauma, 63–64 master craftsmen, 118 Master Race (Herrenrasse), 125

482

Index

Masterson, James F., 47 maternal care, 146 maternal disturbances, 43–45 maternal mind-mindfulness, 409 maternal preoccupation, 153 maternal violent trauma, 20–21 mature citizenship, 173 MBT. See mentalization-based treatment McEwen, Linda, 351 meaning-making, 368, 377, 379, 381 mental disorders, 3–4, 66, 85, 412 mental health, 64–65 mental illness, 200 mentalization: by caregiver, 404; in communication, 413–14; developmental origins to, 404; ostensive cues and, 410; political violence and, 407–11; trauma consequences and, 403–6; trauma treatment and, 403, 414–17 mentalization-based treatment (MBT), 414–17 mentalizing capacity, 379; BPD and, 404–5; from Fonagy, 379; music making and, 380; in music therapy, 379–81, 381; preverbal levels and, 381; in psychotherapy, 311 mental processes, 281 mental traces, 311 mental trauma, 3–4 messy play, 397 microaggressions, 79 micro-trauma, 74–77, 266; chronic ambiance in, 87n2; chronic entrenchment in, 78, 81–82; connoisseurship gone awry in, 78–80; countertransference of, 272; in digestion, 268–72; little murders in, 78, 82–83; misapplied dynamism in, 85; psychic airbrushing and excessive niceness in, 78; repairing, 86–87; unbridled indignation in, 78, 82; uneasy intimacy in, 78, 80–81; unkind cutting back in, 78–79 middle class, 119–20

Miller, Alison, 360 Miller, Arthur, 82 mind control, 357 mindfulness, 397 mirroring, 42, 404, 407–8, 413 misapplied dynamism, 85 mistrust, 317 Mitchell, Stephen, 334, 336 Mojović, Marina, 107 monarchism, 110 Monopolelite, 134 mood swings, 203 moral stance, 156n3 more toward health, 151 mother: children fed by, 84–85; father killing, 283; gaslighting by, 349; infant and, 154; kidnapping of, 273; patients ambivalent relationship with, 259–60; strict treatment by, 197 Mother Party, 181 motivation, 205 MPD. See Multiple Personality Disorder multiple personalities, 350 Multiple Personality Disorder (MPD), 355 music: elements of, 374; emotional attunement through, 376–77; expression through, 377; making, 380 musical instruments, 377–78 musical transference, 372 music therapy: for adults, 380–81; for children, 368–69, 371, 380–81; clinical-theoretical orientation in, 371–74; emotional landscapes in, 375; emotional regulation from, 375–77; felt experiences from, 370; innate communication through, 374–75; lived experiences and, 374– 75; meaning-making in, 379, 381; mentalizing territory in, 379–81, 381; psychotherapy and, 373–74; PTSD and, 368; relational trauma and, 369–71; room equipped for, 378; state of play from, 370–71; traumatic experiences and, 367–69



Index

mutual gaze, 42 “My Fair Lady” (musical), 80 narrative creation stage, 394 Nathan, Debbie, 351 National People’s Army (NVA), 131 National Socialism, 123 Nationalsozialistische Deutsche Arbeiterpartei (NSDAP), 123–25 natural pedagogy, 406 Nazi dictatorship, 123–25 Nazi Germany, xx, 59–60, 115, 328 NDP. See Neuro-Dramatic-Play nebulous mediator, 376 negative capability, 99, 152, 156n5 negative interactions, 73 neuintelligenz (new intelligentsia), 135 neurobiology: of PTSD, 26–27; of stress, 22–23 neurocognitive impairment, 27, 29 neurodevelopment: model, 423; principles, 426, 452; stress-related hormones impacting, 42 Neuro-Dramatic-Play (NDP), 389, 391–92, 397 neuro-hormonal changes, 26 neurological development, 144–47 neuropsychology, 65–66, 442, 448 Neurosequential Model of Therapeutics (NMT), 423, 425; children’s symptoms in, 427–28; clinical practice tools of, 433–35, 449, 451; core elements of, 438–39; intervention focus of, 435, 435; neurodevelopmental principles of, 426, 452; neuropsychology and, 442; occupational therapy of, 442–43; person centered approach of, 426–27; principles of, 431–33; process overview of, 434; therapeutic approach of, 436–37; trauma forms treated by, 427 neurosis, 5, 10, 17 neutrality, 360

483

New Economic System for Planning and Direction (NÖSPL), 132 new intelligentsia (neuintelligenz), 135 Newman, Louise, 390 nightmares, 448 Nijenhuis, Ellert R. S., 353 NMT. See Neurosequential Model of Therapeutics no-entry syndrome, 269 non-conflict language, 357 nonverbal domain, 353 Nordoff, Paul, 372–73, 375 Nordoff Robbins Music Therapy Centre, 371 Northfield military hospital, 165 NÖSPL. See New Economic System for Planning and Direction not-good-enough care, 147 not-good-enough experiences, 155 notion of containment, 49 not-me, 84–85 not-me ghost, 359 NSDAP. See Nationalsozialistische Deutsche Arbeiterpartei nuclear medicine, 58 NVA. See National People’s Army object-relations theories, 334 observing self, 262 occupational therapy, 442–43 Occupational Therapy Consultancy, 442 Oedipal conflicts, 284, 301 Oedipal relationship, 277 Ogden, Thomas H., 84, 164 oil crisis, 133 Oliver Twist (fictional), 143, 148 omnipotence, with trauma, 260 omnipotent state, 145 openness (Glasnost), 133 operational service class (Operative Dienstklasse), 134–35 ordering and reordering stage, 394 organized sense of self, 377 orienting touch, 356 original aggressor, 182

484

Index

orphans, 285 Orwell, George, 348 ostensive cues, 406, 410 other-world experiences, 395 out-of-body experiences, 395–97 out of sight, out of mind, 289 over-identification process, 269 Panksepp, Jaak, 375 paradox of infant maltreatment, 71 parasympathetic nervous system (PSNS), 23 parent-child links, 277 parent-infant interactions, 68 parents: brainwashing by, 349; case studies challenges of, 290–92; children’s dependency and maladaptation of, 83; child’s relationship with, 43, 267–68; depression and high-risk, 69; divorce of, 198, 218–19; Fonagy and reflection of, 48; good-enough actions of, 407; grandparents, 245– 46, 261; hidden abuse by, 290–92; infant anxiety-provoking relationship with, 69; infant interaction with, 43–45; infants and reflection of, 44–45; intergenerational trauma and, 444–46; marked mirroring of, 407–8; mental state, 42; of Mrs. B, 246; of Mrs. M, 233–34; of Mrs. N, 239–40; parental figures, 164; reflection, 44–45, 48; unresolved traumatic attachment issues of, 45–46 Paris treaties, 131 participatory memory, 354 passive-aggressive, 317 pathological accommodation, 74 patients: acting out of, 313; analyst seduction by, 259; being human at risk of, 329; communication and learning and understanding of, 413; countertransference of, 266; defensive aspects of, 304; dissociation of, 358; with

dissociative states, 258; with false memories, 257–58; internal object repair of, 339, 343; internal world of, 278; Lorenza, 274–77; mistrustful, 253; mother’s ambivalent relationship and, 259–60; with MPD, 355; psychology of exception of, 260; psychotherapy and mental state of, 412; sexual abuse of, 5, 256; therapist interactions with, 327–29; totalitarian systems life of, xx; traumatization of, 309, 312–13; trauma transmission by, 261–62; trauma understanding of, 413–14; working-through process with, 304–5 peekaboo stage, 393 penelongo, 275 People-Owned Enterprise scheme (VEB), xx, 131, 133 People’s Council of Germany, 129 perceptual memory registration, 302 Perestroika (restructuring), 133 perfectionist tendencies, 221, 226 permissive social structures, 20 Perry, Bruce, 66, 69, 425 persistent dissociation, 301 personality development, 354 personality traits, xxi person-centered approach, 412, 426–27 PET. See positron emission tomography phase-sensitive treatment, 12 phobic avoidances, 296 phobic symptoms, 200–201 physical absence with psychological presence, 93 physical presence with psychological absence, 93 physiological stress response, 24 Pieck, Wilhelm, 129 PITCM. See psychoanalytically informed therapeutic case management play, world of, 287 play therapy, 397, 437, 449 pleasure principle, 298



pluperfect errand, 339 political authority, 409 political cultures, 110–11 political parties, in Germany, 127 political psychology, 109 political violence, 407–11 Politics and the English Language (Orwell), 348 Politics of Small Things, 410 Pontalis, Jean-Bertrand, 76 pornography, 341 positron emission tomography (PET), 26 posttraumatic anxieties, 310 posttraumatic mental functioning, 297–98 Posttraumatic Stress Disorder (PTSD), 3–4, 11, 261, 282; ambiguous loss and, 93–94; CPTSD and, 18–19, 467; depression and, 94; in DSM-5, 460–61; music therapy and, 368; neurobiology of, 26–27; neurocognitive impairments and, 29; psychiatric approach to, 17–18; severity of, 411; stress neurobiology of, 22–23; trauma therapists and, 463–64; treatment of, 414; types and symptoms of, 324, 465–66; war trauma and, 340. See also stress; stress response Prague Spring, 132 pre-birth stage, 393 prefrontal cortex, 27, 29 premature birth, 224 preverbal levels, 381 primary emotions, 29 primitive defenses, 162–63 primitive existential anxieties, 63 primitive impulses, 279 prisoners, 315, 446 procedural memory, 352 PSNS. See parasympathetic nervous system psychiatric approach, 17–18 Psychiatric Clinic (Belgrade), 166–67

Index

485

psychic airbrushing, 78, 81 psychic borders, 183 psychic equivalence, 408 psychic evolution, 86 psychic life, 85 psychic radioactivity, 57–58 psychic trauma, 45 psychoanalysis, 39; Age of Totalitarianism development of, 160; child in, 273; infant mental health and, 64–65; of infants, 67; interactions in, 337–38; intervention, 278; Klein knowledge of, 265–67; training programs for, 286; translational, 281–82; trauma response of, 307, 309; of war trauma, 340 psychoanalytically informed therapeutic case management (PITCM), 282–83 psychoanalytic field theory, 161 psychodynamic groups, 161–62 psychodynamic theory, 444 psycho-education, 450 psychological aftermath, of sexual assault, 355 “Psychological Effects and Coping with Extreme Trauma and Social Transformations” (research project), xxiii psychology: of being human, 323; developmental, 372; ego, 5–6, 301; family and, 94–95; functions of, 30; neuropsychology, 442; patient and exception, 260; perspective of, 95; political, 109; of self, 87n2, 323; strategies using, xxiii psychopathologies, 58 psycho-physiological development, 28 psycho-sexuality, 407 psychosis, 292 psychosocial dynamics, 160 psychotherapy: attachment-based, 357–58; damaged self-concept in, 178; developmental trajectory from, 290; family context in, 92; histories

486

Index

destructive forces and, 61; infantile trauma in, 48–50; intersubjective context of, 49–50; mentalizing capacity in, 311; music therapy and, 373–74; patient’s mental state in, 412; treatment process in, 316–19 Psychotherapy in the Wake of War (Huppertz), 112 psychotic imagination, 164–65 PTSD. See posttraumatic stress disorder public gaslighting, 351 puerperal psychosis, 292 radiation, nuclear, 53 radioactive fallout, 53–54 radioactive identification, 55–56 radioactive nucleus, 54–56 radioactive processes, 58 radioactive residues, 55–56 radioactivity, 54–58 rape, 4, 10, 335, 465 rapprochement phase, 317 rational therapeutic tools, 303–4 reality: dramatic, 395; gaslighting and validation of, 357; gaslighting distorting, 75, 347–48; therapists with lumps of, 270; trauma, 333 rebuilding, 415 recovery building blocks, 389–91 recovery through relationships, 430–31 reflection, 42 Reflective Citizens, 161, 165–66; Banja Luka matrix of, 170–72; in negative social-psychic-retreats, 170–72; in positive social-psychic-retreats, 169–70; in Serbia, 168–69 reflective functioning, 40 Reflective Functioning Scale, 404 reflective reasoning, 361 reformation movement, 186 regression, 256, 317 regulation theory, 353 Reich, Steve, 378 Reichsgau Wartheland, 125 relational assessment, 97–99

relational disorder, 91–92 relational element, 436 relational home, 326, 328 relational rupture, 94 relational theory, 334 relational therapy, 99–100 relational trauma, 41–43, 325, 369–71 relationships, recovery through, 430–31 relevant element, 436 repetition compulsion, 257 repetitive element, 436 repression, xix–xxiii, 303, 328 repressive systems, 116 resilience: ambiguous loss building, 98– 99; to stress, 92; ToR and, 389–90; trauma and showing, 254 resistance, 317 respectful element, 436 restructuring (Perestroika), 133 rewarding element, 436 Rey, J. Henry, 339, 343 rhythmic element, 436 rhythmic play, 391 rhythm of life, 391 ritual abuse, 357 Ritual Abuse and Mind Control: Manipulation of Attachment Needs (Badouk-Epstein, Schwartz, and Wingfield), 350 Robbins, Clive, 372–73, 375 role reversal stage, 394 romantic love, 119 Roper, Susanne O., 94 Roth, Philip, 82 Roussillon, Renee, 267 ruling class, 134 ruling system, after Second World War, 180–81 Russian labor camp, 212 Sackett, David, 428 sadism, 289 safe-place, 396 SAM. See sympathetic-adrenal medullary



Index

SBZ. See Soviet zone Scarfone, Dominique, 313 schizo-paranoid internal object, 408 Schore, A. N., 352 Schwartz, Harvey, 350, 360 Scott, Catherine, 465–66 SDQ. See Strengths and Difficulties Questionnaire Šebek, Michael, xxi–xxii, 408 secondary emotions, 29 secondary traumatization, 340–42 second-order processing, 296–97 Second World War, 199, 218, 310; Germany and, 125–27; Let There Be Light about, 340; ruling system after, 180–81 secure attachment, 408, 411, 448 SED. See Socialist Unity Party seduction, of therapists, 259 SELF. See Self Ego-type Life Form self-blame, 93 self-brainwashing, 107 self-concept, 178 self-confidence, 230–32 self-destructive behaviors, 71 self-development, 47 self-diminishment, 77 Self Ego-type Life Form (SELF), 375 self-employment, 220 self-esteem, 200, 226, 242, 449 self-experience, 40 self-harming behavior, 19 self-incoherence, 410 self-object relation, 311 self-psychology, 87n2 self-righteous anger, 82 self-soothe, 397 Selye, Hans, 8–9, 24 sensory self-experiences, 377–78 separation anxieties, 231, 236 separation process, 269 September 11, 2001, 261 Serbia, 168–69, 170 severe personality disorder, 67

487

sexual abuse, 5, 256; of children, 338, 398; of victim K, 350; war trauma and, 339 sexual assault, 336; out-of-body experience from, 396; psychological aftermath of, 355; women and, 314 sexuality, 408 sexual relationships, 220 sexual trauma, 333–34 The Shadow of the Tsunami (Bromberg), 358 shame, absence of, 358–59 Shane, Estelle, 7 Shane, Morton, 7 Shatan, Chaim, 340 Shaw, G. B., 80 shell shock, 10 Shengold, Leon, 18 Shoah, 53–54, 59–61 Siegel, Daniel J., 368, 370 Simpson, M. A., 360 single-photon emission computed tomography (SPECT), 26 Slade, Arietta, 336 SNS. See sympathetic nervous system social context, of trauma, 309–10 Social Democratic Party (SPD), 121, 128–29 social history, of Germany, 116–41 socialistic human community, 132 socialist society, 135 Socialist Unity Party (SED), 127, 130– 31, 137–39 social learning, 414 social-psychic-retreats, 162; Reflective Citizens in negative, 170–72; Reflective Citizens in positive, 169– 70; theory of, 167–68; in totalitarian system, 165–66 social systems anxieties, 109 social trauma, 111–12, 299–301 social unconscious, 177–78, 183 society: classless, 130; Communist, xxii–xxiii; FMS and, 358; socialist, 135

488

Index

sociocultural models, 444 socio-legal difficulties, 445 sociological perspective, 95 socio-political violence, 53–56 soldiers, 295–96 Solomon, Judith, 7 somatic treatments, 309, 317 somatosensory, 437 Soviet Union, 140–41, 181 Soviet zone (SBZ), 127–29 SPD. See Social Democratic Party specialist assessments, 442–43 SPECT. See single-photon emission computed tomography spontaneous gesture, 145 Stasi system, xx, 132; human right suppression of, 138; torture by, 356 state of play, 370–71 States of Mind: Tracing the Edges of Consciousness, 348 state transformation, 371 Steele, Kathy, 353 Stein, Helen, 406 Stern, Daniel, 353–54, 372; affective attunement from, 45, 359; forms of vitality from, 373; infantile experience from, 40; mutual gaze comments from, 42; organized sense of self from, 377; temporal feeling shape from, 376 Stige, Brynjulf, 375 stimulus barrier, 254 stolen generations, 446 Stolorow, Robert, 7, 325 Strengths and Difficulties Questionnaire (SDQ), 441, 447–49 stress: ASD, 4, 18, 25, 461; chronic, 25–27; interpersonal regulation of, 411; neurobiology of, 22–23; phases of, 8–9; PTSD and neurobiology of, 22–23; regulatory mechanisms, 65–66; related disorders, 462; resilience to, 92; response syndrome, 9; traumatic, 464 stress-related hormones, 42

stress response, 432; behaviorrelated, 25; cognitive-affect, 25; physiological, 24; stages of, 23 structural barriers, 444 structural dissociation, 354, 359 Studies of Hysteria (Freud, S., and Breuer), 5 sublimation, 149 Sue, Dewald Wing, 79 suffering, 265–66, 341–42 sufficient experience, 145 suicide, 149, 151, 201–2 Sullivan, Harry S., 76, 83–85 “Summertime” (song), 171 Sunderland, Margot, 390 superego, 208; distortions, 255; figure, 197; internalizing, 220; magical thinking and, 260 survivors, of Shoah, 61 Sutton, Adrian, 107 Švejk (the good soldier - fictional character), 187–89, 191 Symington, N, 152 sympathetic-adrenal medullary (SAM), 24 sympathetic nervous system (SNS), 23 sympathetic resonance, 378 symptoms: of ambiguous loss, 96; complex trauma, 22; depression and phobic, 200–201; depressiveanxious, 200, 231, 235; identifying trauma, 465; NMT and children’s, 427–28; of PTSD, 324, 465–66; Take Two program and children’s, 427–28; of trauma, 21–22, 324–26, 465 synapses, 432 syndromes: no-entry, 269; stress response, 9; trauma, 71; traumarelated, 465–66 Take Two program: approach of, 423–25; bio-ecological approach of, 429; biopsychosocial approach of, 430; child protection from,



Index

424–25; children’s symptoms in, 427–28; common treatment elements of, 437–41; culturally respectful approach of, 429; Developmental Consultancies Team of, 442; domains of, 437; levels of focus in, 431; Matthew and role of, 447, 449– 51; neuropsychological processes assessed by, 448; neuropsychology and, 442; occupational therapy of, 442–43; psycho-education in, 450; recovery through relationships in, 430–31; service model of, 441; theoretical intervention of, 429–31; theory of change in, 440; therapeutic approach of, 436–37, 440, 452; trauma forms treated by, 427 Target, M., 40 TEF. See tracheo-esophageal fistula telescoping of generations, 338 television, 248 Temple, Nick, xxi temporal feeling shape, 376 Terr, Lenore, 71 terrorist attack, 93 thalamus, 29 Thalassa (Ferenczi), 335 Theatre of Resilience (ToR), 389–90 theoretical innovation, 334 theoretical intervention, 429–31 theory of change, 440 Theory of Mind (ToM), 40, 389, 405 theory of reclamation, 373 theory of thinking, 381 therapeutic approach, 436–37, 452 therapeutic community, 166–67 therapeutic empathic attunement, 49 therapeutic intervention, 430 Therapeutic Life Story, 437 therapeutic tools, 341–43 therapists: attachment theory and, 49; empathic attention of, 266; lumps of reality from, 270; neutrality of, 360; observing self and, 262; patient interactions with, 327–29; rebuilding

489

and, 415; seductiveness toward, 259; trauma redefined by, 463–64; trauma secrets and, 261 therapy session: bilingual, 327–28; holding environment of, 370; with Lorenza, 274–77; pillars of, 281–82 Third Reich, 125 time tunnel, 59 Titoism, 162–63 TM. See translation medicine Togashi, Koichi, 324–28 ToM. See Theory of Mind tonal-rhythmic field, 378 ToR. See Theatre of Resilience Torok, Maria, 338–39 Torres Strait Islander people, 423, 443 torture, 314–15, 356, 410 totalitarian objects, 408 totalitarian system, 110–12; Age of Totalitarianism and, 160; antitotalitarianism, 161; consequences of, 162; elections in, 183; false collective self in, 180; False Self and, 152–53; of GDR, 115–16; patients living under, xx; postwar elections enabling, 183; psychodynamic groups and, 161–62; psychological strategies in, xxiii; psychotic imagination in, 164–65; repression influence in, xix–xxiii; resistance to, 159–60; responding to, xxi–xxii; social-psychic-retreats in, 165–66; Titoism and, 162–63; zerolevel subjectivity in, 171–72 tracheo-esophageal fistula (TEF), 287–88 trade union (Einheitsgewerkschaft), 129 training programs, for psychoanalysis, 286 trance-experience, 394 transference: in clinical environment, 302–3; MBT using, 416; Mr. Q and, 209–10; Mr. R and, 222; Mrs. B and, 248–49; Mrs. M and, 237; Mrs. N and, 243; Mrs. O and, 227; Mrs. U

490

Index

and, 215; musical, 372; traumatized person and, 312; in treatment process, 317–19 transgenerational transmission, 184, 189, 343 transgenerational trauma, 49, 183 translational psychoanalysis, 281–82 translation medicine (TM), 281 transposition, 59 trauma, 330n1; absence from, 333; acute, 467; ADs from, 461–62; ASD from, 461; attachment, 337; cases, xxi; child interventions for, 436–37; children’s symptoms related to, 21– 22; chosen, 184; chronic, 283–84, 299–300; civilian, 10; collective, 21; communication impacted by, 406–7; complex psychological, 464; complex symptoms of, 22; conceptual history of, 4–8; creative exploration and, 292n2; cumulative, 83; defining, 254–55, 295; developmental, 64–65, 464, 467–68; dissociation correlations with, 352; DSM-5 and diseases from, 462–63; ego equilibrium disruption in, 6; ego regression in, 297; etymological study of, 3; existential, 330; False Self origins in, 152–53, 178; Ferenczi and reality of, 333; historical, 65, 443–46; identifying symptoms of, 465; individual, 64, 465; infancy with hidden, 41–42, 267–68; inner configurations in, 266; intergenerational transmission of, 338–39, 444–46; layers of, 257; mass, 63–64; mental, 3–4; mentalization and consequences of, 403–6; NMT and Take Two treating, 427; omnipotence with, 260; patient’s understanding, 413–14; phases of, 11–12; psychic, 45; psychoanalysis response to, 307, 309; relational, 41–43, 325, 369–71; resilience shown after, 254; secrets

and, 261; social context of, 309–10; social/cultural, 111–12; stress related disorders and, 462; theory, 360; therapists redefining, 463–64; Togashi angles on, 324–25; ToR and, 390; transference and people with, 312; transgenerational, 49, 183; transmission of, 261–62; treatment, 403, 466–68; treatment of existential, 325; types and symptoms of, 324–26; war-related, 9–10, 339–40; Winnicott and, 282; witnessing in, 342; zero process and, 297–303. See also micro-trauma trauma/affect theory, 350 Trauma Focused Cognitive Behavioral Therapy, 437 trauma-related diseases, 21–22, 462–63, 465–66 Trauma Symptom Checklist for Children (TSCC), 441 trauma syndrome, 71 traumatic attachment issues, 45–46 traumatic experiences: affective responses after, 29; anxieties from, 254–55; in child development, 6, 8; complexity of, 256–57; depression from, 21–22, 198–99; emotion regulation after, 30; within family, 398; Freud, S., recreating, 257; music therapy and, 367–69; psychological structures and functions influenced by, 30; transference and, 312 traumatic neurosis, 17 traumatic process, 295–97 traumatic ruptures, 270 traumatic stress, 464 traumatization, 330n1; depression and, 308; emotional meaning in, 308–9; enactments and, 313; of patients, 309, 312–13; phenomenology of, 310–11; responses from, 308; responses to, 307; secondary, 340– 42; vicarious, 340–41 traumatology, 3



Index

treatment: ambiguous loss guidelines for, 100–102; ambiguous loss perspectives in, 97; conceptualizing, 326–29; countertransference in, 317–19; of existential trauma, 325; mentalization in, 403, 414–17; of Mr. Q, 207–9; of Mr. R., 220–22; of Mrs. B, 247–48; of Mrs. M, 235–36; of Mrs. N, 241–42; of Mrs. O, 225–27; of Mrs. P, 230–32; of Mrs. U, 214–15; phase-sensitive, 12; in psychotherapy, 316–19; of PTSD, 414; somatic, 309, 317; Take Two elements of, 437–41; therapeutic tools in, 341–43; transference and countertransference in, 317–19; trauma, 403, 466–68 Treaty of Versailles, 125 Tree of Life, 450 Trevarthen, Colwyn, 372–73, 376–77 True Self, 148, 156n3; autonomy expressions of, 287; human rights activities of, 153–55; manifestations of, 150–51; sublimation in, 149; Winnicott and, 143–46 True-Self-denied, 149 Truman Doctrine, 127 TSCC. See Trauma Symptom Checklist for Children tuberculosis, 212 Uganda, 284–85 Ulbricht, 131–33, 138 unbridled indignation, 78, 82 unconscious mind, 54 unconscious wishes, 313 uneasy intimacy, 78, 80–81 un-housed ghosts, 162 unification, of Germany, 120–21 United Nations Universal Declaration of Human Rights, 154 United States (U.S.): Hitler declaring war on, 125; Truman Doctrine of, 127 universal-seeming benchmarks, 75

491

unkind cutting back, 78–79 un-object-relatedness, 145 unspeakable anxieties, 63 U.S. See United States use-dependent functioning, 432 usefulness, 271 use it or lose it principle, 432 utopian communism, 111, 138 VACCA. See Victorian Aboriginal Child Care Agency Van Derbur, Marilyn, 353 Van der Hart, Onno, 353, 355, 359 Van der Kolk, Bessel, 19, 392 VEB. See People-Owned Enterprise scheme vegetative excitation, 144 The Velveteen Rabbit (Williams, M.), 360 verbal disparagement, 256 vicarious traumatization, 340–41 victim: identification with aggressor of, 63, 179, 311, 335–36; original aggressor and, 182; responsibility absolved by, 260; sexual abuse of, 350 victim-blaming culture, 358 Victorian Aboriginal Child Care Agency (VACCA), 424 Vietnam War, 10 violence: DID and, 355; of father, 298–99, 446; interpersonal, 409–10; maternal trauma from, 20–21; mentalization and political, 407–11; socio-political, 53–56 Vogt, Irena, 356 Volkan, Vamik, 107, 183–84, 305 Volksdeutsche, 126 vulnerability, 271 Waldheim Tribunal, 130 Wallerstein, Robert S., xi, 112 war criminals, 130 war neurosis, 10 war personality, xxii

492

Index

war-related trauma, 9–10 Warsaw Pact, 131–32, 140 war trauma, 9–10, 339–40 Wehler, Hans-Ulrich, 116 Weimar Republic, 122–24 Weinberg, Haim, 177 Western European Union (WEU), 127 West Germany, 133 WEU. See Western European Union “When the Third is Dead” (Gerson), 336, 341 white noise, 451 whole body stage, 393 Wilhelm, Kaiser, II, 121 Williams, Gianna, 269 Williams, Margery, 360 Williams, William Carlos, 42 Willkürstaat (despotism), 139 Wingfield, 350 Winnicott, Donald W., 6, 372; actual objects and, 377; antisocial tendencies and, 291; creative exploration from, 292n2; distorting influences and, 83; emotional life from, 41; False Self from, 143, 146–50; formulations applied by, 282–92; health as compromise from, 152; infant anxieties described by, 45; infant development and, 70; infant gaze from, 42, 46–48; living

unaliveness and, 151; maternal care and, 146; maternal preoccupation and, 153; mental processes and, 281; moral stance from, 156n3; mother and baby, 154; state of play from, 370–71; sufficient experience and, 145; trauma and, 282; True Self from, 143–46; unspeakable anxieties from, 63 witch hunt narrative, 351 withdrawal, 215 witnessing, 336, 342, 360 women, 314, 348 working class, 135–37 working-through process, 304–5 world-as-it-is, 148 world-as-it-should-be-for-me, 148 Yehuda, Rachel, 183–84 Yugoslavia, 163, 165–69 zero-level subjectivity, 159, 163, 171–72 zero process: depression and, 298; Freud, S., and, 298; memories, 300–301; rational therapeutic tools from, 303–4; structures, 305; trauma and, 297–303 Žižek, Slavoj, 163

About the Editor and Contributors

Bernd Huppertz, MD, is a physician, psychotherapist (child, adolescent, and adult), psychiatrist, neurologist, and former brain researcher. He has had a private practice in Germany since 1998. He is a member of the APA, a fellow of the International College of Psychosomatic Medicine (ICPM), and founded the Institute for Comparative Psychotherapy. In 2002, he became qualified to teach Further Education in Psychiatry and Psychotherapy (Medical Council/ Medical Association, Brandenburg, Germany). He has published widely in the field of psychiatry, psychoanalysis, psychotherapy, and psychosomatic medicine and is editor of Psychotherapy in the Wake of War: Discovering Multiple Psychoanalytic Traditions (Jason Aronson, 2013).  Orit Badouk Epstein is an attachment-based psychoanalytic psychotherapist at the Bowlby Centre, a supervisor working in private practice (UKCP registered) and a writer who regularly writes articles, film reviews, and book chapters. She is the coauthor of the book Ritual Abuse and Mind Control: The Manipulation of Attachment Needs and coeditor of the book Terror Within and Without: Detachment and Disintegration: Clinical Work on the Edge. She is editor for the journal Attachment: New Directions in Psychotherapy and Relational Psychoanalysis and coeditor of the ESTD (European Society for Trauma and Dissociation) Newsletter. Anna Balas, MD, is a modern Freudian in orientation, integrating ego psychology and object relations theory. She is a member of the New York Psychoanalytic Society and Institute, the Center for Advanced Psychoanalysis, 493

494

About the Editor and Contributors

the American Psychoanalytic Association, the International Psychoanalytic Association, the Association for Child Psychoanalysis, and the American Psychiatric Association. She is associate professor of psychiatry at Payne Whitney Division of New York Presbyterian Hospital, Cornell Medical Center, and is a member of the faculty at New York Psychoanalytic Society and Institute. Carlina Black, BA (Hons) in science (psychology) from the University of Melbourne has worked in the area of child abuse and neglect and is a sessional teacher in the Department of Social Work and Social Policy at La Trobe University. Significant publications include coauthoring a series of three evaluation reports on the Berry Street Take Two program and associated journal articles. Pauline Boss, PhD, is professor emeritus at the University of Minnesota, a fellow in the American Psychological Association and American Association for Marriage and Family Therapy, a former president of the National Council on Family Relations, and a family therapist in private practice. With her groundbreaking work as a scientist-practitioner, Dr. Boss is the principal theorist in the study of ambiguous loss, a term she coined in the 1970s. Since then, she has researched various types of ambiguous loss, summarizing her work in the widely acclaimed book, Ambiguous Loss: Learning to Live with Unresolved Grief. For professionals and for treatment she had written her book, Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss. Dr. Boss’s most recent book, written for families, is Loving Someone Who Has Dementia: How to Find Hope While Coping with Stress and Grief. For more information, see her website: www.ambiguousloss.com. Chloe Campbell, PhD, is a research fellow at the Psychoanalysis Unit, University College London. Her research interests involve mentalizing, epistemic trust, and the history of childhood. Allison Cox, PhD, is the deputy director of the Take Two program. She has a bachelor’s degree and doctorate in occupational therapy, with current registration, and a master’s degree in child psychoanalytic psychotherapy. She has worked for fifteen years in a child and adolescent mental health service providing psychodynamic-oriented therapy and developmentally focused specialist consultation. Margaret Crastnopol, MD, is a psychologist/psychoanalyst who practices within the contemporary relational tradition. She is a graduate of the William



About the Editor and Contributors

495

Alanson White Institute in New York City, is currently on the faculty there and at the Seattle Psychoanalytic Society and Institute, and is on the executive board and was a founding member of the International Association for Relational Psychoanalysis and Psychotherapy. Dr. Crastnopol is the author of Micro-Trauma: A Psychoanalytic Understanding of Cumulative Psychic Injury (2015) and has published widely. She is in private practice in Seattle, Washington, where she resides. Joseph Fernando, MD, is a psychoanalyst with an ego psychological theoretical orientation; has a master’s degree in psychology from the University of Ottawa and a medical degree from McGill University; and is a member and past president of the Toronto Psychoanalytic Society, a member of the International Psychoanalytical Association, and a training analyst for and a member and associate director of the Toronto Institute of Psychoanalysis. He has published papers in major psychoanalytic journals on narcissism, guilt, and trauma. His book, The Processes of Defense: Trauma, Drives and Reality, a New Synthesis won the 2010 Gradiva award for psychoanalytic theory. Peter Fonagy, PhD, FMedSci, FBA, FAcSS, OBE, is professor of contemporary psychoanalysis and developmental science and head of the Research Department of Clinical, Educational and Health Psychology at University College, London. He is chief executive of the Anna Freud National Centre for Children and Families, London; consultant to the Child and Family Program at the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, Houston; and holds visiting professorships at Yale and Harvard Medical Schools. His clinical and research interests center on issues of early attachment relationships, social cognition, borderline personality disorder, and violence. A major focus of his contribution has been an innovative, research-based psychodynamic therapeutic approach, mentalization-based treatment, which was developed in collaboration with a number of clinical sites in the United Kingdom and United States. He has published over four hundred fifty scientific papers and two hundred fifty chapters, and has authored or coauthored eighteen books. Margarita Frederico is an associate professor with an MBA and MSW and graduate research coordinator (social work and social policy) at La Trobe University and is principal research consultant at Berry Street Take Two in Melbourne, Australia. She is a graduate of Smith College School of Social Work and trained at Yale University Child Study Center in the 1970s. Margarita is an elected life member of the Australian Association of Social Workers and of Berry Street Victoria. Topics of her publications have included

496

About the Editor and Contributors

chronic neglect, cross-sector collaboration, international social work, and evaluations of the Take Two program. Yolanda Gampel, PhD, is a professor in the faculty of social sciences, the Department of Psychology, and the Program of Advanced Psychotherapy at Sackler Medical School, Tel-Aviv University. She was invited to be an associate professor at l’Université de Paris, Nanterre, 1985–1987 and at l’Université Lumière II, Lyon, 2000–2001. She was a training analyst and the past president, 1989–1991, of the Israel Psychoanalytic Society and Institute and the vice president of the European Federation of Psychoanalysis, 2001–2005. She was recipient of the Hayman International Prize for Published Work Pertaining to Traumatized Children and Adults in 2001 and the Mary S. Sigourney Award in 2006. She has published many papers in various psychoanalytic journals, and her book Ces parents qui vivent à travers moi: Les enfants de guerres was translated into four languages. Adrienne Harris, PhD, identifies as a relational psychoanalyst with a strong interest in object relations theory, particularly the work of Winnicott, Green, and Rey. She is faculty and supervisor at New York University Postdoctoral Program in Psychotherapy and Psychoanalysis and at the Psychoanalytic Institute of Northern California. She is an editor at Psychoanalytic Dialogues, and Studies in Gender and Sexuality. In 2009, with Lewis Aron and Jeremy Safran, she established the Sandor Ferenczi Center at the New School University. She coedits the book series Relational Perspectives in Psychoanalysis, with over seventy published volumes. She is a member of the nongovernmental organization that the IPA developed to work with the UN and is an editor of the IPA ejournal Psychoanalysistoday.com. Her current work is on analytic subjectivity, intersectional models of gender and sexuality, and ghosts. Annette Jackson, a bachelor and master of social work, has worked for thirty-three years in various ways with children who have experienced abuse and neglect in their families. Her psychotherapeutic orientations are personcentered (Rogerian), ecological, and family systemic. She is currently a PhD candidate focusing on the topic of child neglect. Annette Jackson is a member of the Australian Association of Social Workers, a fellow of the ChildTrauma Academy (US) and a mentor for the CTA’s Neurosequential Model of Therapeutics, a senior fellow with the University of Melbourne, and an adjunct associate professor at La Trobe University. She has published in the areas of family reunification, childhood trauma, evaluations of the Take Two program, and the child protection and out-of-home care systems.



About the Editor and Contributors

497

Sue Jennings, PhD, has a theatre-based resilience orientation. She is a drama therapist and play therapist and founding member of the British Association of Dramatherapists. She is professor of Play (European Dramatherapy Federation) and Honorary Professor in Creative Arts Therapies, University of Derby. She is now retired. She is the author of Theatre, Ritual and Transformation and Healthy Attachments and Neuro-Dramatic-Play. She is president emeritus of the Romanian Association of Play Therapy and Dramatherapy. Helena Klímová is a training group analyst, psychoanalytic therapist, and author who trained in group therapy, family therapy, and group analysis. Klímová is a member of the Czech Psychotherapeutic Society of the Czech Medical Society of Jan Evangelista Purkyně and the Czech Association of Psychotherapists; a founding member of the Czech Society for Psychoanalytic Psychotherapy, the Institute of Group Analysis–Prague, the Rafael Institute, and Irene Press; and an honorary member of the Group-Analytic Society International–London. She is a signatory of the Charter 77 manifesto in 1977 against the totalitarian regime in Czechoslovakia. Klímová works in her private practice in Prague and in the Rafael Institute, Prague. Amanda Kottler, MA (clin. psych.) has an orientation in contemporary selfpsychology and relational psychoanalysis. Kottler is a clinical psychologist practicing as a psychoanalytic psychotherapist in Cape Town, South Africa. She is a founding and faculty member of the Cape Town Psychoanalytic Self Psychology Group and an emeritus council member of the International Association of Self Psychology. She has previously been a senior lecturer at the University of Cape Town but now works full-time in private practice. She has published numerous articles in South Africa, the UK, and the United States and coedited two previous books. She is a coauthor of Kohut’s Twinship across Cultures: The Psychology of Being Human. Nicolas Lorenzini, MSc. and PhD, is a researcher at the Psychoanalysis Unit, University College, London, and a psychoanalytic psychotherapist, from a Bionian/attachment orientation, for adolescents in London. He is vice president of the Asociacion Internacional Para el Estudio y Desarrollo de la Mentalizacion (AIEDEM; International Association for the Study and Development of Mentalization). Mariângela Mendes de Almeida has a Kleinian/post-Kleinian orientation, with a strong influence in her psychoanalytical practice with children and primitive states of mind, where infant observation and child development are relevant foundations in training and early intervention with parents and

498

About the Editor and Contributors

infants are inspiring clinical tools. She is a clinical psychologist with a master’s degree at the Tavistock Clinic and University of East London and works as a coordinator of a clinical service with parents and young children within a Pediatric Department in a teaching hospital and as a psychoanalytic psychotherapist in private practice in São Paulo, Brazil. She is in psychoanalytic training at the Brazilian Association of Psychoanalysis of São Paulo (SBPSPIPA) and has published chapters in books and journals in the psychoanalytic field in Brazil, England, and Italy. Among others, she has coedited the book Looking and Listening, about the psychoanalytic observational approach and its developments in São Paulo, and participated in Psychotherapy in the Wake of War, edited by Bernd Huppertz. Marina Mojović, MD, MA, is a psychiatrist, psychoanalytic psychotherapist, group psychotherapist, group analyst, training group analyst, and supervisor. She works in her private psychiatric practice and in Consulting-Art, her company for consultancy and education. She is a member of the International Association for Group Psychotherapy and Group Processes (IAGP), Group Analytic Society International (GASI), and GASI Management Committee. Currently, she is a co-leader of the Group Analytic Dictionary Project and also a member of the International Society for Psychoanalytic Studies of Organizations (ISPSO), the Organization for Promoting Understanding of Society (OPUS), the European Federation of Psychoanalytic Psychotherapy (EFPP), the European Group Analytic Training Institute Network (EGATIN), and the Serbian Society of Psychoanalytic Psychotherapists. In the Group Analytic Society–Belgrade, she is a training group analyst, supervisor, and the founder of its Psycho-Social Section and Training. She is the founder of Serbian Reflective Citizens Program with Social Dreaming Training. She is involved in the international project on “Social Unconscious,” and also conceptualized the “Social-Psychic Retreats.” Louise Newman, PhD, AM, BA (Hons) MBBS (Hons), FRANZCP Cert., Child Psych., RANZCP, is professor of psychiatry at the University of Melbourne. She works from an object relations and Winnicotian perspective and is an infant and adult psychoanalytic psychotherapist and practicing infant psychiatrist. She is director of the Centre for Women’s Mental Health at the Royal Women’s Hospital in Melbourne. She was the founding chair of Perinatal and Infant Psychiatry at the University of Newcastle. She is the convenor of the Alliance of Health Professions for Asylum Seekers, has been a government advisor on asylum seeker and refugee mental health, contributed to the development of policy for mental health screening and for the response to torture survivors, and was appointed as a Member of the Order of Australia for work in child protection and asylum-seeker advocacy.



About the Editor and Contributors

499

She has published in the areas of infant mental health, attachment disorders trauma, and prevention of child abuse and is coauthor of the textbooks Clinical Skills in Infant Mental Health and Contemporary Approaches in Child and Adolescent Mental Health. Jacqueline Z. Robarts is a pianist, music therapist, and teacher of music therapy, with over three decades working in the NHS child development and child and adolescent mental health services, with a focus on early trauma, attachment, and eating disorders. Until 2015, she also worked in a private clinic setting with adults with mental health problems. She has grounded her improvisational Nordoff Robbins music therapy approach in a developmentally informed psychodynamic (object relations) perspective. Her main influences are music therapists Nordoff and Robbins; developmentalists such as Trevarthen and Stern; and analysts and therapists such as Klein, Winnicott, and Anne Alvarez. Robarts is an associate of the Royal College of Music (ARCM Performer), has a master’s degree in modern languages and music, is a member of the British Association of Music Therapy (BAMT), and is registered with the Health and Care Professions Council (HCPC). She is currently a professor of music therapy at Guildhall School of Music and Drama, London. She supervises and teaches internationally. Adrian Sutton’s orientation is Winnicottian and a synthesis of contemporary Freudian and Winnicottian approaches to child, adolescent, and family psychiatry and psychotherapy. He is a BSc (Hons), MB BS, FRCPsych., honorary senior teaching fellow in medical education at Manchester Medical School, research fellow at the Humanitarian & Conflict Response Institute at University of Manchester, director of Squiggle Foundation, and visiting professor of Psychiatry at Gulu University in Uganda. He works in private practice and as a consultant in child and family mental health. Koichi Togashi, PhD, LP, is a certified clinical psychologist in Japan, a licensed psychoanalyst in the State of New York, and a certified psychoanalyst of the National Association for the Advancement of Psychoanalysis (NAAP). Togashi’s orientation is contemporary self-psychology and relational psychoanalysis, and he is on the faculty and a training and supervising analyst at the Training and Research in Intersubjective Self Psychology Foundation (TRISP), New York, as well as a professor and clinical supervisor at Konan University, Kobe, Japan. He has a private practice in Hiroshima and Kobe, Japan. He has published numerous books and articles in the United States, Japan, and Taiwan and has translated numerous books and papers into Japanese. He is a coauthor of Kohut’s Twinship across Cultures: The Psychology of Being Human.

500

About the Editor and Contributors

Sverre Varvin, MD, PhD, is a training and supervising analyst of the Norwegian Psychoanalytic Society. He is broadly oriented toward object relations theory but incorporates findings from his research on development, mentalization, and cultural studies. He is professor at Akershus and Oslo University. He has long experience in treating traumatized patients, especially traumatized refugees. He has twice been president of the Norwegian psychoanalytic Society and has held several positions in IPA, among others as vice president and board member. He is presently chair of IPA China Committee. He has published several articles and books.