Trauma

Contemporary Directions in Theory, Practice, and Research

Shoshana Ringel, Jerrold R. Brandell, Shoshana S. Ringel, Jerrold R. Brandell

• Publisher: SAGE Publications, Inc
• Year: 2011
• Print ISBN: 9781412979825
• eBook ISBN: 9781452239408
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Trauma: Contemporary Directions in Theory, Practice, and Research is a comprehensive text on trauma, including such phenomena as sexual abuse, childhood trauma, PTSD, terrorism, natural disasters, cultural trauma, school shootings, and combat trauma. Addressing multiple theoretical systems and how each system conceptualizes trauma, the book offers valuable information about therapeutic process dimensions and the use of specialized methods and clinical techniques in trauma work, with an emphasis on how trauma treatment may affect the clinician. Intended for courses in clinical practice and psychopathology, the book may also be useful as a graduate-level text in the allied mental health professions.

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1

Overview

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_________________________History of Trauma Theory

The relationship between trauma and mental illness was first investigated by the neurologist Jean Martin Charcot, a French physician who was working with traumatized women in the Salpetriere hospital. During the late 19th century, a major focus of Charcot’s study was hysteria, a disorder commonly diagnosed in women. Hysterical symptoms were characterized by sudden paralysis, amnesia, sensory loss, and convulsions. Women comprised the vast majority of patients with hysteria, and at the time, such symptoms were thought to originate in the uterus. Until Charcot, the common treatment for hysteria was hysterectomy. Charcot was the first to understand that the origin of hysterical symptoms was not physiological but rather psychological in nature, although he was not interested in the inner lives of his female patients. He noted that traumatic events could induce a hypnotic state in his patients and was the first to “describe both the problems of suggestibility in these patients, and the fact that hysterical attacks are dissociative problems— the results of having endured unbearable experiences” (van der Kolk, Weisaeth, & van der Hart, 1996, p. 50). In Salpetriere, young women who suffered violence, rape, and sexual abuse found safety and shelter, and Charcot presented his theory to large audiences through live demonstrations in which patients were hypnotized and then helped to remember their trauma, a process that culminated in the abrogation of their symptoms (Herman, 1992).

Pierre Janet, a student of Charcot, continued to study dissociative phenomena and traumatic memories. Janet investigated the influence of patients’ traumatic experiences on personality development and behavior. He recognized that patients’ intense affects were reactive to their perceptions of the traumatic events that happened to them, and he found that through hypnosis and abreaction, or reexposure to the traumatic memories, patients’ symptoms could be alleviated (van der Kolk, Weisaeth, et al., 1996). In his early studies of hysteria (1893–1895), Freud, too, was initially influenced by Charcot and adopted some of his ideas. In Studies on Hysteria (1893), coauthored with Josef Breuer, Freud suggested that

we must point out that we consider it essential for the explanation of hysterical phenomena to assume the presence of a dissociation, a splitting of the content of consciousness. [T]he regular and essential content of a hysterical attack is the recurrence of a physical state which the patient has experience earlier. (cited in van der Kolk, Weisaeth, et al., 1996, p. 30)

Freud and Breuer termed traumatic dissociation “hypnoid hysteria” and highlighted its relationship to a traumatic antecedent. In 1896, Freud suggested that “a precocious experience of sexual relations … resulting from sexual abuse committed by another person … is the specific cause [italics added] of hysteria … not merely an agent provocateur” (1896/1962, p. 195, cited in van der Kolk, Weisaeth, et al., 1996, p. 54). In the 1880s, Freud and Breuer as well as Janet independently concluded that hysteria was caused by psychological trauma. They agreed that unbearable reactions to traumatic experiences produced an altered state of consciousness that Janet called “dissociation.” According to Janet, dissociation manifested in hysterical symptoms (Herman, 1992). Putting the emotions into words and reconstructing the past helped alleviate the patients’ symptoms.

However, Freud eventually moved from what has been termed “seduction theory” to conflict theory (see Chapter 3 for a more detailed discussion of this development), suggesting that it was not memories of external trauma that caused hysterical symptoms but rather the unacceptable nature of sexual and aggressive wishes. What his followers neglected to notice, however, was that whereas Freud privileged intrapsychic theory and fantasy over external trauma, he did suggest that it was possible for external trauma to influence the patient’s state of mind (Diamond, 2004). Ferenczi (1933/1955) was the only one among Freud’s followers who regarded his patients’ stories of childhood sexual abuse as veridical recollections, but he remained somewhat of an outsider in the psychoanalytic movement during his lifetime, his theories gaining favor only in the decades following his untimely death in 1933.

Crisis intervention methods to address traumatic events developed gradually, with the establishment of the first suicide hotline in 1902 in San Francisco. Psychological “first aid” was then further developed in the context of military combat. During World War I, psychiatrists observed that soldiers returned with “shell shock” syndrome. Psychological first aid was first developed to help World War I soldiers overcome their symptoms of uncontrollable weeping and screaming, memory loss, physical paralysis, and lack of responsiveness (Herman, 1992). The goal of psychological first aid was to provide a short intervention that would help the soldiers recover and return to the front as soon as possible. It was observed that by providing intervention close to the front and soon after deployment, traumatized soldiers were able to overcome their shell shock symptoms and return to active combat duty. In 1923, following World War I, Abram Kardiner started to treat traumatized U.S. war veterans (Kardiner, 1941). Like Janet and Freud, he observed the nature of reenactment, a central construct in modern trauma theory, and noted that “the subject acts as if the original traumatic situation were still in existence and engages in protective devices which failed on the original occasion” (p. 82; also cited in van der Kolk, Weisaeth, et al., 1996, p. 58). Kardiner also foresaw an important controversy that continues to haunt trauma therapists, that is, whether to bring the traumatic memories into the patient’s consciousness or to focus on stabilization (van der Kolk, van der Hart, & Marmar, 1996). Although earlier trauma theorists blamed the soldiers’ symptoms on their poor moral character, Kardiner understood that any man could be affected by the atrocities of war and that the traumatic symptoms were a normal response to an unbearable situation.

Kardiner and his colleague Herbert Spiegel argued that the most powerful intervention against overwhelming terror was “the degree of relatedness between the soldier, his immediate fighting unit, and their leader” (Herman, 1992, p. 25). Consequently, treatment for traumatized soldiers during the Second World War focused on minimizing separation between these soldiers and their comrades and providing brief intervention methods such as hypnosis. Kardiner and Spiegel warned, however, that cathartic experiences and hypnosis by themselves, without consistent follow-up, were not sufficiently helpful and that unless the traumatic memories were integrated in consciousness the improvement would not last (Kardiner & Spiegel, 1947, cited in Herman, 1992). During World War II, psychiatrists reintroduced hypnosis as a treatment for trauma, and the U.S. Army instituted the use of “group stress debriefing” (Shalev & Ursano, 1990, cited in van der Kolk, Weisaeth, et al., 1996, p. 59).

After World War II, studies on the impact of prolonged stress and trauma on concentration cam survivors coincided with observations of combat stress. Henry Krystal (1968, 1978, 1988) was a psychoanalyst who studied outcomes of prolonged traumatization on concentration camp survivors, observing that “traumatized patients come to experience emotional reactions merely as somatic states, without being able to interpret the meaning of what they are feeling” (van der Kolk, Weisaeth, et al., 1996, p. 60). Krystal elaborated on the diagnosis of alexithymia, a typical syndrome in chronically traumatized people. He described the effect of trauma on the capacity to experience, identify, and verbalize feelings as well as physiological needs and these patients’ tendency to somatize affective experiences, express themselves in an overly concrete manner, and their lack of capacity to symbolize and dream. McDougall, who also worked with traumatized patients, suggested that it was not the absence of affect that was the issue. Instead, she stated, her patients “were not suffering from an inability to experience or express emotions, but from an inability to contain and reflect over an excess of affective experiences” (McDougall, 1989, p. 94).

Contemporary trauma theory in civilian contexts developed following the 1942 Cocoanut Grove fire in Boston. During that fire, 493 people perished in a nightclub, many of them trampled to death. Following the tragedy, Dr. Lindemann, who treated a number of the survivors, observed that they displayed common responses. He began to theorize about normal grief reactions, including preoccupation with lost loved ones, identification with the deceased, expressions of guilt and hostility, disorganization, and somatic complaints (Lindemann, 1944). Caplan, who also worked with the survivors of the Cocoanut Grove fire, was the first to systematically describe the components of crisis. He spoke of people’s being

in a state of crisis when they face an obstacle to important life goals, … an obstacle that is, for a time, insurmountable by the use of customary methods of problem solving. A period of disorganization ensues, a period of upset, during which many abortive attempts at solution are made. (Caplan, 1961, p. 18)

During the same time Parad was interested in examining the impact of particular types of crises and identified five components that affected victims’ abilities to cope with overwhelming life events:

• The stressful event poses a problem which is by definition insoluble in the immediate future.
• The problem overtaxes the psychological resources of the family, since it is beyond their traditional problem solving methods.
• The situation is perceived as a threat or danger to the life goals of the family members.
• The crisis period is characterized by tension which mounts to a peak, then falls.
• Perhaps of the greatest importance, the crisis situation awakens unresolved key problems from both the near and distant past. (Parad & Caplan, 1960, pp. 11–12)

During the Vietnam War, soldiers and veterans returned with incapacitating symptoms that often developed into chronic problems affecting their capacity to cope with, and function in, civilian life. Many of them started to abuse drugs and alcohol, behaved violently toward their partners, or became homeless and unemployable. Lifton and Shatan, who worked with Vietnam veterans, conducted “rap groups” for the veterans, during which they could share their experiences with their comrades and receive validation and support. Based on their work, Lifton and Shatan identified 27 common symptoms of “traumatic neurosis” (Lifton, 1973). These symptoms were catalogued based on the authors’ observations of veterans as well as on their readings of Kardiner and the literature on Holocaust survivors and victims of accidents, which they compared with clinical records of Vietnam veterans. Many of these symptoms were later included in the Diagnostic and Statistical Manual of Mental Disorders (third edition; DSM-III) diagnosis of posttraumatic stress disorder (PTSD) and utilized in panel discussions leading to the inclusion of this diagnosis (van der Kolk, Weisaeth, et al., 1996). Figley (1978) also contributed to the growing treatment literature on Vietnam veterans, and Shay (1994) made theoretical contributions to the understanding of the long-term impact of combat trauma on Vietnam veterans by applying Greek mythological imagery. He used, for example, the story of Achilles to anchor his discussion of Vietnam veterans’ experiences and psychological wounds.

Along with combat trauma and the trauma of Holocaust survivors, trauma in the lives of women moved from the private domain of the home to the public arena as a consequence of the women’s movement in the 1970s. Women’s consciousness-raising groups shared common characteristics with the Vietnam veterans’ rap groups in that they were based on open sharing, validation, and support and “helped overcome barriers of denial, secrecy and shame” (Herman, 1992, p. 29). The purpose was not only to provide psychological healing but to bring about social change in policies and institutions. An epidemiological survey by Diana Russell in the 1980s of more than 900 women chosen at random showed that 1 woman in 4 had been raped and 1 woman in 3 had been sexually abused in childhood, statistics that were quite shocking insofar as such problems had been well hidden and denied until that era (Russell, 1984). The first rape crisis center opened in 1971, and a more comprehensive understanding and treatment of domestic violence followed (Herman, 1992). Additional contributions to the understanding of types of trauma and their impact were made by Lenore Terr (1979) through her work with children involved in a school bus kidnapping in Chowchilla, California.

_______________________________ PTSD and the DSM-III

Psychological trauma and PTSD were not included in the DSM until 1980, when returning Vietnam War veterans presented with severe symptoms and clearly needed prolonged psychological services. Advocates for combat veterans and mental health professionals collaborated in bringing these events and their aftermath to public view (Herman, 1981, 1992; van der Kolk, Weisaeth, et al., 1996). Together with advocates of battered women, rape victims, and abused children, these clinicians brought their influence to bear on the DSM-III committees, and all of these groups were included under the diagnosis of PTSD in 1980. Veterans’ advocates, mental health professionals, and others working with victims of domestic violence and adult survivors of childhood incest/sexual abuse reported similar symptoms in their traumatized clients. Many had been further victimized owing to social stigmata and a lack of understanding of their behavioral, emotional, and cognitive symptoms. In addition to advocating for the acceptance of PTSD diagnosis, women’s advocates opposed the inclusion of certain personality disorders that they regarded as being sexist and/or culturally biased, such as masochistic and histrionic personality disorders.

The DSM diagnosis of PTSD addressed immediate symptoms following combat experiences, rape, domestic violence, and child abuse; symptoms were then categorized along four clusters: intrusive reexperiencing, avoidance, hyperarousal, and hypervigilance, with general symptoms of anxiety and dysphoria in addition (Ford & Courtois, 2009). Although the PTSD diagnosis addresses the symptoms of posttraumatic stress, it does not focus on causes in a patient’s early developmental history, which may include childhood abuse and neglect; nor does it offer a more complex and comprehensive view of psychosocial stressors and daily functioning that exert influence over all areas of adult life.

Complex Traumatic Stress Disorder ____________________

As stated above, although the diagnosis of PTSD included the comprehensive symptoms of trauma, it did not address early antecedents in childhood, the impact on long-term social and professional functioning, and the role of trauma in personality disorders. Herman (1992) was the first to suggest that “Complex PTSD” be included as a new diagnosis that would address the multiple origins of trauma and their impact on all aspects of a person’s life. She noted that frequently, women with borderline personality disorder were marginalized by mental health professionals who failed to understand the connection between their early experience of sexual abuse and their present personality structure. More recently, Courtois developed the comprehensive diagnosis of complex trauma (Courtois, 2004, 2009), which she explains as the “inability to self regulate, self organize, or draw upon relationships to regain self integrity” (Ford & Courtois, 2009, p. 17). Complex trauma is “associated with histories of multiple traumatic stressors and exposure experiences, along with severe disturbances in primary care giving relationships” (Ford & Courtois, 2009, p. 18). It can lead to substance abuse, unemployment, and homelessness and affects...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Introduction
• Chapter 1: Overview
• Part I. Theoretical Frameworks
• Part II. Clinical Applications With Selected Populations
• Index
• About The Editors
• About The Contributors