September 11

Trauma and Human Bonds

Susan Coates, Jane Rosenthal, Daniel Schechter, Susan Coates, Jane Rosenthal, Daniel Schechter

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9781138005747
• eBook ISBN: 9781134910212
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Drawing on research from a variety of domains - clinical studies of trauma, developmental psychopathology, interpersonal psychobiology, epidemiology, and social policy - September 11: Trauma and Human Bonds addresses especially the fundamental relationship of human bonds to trauma and underscores the manner in which developments in all these fields are coming together in complementary ways that sustain a key finding: that trauma must be understood in its relational and attachment contexts. The quality of early emotional attachments, differences in attachment styles to family milieus, and the psychological qualities that enable traumatized parents to avoid traumatizing their children are among the topics through which these contexts are explored. From their various disciplinary vantage points, the contributions converge to show how human relationships can either provide an anodyne to trauma or serve as the vehicle of its transmission.

As Susan Coates observes, a major legacy of 9/11 is the realization that "there are no simple truths in the world of trauma studies, no easy-to-remember anodynes or pharmacologic magic bullets or depth-psychological schematizations that will hold true for a majority or even a sizable minority of cases." Yet, in delineating the multiple connections between human relations and trauma, and in elaborating these connections from multiple disciplinary perspectives, the contributors to September 11 have taken a decisive first step to consolidate new knowledge about trauma and to demonstrate how it can assist clinicians who encounter diverse responses to trauma in their day-to-day work. A sobering reminder of shared human vulnerability in the face of devastating events, September 11 is also a heartening reminder of resiliency in the face of overwhelming loss and of the healing potential of human connection.

Chapter 1

Introduction

Trauma and Human Bonds

Susan W. Coates

The original intention of the editors of this volume was to bring into focus a new view of trauma in relation to human bonds. That intention was transformed by the events of September 11, 2001. The result is a multidisciplinary volume, with contributions by leading scholars, researchers, and clinicians, that focuses on the World Trade Center attack while trying to put the psychological consequences of that terrible event into a context that will help clinicians understand better the variety of human responses to trauma as these appear in their day-to-day clinical work.

Let us begin with our subtitle and our original intention. In the past decade, a host of new observations have been made by psychodynamically oriented clinicians and psychoanalysts about the compelling consequences of trauma as these emerge in the course of intensive treatment. To some extent, these observations have merely been a corrective on older, historically received views that privileged wishes over events, internal psychic reality over the traumatic impingements of the external world, in determining what the therapist should attend to and respond to. Most readers will already be familiar with this change in the psychoanalytic landscape. Most clinicians now grasp that sexual and violent physical trauma occurs with much greater frequency in childhood than had once been previously thought—and that when such abuse has occurred it is likely to make its presence felt in treatment in ways that transcend the older interpretive strategies based on the concepts of wish and defense.

But an appreciation for the reality of abuse, and the correlative though quite complex issue of traumatic memory that has lately occupied both mental-health professionals and the public at large, is but one feature of a much wider understanding of the diversity of traumatic phenomena and of the multiple meanings and manifestations that traumatic events can acquire. Indeed, so great is the diversity of phenomena that many contemporary trauma specialists are occupied at present with trying to fashion a clearer definition of what psychological trauma entails. One of the new understandings is that trauma must be understood in its relational and attachment context.

An interesting approach to the definition of trauma, on which I draw in this paper, is that of Gilkerson (1998). He has proposed that trauma be defined in relation to a continuum of arousal and emergency responses. At the lowest level of arousal, which can be defined as a “challenge,” there is an increase in adrenaline and Cortisol. Accompanying this limited response, there may be enhanced formation of explicit memory, or declarative memory as cognitive researchers call it, as well as enhanced emotional memory. The emotional tone may even be partially or wholly positive, entailing a feeling of exhilaration and ultimately learning and mastery. At higher levels of perceived threat, danger, or uncontrollably aversive stimuli, “challenge” shades into “stress,” an equally familiar and hard-to-define psychiatric pathogen. In “stress,” the hormonal activation of the hypothalamic-pituitary-adrenal axis, the sympathetic nervous system, and the limbic brain moves into higher gear. There evolves a negative impact on the formation of declarative memory, accompanied by a further heightening of emotional memory. The organism is primed for emergency action. The whole response is a marvel of evolutionary adaptation, suspending ordinary functioning and instituting an organized battle plan involving immediate deployment of all the major action systems of the brain. But as with the placement of an army in the field, the operation is incredibly costly. If it has to be sustained for any length of time, there begin to be huge secondary costs. The ordinary civilian life of the organism begins to deteriorate; the psychic economy moves to a more or less permanent wartime footing.

But this state is not yet trauma. Trauma entails yet a further escalation of the system toward a kind of dramatically hyperaroused state in which the organism's ability effectively to respond to the threat begins to break down. The threat is too massive, too immediate, too “unthinkable” in its proportions and implications to be encompassed by the organism's response systems. And yet the threatened event happens, even as behaviorally and neurophysiologically everything is being done to keep it from happening.

It is useful to pause to elaborate, from a clinical perspective, on the extreme point of Gilkerson's continuum. The events that transpire in the traumatic state will not thereafter be accessible to memory in the usual way; they will not be integrated into the individual's ordinary life narrative. In Winnicott's (1965) terms, there has been a discontinuity in “going on being.” In traumatologist Lenore Terr's (1984) terms, there has been a change in the attitude toward life, a sense that things can never be quite the same again, which may bring with it a foreshortened sense of future possibility. In the understanding of the relational psychoanalyst Philip Bromberg (1998), there has been a fractioning of the self that goes beyond the ordinary day-to-day use of dissociation as a defense, such that major portions of the self can no longer be accessed except by reexperiencing the threat of traumatic dissolution.

But there is another way of thinking of Gilkerson's continuum, and it takes us to the central topic of this volume. Ordinarily, when we think of trauma we think in terms of the individual and how he or she is overwhelmed. The tendency to supplement our knowledge of the psychological experience of trauma with neurophysiological data, which have been so clarifying in terms of understanding some of the effects of trauma, particularly on memory, only strengthens this tendency to think of the traumatized person in isolation: that is, we think about the hormonal and other changes occurring within the individual organism. But what defines trauma in the first place, what changes a challenge into stress and stress into a genuine trauma, may in part be derived from the fact that it is undergone alone. Facing a dangerous situation with others is quite different from facing a dangerous situation alone. And the memory of terrible events can be made more tolerable when shared with others.

In short, one can begin to think of trauma and human relatedness as inversely related terms. The greater the strength of the human bonds that connect an individual to others, and the more those bonds are accessible in times of danger, the less likely it is that an individual will be severely traumatized and the more likely it is that he or she may recover afterward. There is a limit, to be sure, when even the most securely related individual will be overwhelmed by a threat that is too massive to be borne, whether it occurs in war or on the 96th floor of a burning building. But one must also remember that the basic human instinct, even on the 96th floor, is to make contact with someone else—even if it has to be by cell phone and even when it is clear that it will be futile in terms of rescue.

In retrospect, the importance of human connection as a protection against later trauma and as a means of healing afterward seems so obvious and straightforward an observation of human nature that one might suppose that clinicians have always known this. In a sense they have, but not with clarity. For the longest time, the understanding of trauma has remained connected to the events of wartime, where physical injury and death merit first consideration. Nonetheless, soldiers fight for and with their fellow soldiers. And this aspect was not lost on those who worked with them: Consider that the death of a comrade, rather than personal injury, was often identified as the cause of the traumatic reaction. And Fairbairn (1994) understood well that what might trigger a soldier's breakdown in the absence of an injury was a sudden disconnection from the officer in charge. Consider, too, the famous observation of Anna Freud and Dorothy Burlingham in their study of children in wartime London during the German blitz (Freud and Burlingham, 1943):

The war acquires comparatively little significance for children so long as it only threatens their lives, disturbs their material comfort, or cuts their food rations. It becomes enormously significant the moment it breaks up family life and uproots the first emotional attachments of the child within the family group. London children, therefore, were on the whole much less upset by bombing than by evacuation to the country as a protection from it.

It is hard to recall now how startling the foregoing observation was at the time. Indeed, it was so novel that its full import could not be integrated into the field. What Freud and Burlingham had discovered went beyond the awful facts of the London blitz: it was the child's separation from the mother that was traumatic.

The full realization that a prolonged separation from the mother was innately traumatic for a child had to wait for the work of John Bowlby, whose legacy is hard to overestimate. Bowlby's interest in separation and loss in early childhood had multiple sources. Even though much of his career lay in front of him, as the author of the coming World Health Organization (WHO) report on homeless children in postwar Europe he already knew enough to expect trouble ahead when he was approached in 1950 by James Robertson—a young conscientious objector who had been previously employed at Anna Freud's Hamp-stead Clinic—to make a film about a child going to the hospital. This film was made at a time when public health policy still dictated that the child be dropped off by the parents, who had no further role to play in the treatment, until they came to retrieve the child days or weeks later. Attachment researcher Inge Bretherton (1995) tells the story:

After two years of collecting data on hospitalized children for Bowlby's research projects, Robertson protested that he could not continue as an uninvolved research worker but felt compelled to do something for the children he had been observing. On a shoestring budget, with minimal training, a handheld cinecamera, and no artificial lighting, he made the deeply moving film A Two-Year-Old Goes to Hospital Foreseeing the potential impact of this film, Bowlby insisted that it be carefully planned to ensure that no one would later be able to accuse Robertson of biased recording. The target child was randomly selected, and the hospital clock on the wall served as proof that time sampling took place at regular periods of the day. Together with Spitz's film, Grief: A Peril in Infancy, Robertson's first film helped improve the fate of hospitalized children all over the Western world, even though it was initially highly controversial among the medical establishment [p. 50].

Again, it is difficult to recall now just how shocking Robertson's film was. Spitz's earlier film had been devastating, but it was about orphans, and the level of neglect was total. Little “Laura” in Robertson's film was an ordinary child, and she came from an ordinary family; her stay in the hospital lasted all of a week. Yet what viewers of the film witnessed as it unfolded was a manifestly terrible traumatization of the child, which culminated in a visibly profound psychological detachment toward her parents when they came to pick her up. What the viewer saw was so striking that it changed hospital policies around the world. And all that had happened was a weeklong separation.

Could the simple loss of human connectedness constitute for a child a trauma equal to the trauma of war? It was a thought almost too daunting to think. And matters shortly became yet more complicated, thanks to the work of Mary Ainsworth, who turned up in London as a skilled Rorschach expert looking for work just when Robertson began working on his film and Bowlby was finishing the WHO report. Ainsworth initially doubted that the model of a secure bond with an attachment figure, which Bowlby argued was key to the child's development, would survive cross-cultural comparison. Her studies of children in Uganda, conducted in the years immediately following, changed her mind. But when she then moved on to Baltimore, and discovered in her famous study of 26 mother-infant dyads that there actually were qualitatively different forms of the basic attachment, it was Bowlby's turn to be astonished. For a time, he did not believe what she had found. The children whom Ainsworth classified as “avoidant” seemed to be reacting in a detached way to a reunion with their mothers in the famous “strange-situation” experiment, much as little Laura had reacted in Robertson's film. Could a level of posttraumatic detachment really occur between a child and a mother who had never been separated for more than a few hours? Bowlby didn't believe it.

It turned out that the avoidant child's disregard of his or her mother in the reunion phase of the strange-situation experiment is not the same as what little Laura showed in Robertson's film. But Ainsworth's findings, including her description of the avoidant attachment style, have been replicated in study after study. It is now incontestable that there is no single kind of basic human bond between mother and child. Attachment relationships come in different styles; some are more benign, or rather secure, than others.

How might the differences in attachment style bear on what I have said about trauma and human relatedness being inversely related? This issue is extremely complicated, and it would take years to even begin to sort it out. Indeed, its proper explication required Mary Main's (George, Kaplan, and Main, 1985) development of an instrument for measuring attachment style in the adult, the Adult Attachment Interview (AAI), which included specific questions about loss and trauma. Main was one of Ainsworth's early and most distinguished students. Further understanding of the puzzle awaited the arrival of a new generation of developmental and clinical researchers attuned to research with clinical populations, including not only Main and her principal collaborator Erik Hesse at Berkeley but also Dante Cicchetti, Sherry Toth, and their collaborators at the University of Rochester, Karlen Lyons-Ruth and her collaborators at Cambridge Hospital in Massachusetts, and Peter Fonagy and Mary Target and their collaborators in London, to name just a few of the outstanding figures in the new field of developmental psychopathology.

The basic issue that led to Bowlby's initial disbelief in Ainsworth's discovery can be stated simply: Could something be going on in an intact mother-child relationship that is somehow traumatizing to the child? That, as a generation of research has shown (and has been animating more research ever since), is a difficult question when posed to a nonclinical mother and her child. But it is akin to a much more easily approached question that was being asked by another pioneer, Selma Fraiberg, who had undertaken to set up a clinic to work with maltreating mothers and their children.

Fraiberg's famous paper, “Ghosts in the Nursery,” coauthored with Edna Adelson and Vivian Shapiro, remains an enduring contribution to the understanding of trauma as it occurs within a relationship. The following scenario was caught on tape: the characters include Ms. Adelson, one of the authors; Mrs. Atreya, a tester; Mrs. March, the first woman ever seen in the clinic; and Mary, Mrs. March's five-and-a-half-month-old daughter (Fraiberg, Adelson, and Shapiro, 1975):

Mary begins to cry. It is a hoarse, eerie cry in a baby. Mrs. Atreya discontinues the testing. On tape, we see the baby in her mother's arms screaming hopelessly; she does not turn to her mother for comfort. The mother looks distant, self-absorbed. She makes an absent gesture to comfort the baby, then gives up. She looks away. The screaming continues for five dreadful minutes on tape. In the background, we hear Mrs. Adelson's voice, gently encouraging the mother. “What do you do to comfort Mary when she cries like this?” Mrs. March murmurs something inaudible. Mrs. Adelson and Mrs. Atreya are struggling with their own feelings. They are restraining their own wishes to pick up the baby and hold her, to murmur comforting things to her. If they should yield to their own wish, they would do the one thing they feel must not be done. For Mrs. March would then see that another woman could comfort the baby, and she would be confirmed in her own conviction that she was a bad mother. It is a dreadful five minutes for the baby, the mother, and the two psychologists. Mrs. Adelson maintains composure, speaks sympathetically to Mrs. March. Finally, the visit comes to an end when Mrs. Adelson suggests that the baby is fatigued and probably would welcome her own home and her crib, and mother and baby are helped to close the visit with plans for a third visit very soon.

As we watched this tape later in a staff session, we said to each other incredulously, “It's as if this mother doesn't hear her baby's cries!” This led us to the key diagnostic question: “Why doesn't this mother hear her baby's cries?” [pp. 389–390].

The answer to this question, many readers will recall, turned out to be that Mrs. March, herself “the outcast child of an outcast family,” could not hear her own cries. With assistance, she could recount her own gruesome history of repeated traumatization, but she did so without feeling and without making a connection to her own suffering. As Fraiberg et al. describe it:

There were, we thought, two crying children in the living room. The mother's distant voice, her remoteness and remove we saw as defenses against grief and intolerable pain. Her terrible story had been first given factually, without visible suffering, without tears. All that was visible was the sad, empty, hopeless look upon her face. She had closed the door on the weeping child within herself as surely as she had closed the door upon her crying baby [pp. 395–396].

Though it was slow to be disseminated among the analytic community, the report of Fraiberg and her colleagues virtually single-handedly created a new field of study: the cross-generational transfer of trauma. This field became all the more important because it was launched at a time when a new generation of children had recently reached maturity and had begun to seek help for complaints that initially seemed to have no name; these were the children of survivors of the Holocaust. Thus, it gradually became clear to clinicians practicing in a wide variety of modalities that trauma could have terrible effects that reached past the individual and affected the next generation.

Thus we come full circle. Human relationships, when they are benign, provide an anodyne for trauma. But they also can become the vehicle for the transmission of trauma, whether through the repetition of maltreatment or through other mechanisms. And traumatization, when it is early and severe, can lead to profound relational difficulties that far transcend the confines of posttraumatic stress disorder.

How then to conceptualize the fundamental relationship of human bonds and trauma? In fashioning this volume, we set out to provide an understanding of the complexity of this topic. We bring together a number of domains: clinical research on trauma, developmental psychopathology, interpersonal psychobiology, epidemiology, and social policy.

The first area of knowledge is derived from the recent experiences of clinicians engaged in intensive psychotherapy and psychoanalysis. Simply put, therapists of different theoretical persuasions have begun to identify a host of phenomena i...

Table of contents

• Front Cover
• Half Title
• RELATIONAL PERSPECTIVES BOOK SERIES
• Title Page
• Copyright
• Contents
• Preface
• Contributors
• Chapter 1 Introduction: Trauma and Human Bonds
• Chapter 2 A Letter from Brooklyn: September 11, 2001
• Chapter 3 Brief Interventions with Traumatized Children and Families After September 11
• Chapter 4 Mental Health of New York City Public School Children After 9/11: An Epidemiologic Investigation
• Chapter 5 Clinical Management of Subsyndromal Psychological Sequelae of the 9/11 Terror Attacks
• Chapter 6 Evolution of the Interpersonal Interpretive Function: Clues for Effective Preventive Intervention in Early Childhood
• Chapter 7 Intergenerational Communication of Maternal Violent Trauma: Understanding the Interplay of Reflective Functioning and Posttraumatic Psychopathology
• Chapter 8 Relational Mourning in a Mother and Her Three-Year-Old After September 11
• Chapter 9 Some Clinical Observations After September 11: Awakening the Past?
• Chapter 10 The Emerging Neurobiology of Attachment and Separation: How Parents Shape Their Infant's Brain and Behavior
• Chapter 11 Neurobiological Effects of Childhood Stress and Trauma
• Chapter 12 An Agenda for Public Mental Health in a Time of Terror
• Chapter 13 Lessons for High-Risk Populations from Attachment Research and September 11: Helping Children in Foster Care
• Index