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THE HOUSE OF TRAUMA
by Robert M. Young
In the house of trauma there are many mansions.
I have been asked to strike a keynote, and it is contained in that sentence. In this short introduction I can only indicate some of them and hope I can intrigue you into returning to them and the broader issues about diagnostic categories which they raise (see, e.g., Young 1998, 1998a, 1999). Trauma conjures up many meanings, extending from a humble term loosely conveying the harm, the injury that leads people to be troubled and seek psychotherapy or counselling, through a complex history of ideas including successively: hysteria, shell shock, war neurosis to the currently fashionable concept of Post-Traumatic Stress Disorder, the last of which strikes me as making a hegemonic bid in psychopathology which is parallel in some ways to the bid that the discipline of Cultural Studies made some years ago to take over all the arts.
Here are some data:
There are currently 601 books listed under trauma at Amazon.co.uk and 1215 for Amazon US.
The traumatic-stress forum on the internet (T-S) has 484 subscribers. Its moderator, Professor Charles Figley, runs a major centre in Florida, one of many in the US and here, for example, there is one in Nottingham. He is the author of sixteen books and innumerable articles and founded the main journal Traumatology. The T-S Forum focuses on the all matters of interest to the emerging field of Traumatology, which is the study, treatment, and reporting of information about the immediate and long-term psychosocial, and psychobiological consequences of highly stressful events and circumstances. Forum members are researchers, practitioners, reporters, policy makers, students, professors, and others who are interested in contributing to the field. There is a world-wide Green Cross network of experts available to respond to disasters.
At a well-attended conference at Sheffield University recently decorated briefcases were handed out and there was a session on the traumatic stress suffered by those who attend to traumatized people. One of the main topics was ‘compassion fatigue’.
A trilogy on war neurosis by Pat Barker (1991, 1993, 1995) was a recent best seller. One volume, The Ghost Road, won the Booker Prize, and another, Regeneration, was later made into a film. At the heart of the trilogy was the work of a psychoanalyst and anthropologist W. H. R. Rivers, who was working compassionately with shell-shocked soldiers. Similar work was done by Wilfred Bion and a number of other founders of the group relations and therapeutic community movement, especially in the Northfield experiment in the Second World War (Harrison, 2000).
If, as we should, we cast the net more widely we come upon the designation hysteria and shell-shock from the nineteenth and early twentieth centuries, the former with its Boswell in Elaine Showalter (1985) and the latter with a truly admirable history by Allan Young (1995) which you should read if you haven’t already. It is a masterpiece on the historicity and the social construction of diagnostic categories.
You will probably know that the term has been used very widely, indeed. The OED concentrates on ‘wound’, ‘injury’, ‘abrasion’ but includes ‘morbid nervous condition’. The social and intellectual historian and biographer of Freud, Peter Gay, wrote of the rapid changes in the eighteenth and nineteenth centuries. ‘You cannot have serious change without trauma’, while diagnosticians of battle fatigues or shell-shock originally conjured up a literal impact from exploding ordinance, only to notice fairly rapidly that the same symptoms were exhibited by people who were not anywhere near artillery bombardment or any impact from such physical shock waves. My computer offers those two meanings: (1) an extremely distressing experience that causes severe emotional shock and may have long-lasting psychological effects; (2) a physical injury or would to the body. In somatic medicine trauma still refers, for the most part, to a physical impact, e.g., to the chest, head or elsewhere. There are, for example, innumerable orthopaedic trauma centres.
What can cause a trauma?
Being under fire in a war
The death of a loved one
The King’s Cross fire
There is no end to it. Any sort of psychic damage will do, and it need not be defined to a single distressing event The idea of trauma as a single event features in the DSM-III criteria (American Psychiatric Association, 1994, pp. 424-29), but an event no longer captures all the meaning of the term. For example, Masud Khan coined the term ‘cumulative trauma’ (1963) to characterize the breakdown of the mother’s role of protective shield, with long-term consequences for the infant.
You begin to see why I mention many mansions.
I turn now to psychoanalytic concepts of trauma. Since the broad field of traumatology and its burgeoning activities, writings and centres are largely behavioural, you might assume that the concept of trauma has little place in psychoanalytic writings. You will find 120 articles on the Psychoanalytic Electronic Publishing CD-ROM containing over 30,000 articles from six main psychoanalytic journals and 3914 occurrences of the term in all those articles. That seems to me to be surprisingly few.
But if you turn to Freud you will find a whole page of the Index to the Standard Edition devoted to references in his writings to trauma, while Laplanche and Pontalis’ dictionary treats trauma as a thoroughly general term accounting for the aetiology of the neuroses, while traumatic neurosis is later introduced by Freud for something very near our PTSD. You will also find a clear and useful account of the history of Freud’s thoughts on trauma in an essay by the editor in Caroline Garland’s collection, Understanding Trauma: A Psychoanalytic Approach. In her own contribution she makes a point which makes nonsense of conceptions of trauma which concentrate on the external impact. Her point is that what makes it not possible to get over that impact is that its psychical meaning homes in on early object relations. She refers to ‘adhesions that develop individual’s early history, particularly when the trauma is felt to provide confirmation of early phantasies’. She also stresses that these links can be ‘hard to shift because of the damage done by the traumatic event to the survivor’s capacity to symbolise’, leading to an impoverishment of understanding and communication (Garland, 1998, p. 7). She and her co-authors give innumerable case studies of this dynamic drawn from their work at the Unit for the Study of Trauma and Its Aftermath at the Tavistock Clinic, which she directs.
I want now to say something philosophical about all this. By this I mean how we are here slip-sliding around from the language of bodily impacts to that of events and enduring – perhaps incapacitating – forms of distress in the inner world. It would be easy to be satirical about this and mock the rhetoric of a relatively new and certainly only recently fashionable approach and set of concepts. Of course, some concepts are, indeed, more subtle and resonant and suggestive and enabling than others, which is why we have literature and pulp, poetry and doggerel. However, I want to point out that there is no escape from physical language in referring to mental events.
The founder of the conceptual framework within which, for better and worse, we think, René Descartes, bequeathed to us a dualism of mind and body which remains our everyday metaphysics nearly four centuries after he wrote his Discourse on Method in 1637. One important feature, and the point of my remarks at the moment, is that he defined body as having extension and motion and as being susceptible to mathematical handling. He defined mind – very unhelpfully – as that which does not pertain to body. It has no language or parameters of its own; we speak of it by analogy to physical phenomena. In succeeding centuries psychology, psychiatry, psychoanalysis have all had to frame concepts in both formal and everyday language which expresses our mental life in various analogies drawn from physics, chemistry, biology and other material sciences – mental elements, compounds, structures, forces, energies, impacts, positions, stresses. We think in terms of mental space (hence the title of my recent book: Young, 1994) and that which makes it more capacious and congenial as contrasted with that which restricts and closes it up.
So, though we may smile at the fashion in military and athletic terms in he trauma industry, let us not deceive ourselves into thinking that we can magically escape from the philosophical box Descartes left us in and somehow evade bodily language and impacts. We can perhaps formulate more moving stories, more subtle narratives, but we cannot evade the reliance on bodily language inherent in our world view. Nor, however, should we give in to the thuggery which says that the bodily story is the whole story. The bottom line is emotion, and the vicissitudes of our emotions constitute our deepest psychology.
I want to cast my vote for narrative accounts in which trauma is a word about suffering which is uncontainable and eliminates the afflicted person’s capacity to defend his or her inner objects from anxiety. To have a traumatic experience is to have one’s defences overwhelmed, resulting in a failure of containment and stark exposure to primary anxieties, listed by Freud as birth trauma, castration anxiety, loss of the loved object, loss of the object’s love and the nameless dread of annihilation. All are linked to loss of what is essential to life, and they lead to a state of melancholy (see Garland, 1998, ch. 1). Trauma engenders helplessness.
In speaking in favour of narrative I am speaking against concentrating on nosology (Young, 1999). I say this, because Allan Young’s account seems to me a cautionary tale in which a dedicated band of opponents of the inner world, generated an approach to psychopathology which placed classification at the heart of psychiatry at the expense of resonating with the human heart, its sufferings and its vicissitudes.
Both his title, The Harmony of Illusions, and his subtitle, Inventing Post Traumatic Stress Disorder, forcibly draw our attention to the historicity of disease categories and to their social construction. He tells us with great eloquence how PTSD was the consequence of framing suffering by a lobby with uncategorised symptoms, the Vietnam War veterans (A. Young, 1995, p. 5; Kulka et al.,1990), intersecting with an audacious coup by psychiatrists who followed the theory of classification of Emil Kraepelin, who argued that psychiatric diseases were natural kinds like physical objects and who ruthlessly and successfully purged all mention of the unconscious, psychodynamics and the inner world from the third edition of the American Psychiatric Association’s official bible, the Diagnostic and Statistical Manual of Mental Disorders, a title usually shortened to DSM-III, published in 1980. Their leader, Roger Spitzer, was quite forthright about this. He wrote that he had assembled a team of writers ’committed to diagnostic research and not to clinical practice… with intellectual roots in St. Louis instead of Vienna, and… intellectual inspiration derived from Kraepelin, not Freud’ (A. Young, 1995, p. 99). The eminent psychoanalyst Franz Alexander described Kraepelin as a ‘rigid and sterile codifier of disease categories’. He, like Freud before him, saw no common ground between Kraepelin’s ‘antipsychological’ approach and a psychodynamic one (p. 96). Thus were drawn up the battle lines between the psychodynamic and the biological approaches which Tanya M. Luhrmann, in her recent and baleful anthropological study, In Two Minds: The Growing Disorder in American Psychiatry (2000), has examined in the training of psychiatrists, with the biological reductionists in the ascendant at the expense of relating to, understanding and treating the inside of human mental suffering.
The editors of DSM-III and DSM-IV profess to be biological in their orientation, but this is no guarantee that the diagnostic categories which they accept are based in natural science, that they are what scientists concerned with classification call ’natural kinds’. Indeed, many of the classifications in DSM are clearly the result of lobbying by social groups. The most famous of these is homosexuality, which was a diagnostic category in earlier editions of the manual. As a result of agitation by gays and lesbians it was removed from the manual in the 1970s. The diagnosis ‘borderline disorder’ has been the subject of much debate, and there is a volume of essays assessing its suitability (Silver and Rosenbleuth, 1992). As you move toward the back of the manual, descriptions of adjustment and personality disorders become more and more familiar descriptions of the vicissitudes of troubled people, sometimes very like ourselves. I have been in the habit of reading out the criteria for one called ‘Self-defeating Personality Disorder’ to my students, and they react very uncomfortably, as if they have suddenly found themselves caught in the net of psychiatric diagnosis (DSM-III-R, 1987, pp. 373-74). They were particularly nervous about diagnostic criterion number six: ‘fails to accomplish tasks crucial to his or her personal objectives despite demonstrated ability to do so, e.g., helps fellow students write papers, but is unable to write his or her own’ (p. 374). Women were considered to me more likely than men to suffer from this condition. As a result of agitation by feminists, the diagnosis was dropped and did not appear in the next edition of DSM (Shorter, 1997, p. 305).
As I said, the inclusion of Post-Traumatic Stress Disorder was the result of agitation. One historian of psychiatry comments that ‘psychiatric diagnosis was up for grabs’ (ibid.). He quotes Wilbur Scott, a student of the campaign to get PTSD into DSM: ‘”PTSD is in DSM-III because a core of psychiatrists and veterans worked consciously and deliberately for years to put it there. They ultimately succeeded because they were better-organized, more politically active, and enjoyed more lucky breaks than their opposition”’ (Scott, 1990, quoted in Shorter, 1997, pp. 304-5). Of course, in gaining official recognition for their distress and suffering as a medical/psychiatric diagnosis, they also gained access to treatment facilities compensation and other benefits bestowed by the state on war injured personnel. Please do not misunderstand my point. It is not to diminish the psychological impact of the Vietnam War on all concerned. Rather, I want to draw attention to the benefits of medicalising it in the form of a recognised, diagnosable mental disorder.
I want to conclude - and to reiterate my theme of many perspectives on trauma (a house of many mansions) - with an eloquent and moving quotation from Allan Young’s introduction which falls squarely inside the philosophical tradition advocated by Richard Rorty which claims that truth is made, not found. PTSD, he claims, is not a natural kind. The generally accepted picture of it is mistaken.
The disorder is not timeless, nor does it possess an intrinsic unity. Rather, it is glued together by the practices, technologies, and narratives with which it is diagnosed, studied, treated, and represented and by the various interests, institutions, and moral arguments that mobilized these efforts and resources. If, as I am claiming, PTSD is a historical product, does this mean that it is not real? Is this the significance of my book’s title? On the contrary, the reality of PTSD is confirmed empirically by its place in people’s lives, by their experiences and convictions, and by the personal and collective investments that have been made in it. My job as an ethnographer of PTSD is not to deny its reality but to explain how it and its traumatic memory have been made real., to describe the mechanisms through which these phenomena penetrate people’s life worlds, acquire facticity, and shape the self-knowledge of patients, clinicians, and researchers. It is not doubt about the reality of PTSD that separates me from the psychiatric insider. It is our divergent ideas about the origins of this reality and its universality (the fact that we now find it in many places and times)’ (A. Young, 1995, pp. 5-6)
He concludes by saying, as I have, that the suffering and pain of PTSD is real, but this does not make the facts attached to it true, i.e., timeless. Questions about truth cannot, he argues, ‘be divorced from the social, cognitive and technological conditions through which researchers come to know their facts and the meaning of facticity’ (p. 10)
Trauma is a useful metaphorical term. We have need of a many-chambered house of ideas of trauma but not, I suggest, a fortress or an arsenal or to be preoccupied with nosology rather than narrative in telling stories about human suffering and in helping people to learn to contain and work though their distress.
Chairman’s Opening Remarks (revised), conference on ‘Thinking about Trauma: Connecting Theory and Practice’, sponsored by University of Sheffield Centre for Psychotherapeutic Studies and Nottinghamshire Healthcare NHS Trust, at Sheffield University, 22 June 2001.
(Place of publication is London unless otherwise specified.)
American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders (Third Edition — Revised). Washington, DC: American Psychiatric Association (DSM-III-R).
______ (1994) Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Washington: American Psychiatric Association (DSM-IV).
Barker, Pat (1991) Regeneration. Viking; reprinted Harmondsworth: Penguin, 1992.
______ (1993) The Eye in the Door. Viking; reprinted Harmondsworth: Penguin, 1994.
______ (1995) The Ghost Road. Viking; reprinted Harmondsworth: Penguin, 1996.
Garland, Caroline, ed. (1998) Understanding Trauma: A Psychoanalytical Approach. Duckworth.
Harrison, Tom (2000) Bion, Rickman, Foulkes and the Northfield Experiments: Advancing on a Different Front. Jessica Kingsley Publishers.
Khan, Masud (1963) ‘The Concept of Cumulative Trauma’, Psychoanal. Stud. Child 18: 286-306.
Kulka, Richard A. et al. (1990) Trauma and the Vietnam War Generation; Report of the Findings from the National Vietnam Veterans Readjustment Study. N. Y.: Brunner/Mazel.
Luhrmann, Tanya M. (2000) Of Two Minds: The Growing Disorder of American Psychiatry. N. Y.: Knopf.
Scott, Wilbur J. (1990), ‘PTSD in DSM-III: A case in the Politics of Diagnosis and Disease’, Social Problems 37: 294-310.
Showalter, Elaine (1985) The Female Malady. N. Y.: Pantheon.
Silver, Daniel and Rosenbleuth, Michael (1992) Handbook of Borderline Disorders. Madison, CT: International Universities Press.
Young, Allan (1995) The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton University Press.
Young, Robert M. (1994) Mental Space. Process Press.
______ (1998) ’Psychopathology: Term and Concept’, Distance Learning Unit, Psychoanalytic Studies, University of Sheffield.
______ (1998a) ‘Descriptive v Psychodynamic Concepts of Psychopathology’, Distance Learning Unit, Psychoanalytic Studies University of Sheffield.
______ (1999) ’Between Nosology and Narrative: Where Should We Be?’, talk delivered to the Toronto Psychoanalytic Society.
My own writings, including those listed above, are available at http://human-nature.com/rmyoung/papers/
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The Human Nature Review © Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM