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Richard Raubolt, Discussant		Linda and Richard Raubolt concluding Richard's presentation

Trauma, despite the literal explosion of written material on the subject, remains elusive to define. Much of the recent work by both analytic and non analytic researchers have sought to elaborate the neurophysiological effects of trauma and subsequent therapeutic experiences.

Yet, to my way of thinking there is no real discussion of severe trauma without the personal and idiosyncratic. The most honest and complete definition of such trauma I have come up with suggests a series of disorganizing experiences once external that have become internalized physically, cognitively and emotionally and which are beyond the individual’s ability to integrate, regulate, synthesize, change or at times even recognize. It, whatever it may be, for it is often different for each person, is experienced as painfully disruptive, disorienting and terrifying; attempts are made to banish any hints, traces, or reminders. The result is frequently a shallow, tightly wound, yet brittle self. Play, humor, spontaneity and any traces of liveliness are absent or greatly diminished. Trauma is a grey ghost present in expressions of blankness, confusion, rigidity, dullness or silence. Seemingly nobody is home. The curtains are drawn and the lights are out.

Now what have I described after suggesting there is no universal definition but only the subjective? I have, as we are so prone to do, described myself in trauma, myself and my patient Marissa. While the attributes are descriptive of us, more or less, they also represent much of what I see in my practice.

Severe trauma can and often does diminish the person. Something goes away when such experiences becomes buried yet nurtured. The word "nurtured" may seem odd yet it succinctly defines a core dynamic of living trauma. So often the traumatized identify with and create self representations as abused, violated but sadly deserving of mistreatment. "I am my abuse" as one patient said to me recently. There is often no emotional separateness or memory as the actual event is buried in a secret crypt that "entombs" the unspeakable (Abraham and Torok, 1994). Hidden away, mysterious, dark, unknown but felt. Something is wrong, terribly wrong. Physical symptoms, elusive in origin yet debilitating, reveal a body at war with and within itself. Memories are often vague, fears unsolvable and the physical pain searing, leading Spohn (2006) to describe these experiences as "body-trauma." Terror, despair and rage accompany the felt experience of having a hole in one’s soul as well as body.

I am coming to realize such thoughts as I have just presented may appear somewhat obvious or dated. Yet, if we don’t immerse ourselves in the obvious, for example, how do we establish the trust to enter what is unknown by both patient and therapist?

So Do Patients Get Better And If So How?

It is interesting to remind ourselves how our bright stars and theories fade in and out of our thinking and treatment rooms. Sandor Ferenczi ,for example, after suffering an early death was banished from psychoanalytic circles until a recent revival in the early 1980’s brought recognition for his contributions to the understanding and treatment of trauma. His paper, Confusion of Tongues Between Adult and the Child, on the dynamics of abuse, sexual in particular, but also neglect, remains unsurpassed. One aspect of his theorizing I see every day in my consulting room is "confusion of tongues." Essentially and briefly, abusive parents use their authority over their dependent children to meet their own narcissistic needs by intentionally confusing necessary tenderness with adult passion. The child is left speechless, alone and guilty. Feelings of self loathing are internalized as the child sees herself through the eyes of the abuser. Such children may become automatons in the face of such shock. Trust in verbal expression is often dealt a crippling blow. Shay (1994) expanding on the Greek term themis ( moral code) as used by Homer refers to this process as a violation of "what’s right" (p.5), including betrayals of ethics, normative expectations and agreed upon social values. The child can no longer trust adults in her life to speak "the truth"; i.e. some representation of reasonableness and predictable reality nor can she count on a modicum of empathic responsiveness and nurturance so essential for the recognition and expression of feeling sates. The child then becomes trapped inside herself; alone, bereft and detached. These feeling states are continually reinforced into adulthood. Ensconced in protecting the presented self, the patient can’t let go, surrender, risk or venture forth without facing the catastrophic despair, annihilation and disintegration experienced in childhood and often confirmed by adult experiences.

In treatment the analyst occupies spaces in between here and there, where there are words and especially where there are no words. He is available in those spaces where he allows himself to be approached and used much like a good enough mother by providing sufficient safety and time for exploration and expansion.

As Winnicott reminds us the most important therapeutic function reminiscent of good mothering and providing safety is to survive attempts at destruction, and to remain emotionally available to be approached. The analyst is both a bright ray of hope and a dark laser of abuse. The traumatized patient must know the therapist can withstand hatred directed his way as a precursor to mourning.

Davis and Frawley (1991) tell us that sexually traumatized patients, although I would argue all severely traumatized patients, must feel their way into mourning, unencumbered and unrestricted. Accordingly they write: "The patient must recognize and come to terms with the finality and irreversibility of the traumatic loss. This is a long and arduous process of working through intense rage and profound pain" (p. 29).

Room must be made to experience the past absence of protection, attachment and soothing for it is not only the brutality of physical abuse that is so damaging. Such patients need to learn to grieve that which wasn’t available and as a result created such calluses on their hearts and souls.

Marissa: Some Pertinent History

Marissa was the first of two unwanted children by a teenage mother. She was often left in the care of a grandmother who was "unhinged" in Marissa’s words and had been lobotomized while in the state psychiatric system. This grandmother could be distant and dreamy one moment and explosive the next. She was to a growing child, horrifying.

Since there was no father in the picture, Marissa’s mother was the sole support in between live-in boyfriends. She drank heavily, was openly and flamboyantly sexual and emotionally self absorbed. She did not however sexually abuse her children. Marissa, her mother and sister moved out when she was two into the first of eight residences in her elementary school years.

While relationships were transient with most men, Marissa’s mother desperately clung to a violent man well practiced in various forms of sexual abuse yet superficially charming and stable appearing. He took on the disguise of provider and father, while using his charisma to establish control and authority. Although she was silenced by a powerful mixture of violence, seduction, and yearning, only Marissa could see the growing threat. Marissa’s mother was firmly entrenched in her dependent denial and drug abuse. Not surprisingly this man eventually moved on to someone younger and more enticing and within a few brief years he was arrested and sentenced to a lengthy prison term. While her mother claimed she learned her "lesson" she offered little evidence of taking seriously her responsibilities for her three young children.

Marissa: A Current Picture

After an interview with a parole board official about her history of profound physical abuse, Marissa discovered her mother, who said she cooperated with the investigation, actually refused to even show up. This was not a hearing Marissa wanted after seven years of analysis but the legal process was initiated by a psychotic childhood friend for whom she still felt some loyalty as they had been sexually abused together. Hearing from the investigator about her mother’s absence ripped apart any remaining hope for Marissa that the mother was different than she recalled. Her mother was now seen clearly, painfully, as an active participant in her abuse and woven deeply into Marissa’s stitched together sense of self.

What is this, is the pain I will carry for the rest of my life? What if I never get another good breath and have to spend everyday feeling like I could drown? Am I having the dreaded nervous breakdown? How ironic it would happen now! When I worked so hard to overcome and did make it and did overcome, and now I am swallowed whole by anxiety…Motherfucking shit-the whole thing, the whole fucking thing is Motherfucking shit! I should have turned back when the detective asked if I wanted to pursue him. My gut told me to turn back-but ALWAYS the fighter I went on…didn’t want to be considered a coward, didn’t want to be judged. And look at the state I got myself into… everyone saying I’m brave and strong, but I CAN’T BREATHE. I dread the simplest things like doing paperwork, cleaning the kitchen, brushing my teeth. Everything feels so damned hard. And talk about being judged-I can’t wait to hear how I just need to get a grip, take a BREATH –no judgment there! The worst judgments come from me, though, and I know it. I wasn’t dreading others’ judgment so much as my own.

Seeing the "way it was" left Marissa enraged, raw and beside herself with despair. The aunt of a former roommate offered to "adopt" her , a loving gesture, Marissa knew and one she always thought she wanted. In relating this story she looked at me and said, "You know what I really want? I want my space, no intrusions; do you know what I mean? I don’t want to be a strong, responsible, good girl. I hate it all. This is no fucking life."

Yes, she needed to mourn and she needed space and holding. She also needed an analyst to be there with her, helping to contain her terror and suicidality. But what if the analyst in distress himself couldn’t be there in these ways? What if he was too jumpy, anxious, preoccupied or wounded? What if the analyst’s own trauma drowned out the words of pain just now discovered by the patient herself? A change of analysts in midstream would not do. Some way back into the analytic process had to be found.

A Personal Crisis: Unseating the Analyst

Three years ago I became seriously ill. I was able to keep working but barely. I had little energy, frequent nose bleeds and a window rattling cough. Pneumonia. I took time off, felt better and went back to work but before I was fully recovered. Suddenly I began to feel my age, older actually, and the loss of a resilient, athletic self was painfully stripped away. I began to doubt I would ever get better. Old feelings of helplessness and abandonment I felt as a young child returned with a vengeance.

At the same time an office mate, who seemingly had more trouble with my perceived weakness than I, maneuvered a new office design that favored him at my financial expense. This I did not know until an ugly and explosive encounter erupted as I was recovering. I found myself in a new lease with a man I no longer trusted. I was on the run emotionally, trying to put pieces together, get ground under my feet and return to the self I recognized as me. My disruption was not as severe as my patient’s which added guilt to my already combustible mixture. Still I felt in full flight. I was there, by which I mean I was in my chair in my office, doing what I could but there was a strain and shallowness to our work. I seemed to be going through the motions hoping something would change and I would return. What could I do?

Finding Meditation and My Way Back

Old yearnings and memories began to stir. Insight meditation, vipassana, a practice I had abandoned years ago (too busy, too rushed, too much to learn), offered direction. Meditation had seemed too slow for a young buck on the run yet here I was running again but more away from than toward. I was running from my life or parts of it and the anxiety, I was discovering, was an unwanted but rather constant companion. Meditation I was now again practicing suggested a different path: being aware of the present, breathing, leaning into it, all of it, accepting what is, not wishing for what isn’t, letting go into unstructured time and space in a word, surrendering. Reading of the Buddhist nun Pema Chodron’s office sign afforded me a strange sense of comfort during this time: "Only to the extent that we expose ourselves over and over to annihilation can that which is indestructible be found in us" (p. 7).

I came to understand more clearly the connection between Marissa and me. We were each in our own way, and at different levels of pain, trying to deny and thereby avoid two basic principles of both psychoanalysis and life: impermanence inherent in everything and the universality of suffering.

Each of us was trying to hold fast to myths about ourselves and our world. We fought against new experiences that made us vulnerable, offered suffering and uncertainty. We wanted our worlds to bend to our fixed definitions of reality. For me letting go, surrendering to life’s mysteries, acknowledging my limits allowed me to sit in my chair again. This time I was more awake, settled and available. Marissa’s pain was more intense; her despair seemed to have no bottom and her rage had taken a dangerous turn toward self-mutilation.

Through all the panic Marissa was still reading me and noticing, in an unconscious and therefore unarticulated, unknown way, a shift in my somatic experience. Marissa and I were deeply involved in some unspoken connection. What I did was to sit quietly and attentively so she could talk about and find her way toward accepting what her life had been. She could then tentatively begin to explore new possibilities; a process still burdened with pain but now perhaps with some new found strength and hope as well. But first the space needed expansion.

Unintegration: Finding open space

As I was settling in, Marissa was falling out like so many puzzle pieces spread randomly about the room. She would use such phrases as "I am falling apart," "I am going to pieces," "I am coming unglued," "I am losing myself," all under the rubric of "I’m disappearing." Old, brittle defenses like outdated levees were swept away under storms of horror and rage. Marissa was losing Marissa: "This is not my life."

What was I seeing? Balint’s idea of malignant regression or perhaps the fragmentation so often discussed in the self-psychology literature? Winnicott was most helpful. He made a distinction between disintegration and unintegration. Marissa, at this point in her treatment appeared to be disintegrating. She was trying to hold on to the old, the known, yet the process was spinning out of control. She could no longer hold herself together as she had before. Still in the midst of this swirling turmoil something else was emerging. In between the cries of panic and pain there were brief quiet spaces like so many small islands of respite if not peace. These brief interludes gave her room to breathe, to regress and, perhaps strangely, wonder about herself.

Experiences of unintegration emerge out of a primary chaos teeming with unformulated and uncontaminated possibilities of self expressiveness. I am reminded here of Eigen’s (1998) description of unintegration as the "Sabbath point of the soul," (p. 154) a time of rest if you will, a time out for drifting, floating and not knowing. Pressure to be, to figure out, to change, recedes fading now to the background. Eigen (1986) again, interpreting Winnicott writes:

Unintegration, by contrast …is a purer state. The subject dips into creative formlessness. He lives between the lines of his built-up personality. He gets to where he was before defensive encapsulation took over. It is implicit in Winnicott’s vision that we sense our baby soul as it was before it was marred, that intimations of a pristine thread continue throughout our lifetime, that we never quite lose contact with something that we sense is our most precious self (p. 334).

So how does this change transpire?

What is the Analyst’s Role in Creating an Atmosphere for Unintegration?

The answer to the above question I believe has to do with facilitating the conditions for surrender as defined by Ghent(1990) when he writes:

The meaning I will give to the term "surrender" has nothing to do with hoisting a white flag; in fact, rather than carrying the connotation of defeat, the term will convey a quality of liberation and expansion of the self as a corollary to the letting down of defensive barriers (p.213)
Ghent then adds: "…I imply that there is, however deeply buried or frozen a longing for something in the environment to make possible the surrender, in the sense of yielding, of false self (p.214)

There are several features central to understanding this conceptualization of surrender especially as it relates to trauma. First of all, surrender is not a choice. The analyst can facilitate the conditions but cannot make it happen which would then become submission. As Ghent points out a patient may surrender in " the presence of another" but not "to another."

Second, surrender may be experienced with dread and terror at least initially as was the case with Marissa. If all goes well relief and clarity may follow. Surrender is about experiencing the present moment, if only fleetingly, where both the past and future drift to the wayside.

In the uncomfortable mix of uncertainty, confusion and fear Marissa was not abandoned but left with herself. I would offer no intrusions into her experience but I was groping to find a connection, a creative process to introduce, however tentatively, different relational possibilities.

Since Marissa was a writer she struck upon the idea of describing her experiences, some of those she had the most trouble revealing directly to me, in periodic journal entries, some of which are included in this paper. Writing allowed for a sense of safety to regress into feelings long held secret, and in so doing she was beginning to give them some form. Giving them to me to read as she left the session was also her way of making sure I didn’t "forget" about her between our meetings.

I also believe a new, different office setting away from my former office mate was of value to Marissa. She remarked how quiet and peaceful it was to her. I offered her the office chair that faced a thick wooded area through large, expansive windows. Even in times of great despair she would sometimes ask me to turn around to see a cardinal, an occasional deer or even a wild turkey. She was asking me to see with her some of the pleasures she was witnessing. I did so with relish always letting her lead the way. I believe at such moments we were sharing emotional space or what neuroanalysts describe as a "limbic to limbic connection."

Still I had to sit quietly, absorb her hatred, reflect her fear and gently, sparingly tell her of her courage. I could not do otherwise as I was deeply connected to her and the world she was giving voice to and it was also my way of staying emotionally alive. To use Winnicott’s words, Marissa went from "form" to "formlessness" and I went with her. I felt no need to explore this arrangement. I did not bring my self in to ask how I was seen or experienced. I waited and concentrated on offering recognition and acceptance for Marissa’s "period of hesitation" (Winnicott, 1941, p. 53) allowing for her own rhythm of exploration to emerge. I was present for her use. These were difficult times, however, marked by silences, contradictions, avoidances and disruptions. As Marissa tried on new voices we were never sure what would emerge or how she would react to hearing herself, although she often felt terror. Who was this woman speaking? Did she have the right to speak or yell or challenge? Where was she going? What would happen to her and most importantly who was she becoming?

Unfucking believable!! I am actually having psychosomatic responses to stress and anxiety—I can’t get a good breath and it’s all in my head! And knowing its in my head doesn’t make it better! Holy shit-is this how it feels to be crazy? I am sorry for all the Judgments I’ve made of others. I am sorry for doubting the sincerity and pain of others.

Sometimes I feel so solid and sure-fleeting visions of competence and certainty. Clear vision, solid. And I wonder what it is that I was nervous about? Why was I so afraid? I am bright and sure and clear. Then, the light shifts and the solidity dissolves into fright and liquid unsureness. How do I hold on to the solidity? And if I can’t, do I have to go so far from it?

Marissa would hate and love within minutes. She would be silent for hours. She would attempt to seduce. She would pray. She turned herself inside out emotionally. I was her witness. I observed and interpreted with hesitation. When the physical symptoms of a gnawing stomach ulcer doubled her over in agony, she would plead for "breath" which became my signal to guide her, but myself as well, through a breath meditation. Relief was temporary but Marissa seemed genuinely appreciative. Still she climbed into my skin, and occupied my thoughts, and feelings. I neither confirmed nor denied many of her perceptions, that is, unless what she saw or felt in me was so foreign as to be destructive, a transference replay of her abuse or when her words were so tender that I was moved to speak with compassion. These were times that I spoke honestly of what I thought and how I felt.

Conscious of prosody, I tried to keep my voice calm, even and gentle. I wanted to offer soothing through my tone of voice in order to help regulate the dysphoric affective disruptions so present with trauma. I did so sparingly and in response to severe, dangerous regressions and to plaintive cries of distress. Slowly and with trepidation Marissa began to develop her own skin and her separateness from me. She had to let go and I had to help her let go of me.

We then entered what Stern et al. (1998) refer to as "moments of meeting" where only the authentic exists. We were together finding regret and mourning for the unalterable defects or faults that had cast such a deep, unabiding shadow over her life (and mine, although mine were kept to myself). A scar appeared in the space created, in the time off and through the slow unfurling of Marissa’s personality and her tentative, faltering efforts at play.

So, Where to From Here? Has Healing Occurred?

I think and hope we are headed into what Calvino (1988) describes as "lightness." After a time when a re-integration, or perhaps a new integration is loosely, flexibly formed the patient moves on. The "where" is to be determined but the direction is clearly into the future. To live only in the shadows of trauma casts a dark, foreboding spell of repetition: numbing, deadly and stone cold. All that was painstakingly created may come undone if both patient and analyst can only stare myopically into the damage of trauma neglecting the nascent life taking root at the edges.

Here Calvino’s (1988) reminder of the myth of Perseus is most instructive.¹ Perseus was able to slay Medusa by avoiding her direct gaze instead capturing her image on his bronze shield. By so doing he rendered her threat of turning him into stone harmless and through his beheading of Medusa sprang forth the magnificent winged horse Pegasus.

Marissa and I move forward separately and together acknowledging and respecting the traumas of her life. Marissa in her own words of wisdom forged in her facing down the darkness of traumatic evil writes:

Vomit and diarrhea began my day—going back to work for the week. How was I so calm and now I’m not? And I know that once I begin working I’ll be fine. That’s the devil of it—that I will be fine, I am always fine. It’s just that everything hurts so damned much. This morning there was this piece on NPR about the Jewish survivors that while they were in the camps sang the Requiem to the Nazis and the painful beauty of it nearly set off another panic attack—that’s the thing for me—the darkness and the light together—it hurts. Beautiful innocence—and the knowledge that innocence and beauty are fleeting. This makes me want to run for the most remote hill where pain does not know my name and doesn't have my address. But, I cannot, can I?

For my part, Calvino’s words help me understand where I am to go as I move on with my work and life. With vision he writes:

Whenever humanity seems condemned to heaviness, I think I should fly like Perseus into a different space. I don’t mean escaping into dreams or into the irrational. I mean that I have to change my approach, look at the world from a different perspective, with a different logic and with fresh methods of cognition and verification. The images of lightness that I seek should not fade away like dreams dissolved by the realities of present and future…..(p. 7)

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References

Balint, M. (1968). The Basic Fault. New York: Brunner/Mazel Publishers.

Calvino, I. (1988). Six Memos for the Next Millennium. New York: Vintage International.

Chodron, P. (1997). When Things Fall Apart. Boston: Shambhala.

Davies, J. and Frawley, M. (1991). Relational Psychoanalysis the Emergence of a Tradition. ed S A Mitchell and L. Aron, Ed.). Hillsdale, New Jersey: Analytic Press

Eigen, M. (1986). The Psychotic Core. Northvale, New Jersey: Jason Aronsen Inc.

Ferenczi, S. (1933), Confusion of tongues between adults and the child. In: Final Contributions to the Problems and Methods of Psycho-Analysis, ed. M. Balint (trans. E. Mosbacher). London: Karnac Books, l980, pp. 156-167.

Ghent,E. (1999). Masochism, submission, surrender: masochism as a perversion of surrender. In Relational Psychoanalysis: The Emergence of a Tradition, ed. S.A. Mitchell and L. Aron, pp. 211-242. Hillsdale, N.J.: Analytic Press

Shay, J. (1994). Achilles in Vietnam. New York: Scribner.

Spohn, N. (2006, November 3). Trauma-Body Psychoanalysis and the Continual "Huh". Paper presented at the 17th annual Interdisciplinary Conference of the International Federation for Psychoanalytic Education, Pasadena, CA.

Stern, D. et al (1998). Non-interpretive mechanisms in psychoanalytic therapy: the ‘something more’ than interpretation. The International Journal of Psychoanalysis, 79: 903-921.

Winnicott, D.W. (1941). The observation of infants in a set situation. In Thru Paediatrics to Psycho-analysis Collected Papers. New York: Bruenner/Mazel. 1992.

Winnicott, D.W. (1962). The aims of psycho-analytical treatment. In The Maturational Processes and the Facilitating Environment, Madison/Connecticut: International Universities Press, Inc., 1965.