Sydney, August 2008
First presented at the IPA Conference, Berlin 2007
Dr. Abigail Golomb
Dr. Abigail Golomb is an adult and child psychiatrist and psychoanalyst. She works in the public health service in Israel and was director of a unit for infant psychiatry that specialised in severe illnesses (such as autism) using a developmental-psychodynamic approach. She has worked with trauma victims and terror victims. She is a past president of the Israeli Psychoanalytic Society.
Introduction: The expression “chronic acute trauma” gives a taste of postmodernism. It is a surreal expression, as chronic and acute are supposed to be opposites, not joined in the same experience. But both for the individual and societies, a history of prolonged, acute and severe trauma has become common. Terrorism and fascism, to mention only two, see the state of chronic fear, chronic acute fear, permanent terrorisation – as a major means to achieve their aims, and often it becomes an aim in itself.
In psychoanalysis, we have dealt for years with the reaction to acute trauma, be it in childhood or adulthood. Modern psychiatry and neuroscience have researched post-trauma, have shown how a severe, acute event can bring about chronic disabilities and psychic changes. Feelings of mastery, control and competence are basic psychic mechanisms both for the individual and for the society to deal with trauma, dissolution of existing structures (such as in war, major disasters of nature, etc.) and internal psychic structures. We are familiar with the defenses that enable us to deal with acute stress and acute trauma: dissociation in the service of the ego, isolation, denial. It is clear, psychoanlytically, and enhanced by neurobrain research, that rational, secondary thinking must control the situation, and the normal, expected affective reaction to disaster must be contained and delayed. These defenses are lifesaving in the short term. But what happens when they become part of the everyday coping? When children are brought up with denial, affective isolation, addressing all psychic efforts towards external survival with no space or time for the inner world, for emotional working through?
Analytic training did not deal with these issues for years. Psychoanalytic treatment is a very private and intimate activity. It takes place between two people, in a closed room, and it deals with the inner world of the analysand, distilled and separated from external reality. It also deals with the inner world of the analyst, drawing on his empathy, his “gut feelings”, his instincts, and his awareness of his own inner world. Part of analytic training is aimed at helping the future analyst be able to become aware of his inner world, his inner conflicts and his own reactions – the better to use these when dealing with analysands.
External stress of either of these parties can impinge on the analytic process. This paper will deal specifically with the problems that arise when there is a joint stress – when the society in which both of them live and function is under longterm stress, in a state of longterm instability, and/or physical danger. Sometimes it is impossible to separate the two, as often what in retrospect is a well-defined period of stress was indefinite in length as it was evolving. Thus, a clearly predicted storm or earthquake that cease at the expected time create different modes of reaction than a war that in retrospect took only so many days, weeks or months; but the length of the war was unknown at the time of its beginning (inception).
Coping with External Stress:
In psychoanalysis, we have a number of expressions used when a patient is resisting dealing with his inner world, his conflicts, his projections. We talk of “flight into health”, resistance, lack of insight, rationalization, concretization, and many more interpretations. But these same words, used with a negative connotation during psychoanalysis, are in effect the basis of good, lifesaving coping with external stress and trauma. The psychic (and physiological) mechanisms that enable us to deal with danger are diametrically opposed to the process of analysis:
Denial in the service of the ego is a basic need, without which we could not deal with any emergency or dangerous situation. In analysis, denial is one of the major defense mechanisms we have to combat.
Focused attention is vital for dealing with danger. We cannot allow ourselves to be distracted – we must be on the alert. But this is diametrically opposed to free association.
Suppression of emotion in favor of clear, rational observation is vital for survival in dangerous situations. In analysis emotion, awareness of emotion and bringing emotions to the surface is one of the basic tools we use.
Functioning in a group, attention to the group’s needs is often vital. The rules of the group (army, hospital, civilian aid, etc.) are vital for everyone’s survival. Analysis aims at looking at one’s inner rules, one’s inner dictates. Constant reference to outside rules would probably be seen as resistance…
Priority to external needs is a prerequisite in times of stress and danger. One’s priority is survival, first of all of oneself and then of one’s family and society. If any of these are in danger, then survival takes on first priority.
The above describes individual functioning, but the same holds true on a societal level.
The issue I wish to address in this paper is the longterm effect of employing these “emergency emotional measures” on a longterm basis. And my basic thesis is that these are meant for the short-term, and one can recover from them and go back to one’s usual psychic functioning if the trauma was not shattering and if these defenses are employed for a short time. They use up enormous psychic resources, and over longer periods of time we begin to see the failure either of these defenses or of other psychic functions. We enter a phase of depletion, wherein our ability to return to a previous level of functioning (both external and internal) is diminished. “Burnout Syndrome” describes fatigue, lack of control, mood swings etc. as typical. A society can also undergo burnout, as every post-traumatic situation has demonstrated. Even when the trauma ends “well” (winning a war, saving earthquake victims, etc.) there is an enormous difference between the recovery after a short period of time and the recovery after a prolonged stress. This is easily described in economic terms, and can be paralleled in psychic economy, both of the individual and of society.
Depletion: though this term is not common in past texts on post-trauma, it is beginning to come into its own. In order to be depleted, one must first have resources, have felt replete. A society must have had resources, a structure, a sense of stability, leadership, inner depth, strengths. The individual within the society felt he could depend on his society, gain security from belonging to it – and also had his own resources and inner strengths that enabled him to contribute to his society, to give – to want to give.
If we now look at prolonged acute chronic crisis in these terms, it becomes apparent that even auspicious beginnings can begin to unravel over time. Let us take two examples: a sudden trauma that destroys a community, without warning and without preparation, such as an earthquake; and a prolonged crisis situation, with constant danger, such as exists in many countries today, from Israel and the Palestinian territories via Africa, cities in fear of terror attacks, etc.
When an earthquake destroys a community, as was witnessed in Turkey, for example, there is destruction both of the physical structures and of the societal ones. Either the leadership is physically destroyed, or the belief in that leadership is destroyed, or its past functions do not suit the crisis/survival situation. After the first shock, the individuals look for survival and structures. They need external physical ones and external and internal psychic ones. New leadership can spring up, totally different strata are defined in society overnight, the past elite is overtaken by people who can pull others out of crevices in the ground. The quicker a structure is formed the faster people can begin to call on their own personal psychic resources. All the defenses described above are brought into play, and the very fact of survival can be the basis for a renewed sense of competence and even belief.
If the situation continues, if the temporary camp which was a haven of security and shelter becomes a “temporary-permanent” structure, both physically and socially, then the sense of insecurity, of no containing and no outer skin within which to organise one’s inner world – begins to take over. Undefined time is one of the greatest depleters: we use up enormous psychic resources trying to deny that the future is totally unclear. If we admit this reality – we are in danger of psychic depletion. If we choose to form false beliefs about our future – we are in danger of living a delusion. In either case, the longterm effects create a different developmental line than that of normal existence. The surreal, abnormal existence must become the normal, real one, and we have to do psychic acrobatics to achieve this.
In some ways, simply flying in an airplane creates the same surreal reality. A group of people is secluded from the rest of the world in a flying machine noone really understands. There are a set of rules and rituals, which the pilots and stewards enforce and we willingly adopt. We know the situation is surreal, but it is clearly time-limited. We still need containing – from the actual plane to the rituals we create, individually and societally – but these are easily sustained for a short period of time, and we have become attuned to it and accommodate it well before entering that quite surreal situation.
But imagine if it were unfamiliar, or we had no idea when it would end, and had to begin relating to the people on the plane as the only ones in our universe. Numerous television series have adopted this premise, some with a great deal of psychological perspicuity. And I purposely talk of a television series, rather than a two hour film, because of the undefined time span.
This new “society” needs to create its rules where none exist, to create societal structures and to create a moral code. And our individual psyches have to make appropriate adjustments.
Now take a longterm, chronic acute crisis. I come from a country that lives this surrealistic state daily, and calls it normality. Many Israelis, especially children, are surprised, when they visit other countries, that there is no checking of bags in every supermarket, cinema or train station. They feel less secure, because a ritual they grew up with is challenged. There is a respite from listening to the news every hour, but also a feeling of being left out of things, that “knowing” what is happening is a form of control they now lack.
Two small, everyday examples: a colleague once asked me if it was safe to come to Israel, as he had a scientific meeting in Jerusalem and had heard there was renewed bombing. “Some kind of missile”. I casually explained that these particular attacks (as attacks were the natural state) were in a town near Gaza, and Jerusalem was not a present target. At that moment I felt guilty for not having thought about this town – Sderot – for a few hours, then I consoled my guilty – and useless – conscience by reminding myself that Tel Aviv had had its turn during the Gulf War and many everyday terror attacks – and went back to thinking what I wanted to change in our furniture.
This is a surrealistic reality that many humorists would have loved. In effect, it is impractical, unrealistic behavior, whether choosing furniture when the present and the future are so unclear, or giving advice on where it is safe to go – about which I have no authority or knowledge. My guilt is useless and my moral coverup no less so. But it is quite a normal and probably healthy way of life, given the external situation. It is quite familiar to people from many countries who have undergone occupation, Fascist regimes, etc. It is not the way other parts of the world live.
The other banal example is the reaction to killing and bombing on the news, which is often heard or viewed at mealtimes. The immediate reaction at the beginning of the second intifada, years ago, was horror, lack of appetite, and fear. Now there is a quick mental checking if we know someone there, and we go on eating. The moral implications are obvious. But so are the survival ones.
The impact on children: What are children exposed to in these situations, especially these banal everyday actions that are major formative influences on children? How does it affect their value system? How does it affect their ability to express emotion, to ask questions? How do we explain the surreal to them? One of the bases for dealing with external and internal stress is to contain and repress emotion. On a short-term basis, we can explain this to children. We can tell them we will relate to the horrible traffic accident they just saw after we have tried to help the people in the car, and that for now we must help the people, not give in to our fear, horror and even need to help them deal with their fear and horror – and lack of mastery of the situation. But on a longterm basis, there is no such explanation. We go on eating dinner and they go on eating dinner, and unless it hits us personally they see almost no moral, value reaction. At most there is anger at the perpetrators, or “advice” to the government how they should have handled the situation. But this is usually in the same tone of voice we discuss all political events, either at home or abroad. There is no constant moral outrage, as noone can survive constant moral outrage with the concomitant sense of helplessness and impotence. There is no graduated, balanced expression of different degrees of emotion, as the mode is denial or reversal, not directly dealing with the fear and the insecurity. For children, any pattern of behavior becomes part of their inner world. Thus, a denial of emotion can spread much wider than a mechanism of survival. The whole ability to express, contain and graduate emotion is endangered. There is a much greater tendency to the extremes: repression versus impulsivity, a sense of impotence versus a sense of omnipotence.
The denial of childhood: a familiar wartime phenomenon is children, even preschoolers, who function as adults during the war. They seem to have not only the cognitive abilities but even the emotional capabilities of adults. There are many explanations for this, the demands of survival being the foremost. But how do the children do this? If this is normal development, why don’t all children? Why do we encourage normal children in normal times in normal societies to play, learn at school, rebel against their parents, experience being denied the right of self-determination even when their cognitive abilities could allow it? Why is childhood considered a necessity of healthy psychic development? Aren’t these 5 year olds who can scavenge for food or 8 year olds who can carry secret messages and bombs psychically healthy? And what happens to them if for years this is their whole environment, not a short survival sprint during a short crisis? What do they lack by not having been children? And how do they do it? How do the adults do it? What happens to “normal” parental instincts when we allow and even encourage our children to do things we “normally” would have considered child abuse?
In order to discuss this, I would like to go back to the question of depletion versus replenishment. In classical psychoanalytical terms, we talk of children as going through the stages of basic trust, of early narcissism. Whatever theoretical terms one uses, there is a clear progression from a feeling of being loved and accepted for oneself and as oneself; the baby internalises this into an ability to love itself; and on the basis of its trust in itself and its surroundings the baby can begin to deal with frustration and reality. The child learns to share in order to retain his significant objects; he learns to give up some things/people in order to have others. He learns to give up totality. At the end of this long developmental route is the ability to take personal responsibility and to form intimate relations with a significant other. He learns to love, as a mature person. He is a whole person, not a part object, who is capable of loving another whole person, not a part object. He learns that giving to another is a way of replenishing his internal world, not diminishing or depleting it.
So when these children survive themselves and help others survive – are they replenishing their sense of internal worth? Have they had the time and space to develop a sense of iintrinsic worth? Does this sense of self exist regardless, or is it dependant on constantly performing acts of survival and nurture?
Can they develop separation-individuation, which demand “normal” anger and aggression? What happens to anger and aggression during chronic acute crisis, in children, adults and societies? Is there a sense of personal responsibility, of individual, free decision-making, or is there a collective dictate due to the need to survive? If so, children have learned to act responsibly, to do all the needed things, but this cannot have affected their inner sense of self, and the whole sense of individuality and personal, individual need is denied by their surroundings – family and society. Things are not done because one wants to but because one has to. Again, on a short term basis this is an excellent way of learning to deal with and accept reality. But on a longterm basis this is extremely detrimental. For the child, this is not a temporary thing. He has no memory and no experience (external or internal) of any other type of development. He never went through a period of being the center of the universe, of being loved and cherished because he exists. He learns that existing is the core of everything. And he learns this even when the external world looks “normal”. Living in a temporary-permanent camp after an earthquake is shocking, both to the inmates and to the external world. But it is less surrealistic than living in a “normal” country with “normal” materialistic existence – yet being under constant threat. The mixture of the surreal and the real, the normal and the abnormal, is a task adults deal with mainly by denial, isolation and occasionally black humor. But hopefully they have had some other kind of inner experience to refer back to. Children born into this confusion incorporate all these defenses into their “normal” development. Externally they may function cognitively on a very high level, but their emotional and moral development by definition – and from the experience of many – is abnormal, and takes different pathways and develops a different kind of personality.
There is some research already ongoing in this field. It shows that for some of them, when they grow up they can only do things that have enormous significance. Just ordinary things don’t have meaning. There is great difficulty with peer relationships and couple relationships. Definition to their lives is given by external events and needs, and not by building up their own needs and desires – healthy narcissism, definition of self, ego-ideal.
These are only preliminary views. And we have yet to deal with the effects these children will have on the next generation, their own children.
Terror in everyday life
Some brief comments in response to paper by Dr Abigail Golomb.
Dr Golomb’s paper begins by conceptualising the importance of the factor of time in relation to the effect of trauma. Her paper brings out the damaging effect of a traumatising environment on anyone, but in particular upon the developing child. It is the chronicity of acute traumas that in particular contributes to the formation of a restricted ‘survival’ state of mind, and when such trauma are prolonged ‘we enter a phase of depletion, wherein our ability to return to a previous level of functioning is diminished’.
Dr Golomb’s focus is the child but her description put me in mind of Winnicott’s conceptualisation of what constitutes trauma for the baby. In his paper ‘The Location of Cultural Experience’, Winnicott states that it is perhaps worth ‘trying to formulate this in a way that gives the time factor due weight.’ The infant, Winnicott suggests, holds an inner imago or feeling of the mother’s existence, and this feeling can sustain the baby for say a certain length of time in the mother’s absence. Call this time ‘x’ minutes. If the mother is absent for more than ‘x’ minutes then the imago fades, there is no sustaining inner object and the baby is distressed. However the distress is able to be mended if the mother returns within a certain period, call this ‘x + y’ minutes. This interval ‘x + y’ represents the period of maternal absence that can be tolerated without permanent alteration of the baby.
If however the mother is absent more than ‘x + y’; if the mother is absent for ‘x + y + z’ minutes, alteration will take place. The mother’s return does not then mend the baby’s altered state. This, says Winnicott, is trauma. ‘Trauma implies that the baby has experienced a break in life’s continuity, so that primitive defences now become organised to defend against a repetition of [such] “unthinkable anxiety”.’
To reiterate, Winnicott is suggesting that at ‘x + y + z’ something happens; there is ‘unthinkable anxiety’ and a split or a shattering of the baby’s psychic functioning, with the likelihood of a permanent effect. This seems equivalent to the chronicity of traumas that Dr Golomb conceptualises as contributing to the permanent alteration of the child’s mind. For the baby terror is not so much the real bombs, but the time bomb of the absence of the maternal function.
Winnicott suggests that this kind of trauma interferes with the experience in the transitional area of relating, or in other words this kind of trauma contributes to what Dr Golomb describes as the survival state of mind.
My point in bringing in these ideas of Winnicott is to broaden the concept of terror to include some of what we might call ‘everyday life’. Each of us was a baby once. In the next paragraph of his paper Winnicott writes: ‘We must assume that the vast majority of babies never experience the x + y + z quantity of deprivation. This means that the majority of children do not carry around with them for life the knowledge of the experience of having been mad.’
Well, I wonder about this. I suspect that many, most, or perhaps even all of us, have at least the unconscious memory and knowledge of such experience. Certainly I think those of us who come for therapy are often contending with experience that has left a traumatised survival state of mind, and a limitation of the capacity to enter into the transitional area of relating.
Some kind of representation of an inner terrorist is frequent enough in the dreams of many of us, and if the terrorist does not appear in the dreams of our patients he is often a felt presence in the therapy room. To explain the presence of this figure we need to consider what he might reflect in terms of our own, and our patients’, developmental experience. We might not readily associate the concept of terror with the baby, but we may need to do so if we are to understand the experience of terror more deeply.
Finally, thinking about the subject reminded me of reading Cormac McCarthy’s novel ‘The Road’. McCarthy is a brilliant stylist, but I think the other ingredient that makes this novel a great one is his subject matter. He seems to me concerned with how it is possible for a mind to be in ‘chronic acute terror’ and not only survive but to preserve the capacity to continue to grow, as seems to be the case for his boy protagonist of his novel.