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?
An accident
Being under fire in a war
The death of a lovedone
Rape
Cruelty
The King’s Cross fire
Zebrugge disaster
The Blitz
Being evacuated
Sexual abuse
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.
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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
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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
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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,
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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.
REFERENCES
(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.
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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 Disordeline
Disorders. Madison, CT: International Univers
ties Press.
Young, Allan (1995) The Harmony of Illusions: Inventing Post-Traumatic Stress
Disorder. Princeton Univer
ity Press.
Young, Robert M. (1994) Mental Space. Pr
cess Press.
______ (1998) ’Psychopathology: Term and Concept’, Distance Learning Unit,
Psychoanalytic Studies, University o
Sheffield.
______ (1998a) ‘Descriptive v Psychodynamic Concepts of Psychopathology’,
Distance Learning Unit, Psychoanalytic Studies University o
Sheffield.
______ (1999) ’Between Nosology and Narrative: Where Should We Be?’, talk
delivered to the Toronto Psychoanalyt
Society.
My own writings, including those listed above, are available at http://humannature.com/rmyoung/paper
index.html
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