The Concept of Cumulative Trauma

Assaultive Projective Identification and the Plundering of the Victim's Identity

A destructive mode of projective identification is delineated: a predator's catastrophic attack calculated to cause the victim a stress disorder marked by a disarrayed identity. This discomposure enables the perpetrator to aggrandize a manifold inroad upon the victim's identity to imprint, intrude, mingle and/or lodge his representation into it; to ravage, steal from, impoverish, and/or corrupt it; finally to have his representation emerge as an internal regulator of the traumatized prey's functioning. The victim's debased integrity is manifest in the symptoms of his ensuing posttraumatic stress disorder (PTSD).

A modest proposal: (re)defining unconscious fantasy

The author argues that unconscious fantasy, properly defined, necessarily represents the three-dimensional intersection of wishful thinking (fantasy), veridical perception of the environment (reality), and the naive cognition of childhood. It is proposed that, although attachment theory developed out of the intent to capture the unalloyed reality of dyadic experience, that experience is inextricably entangled with the other two components, wishes and naive cognition, and furthermore, that the behavior of children in the attachment paradigm can only be accounted for by positing the existence of underlying unconscious fantasies. In making these arguments, the author also addresses the development of unconscious fantasies and their relationship to compromise formations and trauma.

Heroin addiction: the needle as transitional object

The etiology of heroin addiction is examined from the perspective of object relations, one psychoanalytic model among many that can offer fruitful understanding. Material is drawn from the literature and from a case example. The major specific focus is on the needle as a transitional object in patients who have experienced early childhood deprivation and separation trauma.

Psychic trauma and traumatic object loss

Psychoanalysis began with the concept of psychic trauma, which was subsequently not clearly differentiated from traumatic object loss or from unconscious conflict and fantasy. Psychic trauma is investigated in relation to unconscious conflict, with and without concurrent object loss. The syndromes of PTSD, uncomplicated by object loss, of traumatic bereavement, and of relatively nontraumatic bereavement, though often interwoven and inseparable, are all different. The significance of the loss, sociocultural factors, and group process influence individual responses to trauma and traumatic bereavement. There are specific neurobiological and psychological sequelae of traumatic experience. Clinical applications are noted.

Representations of dread: the dreaded self and the dreaded state of the self

The experience of dread, an extreme form of fear that is induced by terror and horror, is seen as manifested in the shapes of a "dreaded self" and a "dreaded state of the self." These representations reflect psychic dangers ranging from a common, feared identification to states of disconnection, desolation, ego dissolution, and nonexistence. It is suggested that life crises and traumatic impingements, informed by developmental and psychic realities, are critical determinants of multiple dreaded self-representations; that disavowal often serves to massively ward off the recognition of the awful; and that these representations serve a preconscious signal function that anticipates the danger of reexperiencing an original terror. Case examples illustrate these points and reflect the utility of the language of dreaded representations in the treatment situation.

The transgenerational transmission of holocaust trauma. Lessons learned from the analysis of an adolescent with obsessive-compulsive disorder

This paper outlines an attachment-theory based model of transgenerational trauma inspired by the successful psychoanalytic treatment of a severely disturbed adolescent with obsessive-compulsive disorder who was the first child of the first daughter of a holocaust survivor. It is proposed that the transmission of specific traumatic ideas across generations may be mediated by a vulnerability to dissociative states established in the infant by frightened or frightening caregiving, which, in its turn, is trauma-related. Disorganized attachment behaviour in infancy may indicate an absence of self-organization, or a dissociative core self. This leaves the child susceptible to the internalization of sets of trauma-related ideation from the attachment figure, which remain unintegrated in the self-structure and cannot be reflected on or thought about. The disturbing effect of these ideas may be relatively easily addressed by a psychotherapeutic treatment approach that emphasizes the importance of mentalization and the role of playful engagement with feelings and beliefs rather than a classical insight-oriented, interpretive approach.

Anniversary reactions in a five-year-old boy. Unresolved conflict, guilt, and self-identifications

This paper examines the important role of anniversary reactions in the psychological adjustment of seriously traumatized individuals. The clinical case study examines the impact of anniversary reactions on the posttraumatic symptoms and accommodation of a five-year-old boy. Unresolved conflict with the mother, an intense sense of guilt, and difficulty in self-identification were explored during subsequent sessions of psychoanalysis. The clinical significance of considering the possibility of anniversary reactions in children manifesting repetitive attempts of trauma mastering is discussed.

Seduction trauma: representation, deferred action, and pathogenic development

Seduction trauma refers to a range of phenomena currently described under the rubric of child abuse. Freud elucidated the fantasy distortion and elaboration of traumatic experience and retained the importance of actual trauma. Psychic trauma is associated with the alteration of self and object representations and ensuing new identifications, e.g., with victim and aggressor. The "deferred action" of psychic trauma is an antiquated concept and psychic trauma has immediate effects as well as far reaching developmental consequences. Prior trauma predisposes to later traumatic vulnerability and to trauma linked to phase specific unconscious conflict. The pathogenesis of child sex abuse and the enactment of oedipal incest extends before and after the oedipal phase, is often associated with other forms of abuse, and has a history of pathogenic parent-child relationship.

Comparing child victims and adult survivors: clues to the pathogenesis of child sexual abuse

Sexual abuse consists of two discrete traumatic elements; the repeated infliction of sexual assault that is superimposed on a chronic background of pathological family interaction, including betrayal, stigmatization, role reversal, and violation of personal boundaries. The acute episodes of sexual assault may be overwhelming to the child and result in anxiety-related symptoms, including PTSD. The long-standing family dysfunction leads to a pathological defensive organization that becomes woven into the victim's personality structure, resulting in long-term characterological changes. As the sexually abused child progresses through adolescence into adulthood, and the immediacy of his or her victimization recedes to the background, the acute posttraumatic anxiety symptoms are gradually replaced by more enduring symptoms and characterological defenses. Traumatic memories of the abuse become repressed or dissociated from consciousness. Identifications, attitudes, and affects derived from the abusive environment are usually organized around victimization experiences, leading to identifications with the aggressor or victim, which contribute to sadomasochistic object relationships and problems with the regulation of sexual behavior. The repressed or dissociated traumatic memories of sexual abuse carry the potential for producing future psychopathology through displacement in the form of conversion symptoms or somatization, and by generating delayed PTSD when these memories are elicited by current experiences. Anxiety and depression triggered by the emergence of these traumatic memories often lead to alcohol and drug abuse. These substances may be used for their anxiolytic and antidepressant effects.

Psychological-mindedness as a defense

Many patients seen today use sophisticated capacities for psychological reflection and premature synthesis to ward off knowledge of more primitive conflict and islands of unintegration. They show a precocious talent for free association, a talent they perversely misuse. Similarly, they enjoy access to a rich fantasy life, even as they subtly impoverish it. Effective therapeutic work requires that they suffer "traumatization"--experiences of dedifferentiation that undermine their considerable capacity to know what they feel and think. Structural and process variables interact with content variables in complex and ambiguous ways. As a consequence, estimates of the authenticity and "fit" of personal and interpersonal experiences and behaviors of both partners in the therapeutic encounter become necessarily involved. Such factors may increase the possibility of misunderstandings, but also of more authentic and firmly grounded understandings. Similar issues are eventually revealed in these patients' early lives, where psychological and other formulaic understandings were prematurely applied to offset overwhelmedness and other unarticulable experiences; the patient's talents for ambiguity, irony, self-soothing, or responsiveness to others were, in effect, exploited at the expense of full psychological growth. Versions of this clinical presentation may be increasingly common in a new generation of analyzable patients. Clinical work with them is facilitated by a synthesis of contemporary developmental, structural, and object relations theory.

Analytic abstinence and preoedipal disturbance

Analytic abstinence entails a technical frustration that may have different meanings for those with primarily neurotic disorder and those with significant preoedipal pathology. It is posited that the greater the degree of preoedipal disturbance, the greater will be the tendency to experience the frustration of the technique itself as transference-laden: conflicts related to frustrating experiences in early childhood are revived owing to the abstinent form of psychoanalytic treatment. Ramifications regarding the analyst's work-ego, countertransference, general strategic considerations, and technical difficulties are discussed.

The dissociative character: a reconsideration of "multiple personality"

The author has interviewed and reviewed the cases of over 100 patients with a suspected diagnosis of multiple personality disorder (MPD). He finds it clinically useful to think of a continuum of character pathology in which dissociative and defensive altered states predominate. At one end of this continuum is MPD, which he considers a lower-level dissociative character. He redefines dissociation as a defensive altered state, due to autohypnosis, which augments repression or splitting. Depending on the degree of integration of the ego, it may result in a broad range of disturbances of alertness, awareness, memory, and identity. Four vignettes are presented which illustrate a transient hypnoid state, "characterological" dissociation in an upper-level dissociative character, and two cases of MPD, including one emerging in analysis.

Ecological integrated model of children of war: individual and social psychology

The psychological trauma associated with war is a topic that has occupied the attention of mental health researchers and practitioners for some time. Most of their attention, though, has focused on the traumatic stress of soldiers, and little attention has been paid to the problems and traumatization of civilians caught in war zones, especially the children. In this paper, the limited research on children of war is reviewed, and themes are extracted. Children suffer from both acute and chronic traumatic stress. The key to determining the amount of suffering has to do with the dynamic interaction among five processes within an ecological framework: the child's psychobiological makeup, the disruption of the family unit, the breakdown of community, and the ameliorating effects of culture. The intensity, suddenness and duration of the war-like experience itself constitute an additional component to this ecological model. In the final section, psychotherapeutic guidelines to help children cope with symptoms associated with war are presented for current and future caregivers. The prevention of war should be the primary task of all.

Child sexual abuse: immediate and long-term effects and intervention

OBJECTIVE

The primary purpose of this review is to highlight the progress made in the area of child sexual abuse during the recent decade and to identify the gaps in our current knowledge about this syndrome.

METHOD

More than 100 articles on child sexual abuse were reviewed, the majority written from 1980 to the present concerning the demographics of child sexual abuse, the psychological effects of child sexual victimization, the psychopathology encountered in adult survivors of child sexual abuse, hypotheses regarding the nature of the trauma, a critique of the research, and approaches to intervention.

RESULTS

Although a wide variety of psychological sequelae have been documented in sexually abused children referred for evaluation or treatment, there appears to be considerable variability in the severity of the symptoms, and we remain ignorant of sequelae in abused children who never enter the mental health system. However, some of these children may become symptomatic in adult life. Validation of sexual abuse is hampered by the lack of specific behavioral markers. Methodological difficulties in child sexual abuse research include problems with definition, failure to measure severity of the abuse, sampling problems, failure to use standardized or appropriate instruments, problems with validation, and failure to use control groups.

CONCLUSIONS

Despite an increased focus on child sexual abuse in the recent decade, many gaps remain in our knowledge. Prospective longitudinal follow-up studies of sexually abused children and treatment outcome studies are urgently needed.

A study of the relationship between life events and disturbed self image in adolescents

The occurrence and subjective importance of a list of life events were determined in 1296 adolescents and compared with the risk of a disturbed self image, as assessed on the basis of Offer's (1981) questionnaire. A disturbed self image was shown by 24.2 per cent of the sample, and it was significantly associated with a reported excess of events (one standard deviation above the mean), and with the reporting of specific classes of events. These included serious disagreement between parents, sudden decrease in family income, serious abuse either within the family or outside the family, and having had an abortion. The events were sorted and ranked by the observed values of their sample frequency, subjective importance, and assessed risk of a disturbed self image. The rarest and subjectively most important events were often associated with a higher risk of a disturbed self image, and the role of reporting such "exceptional" experiences is discussed.

The "holding function" of the therapist in the treatment of borderline patients

In this paper, I have attempted to show that during crises in the therapy of borderlines it is crucial not to respond, needless to say in reality, but neither by confrontation nor with interpretation to the apparently impulse-ridden transference. To interpret to the patient, during such periods, the vicissitudes of the object hunger in the transference often intensifies the turmoil, confuses the issue, and precipitates further regression. It is of primal importance to recognize that during these crises the patient needs a holding environment to restore and enhance the observing, anxiety-containing, and integrative capacity of the ego. This holding environment rests not only on the stability of the therapeutic setting, including the reliability and acceptance of the therapist, but on helping the patient acknowledge and process the precipitants of the emotional crises.

Precocious ego development and obsessive compulsive neurosis

Precocious ego development is frequently mentioned in psychoanalytic theory as an important determinant of obsessive-compulsive neurosis. Writers such as Anna Freud suggest that an imbalance in the development of ego over drive may lead to obsessional neurosis. However, further examination of the psychoanalytic literature reveals that the nature of this supposed link is not clear. Explanations couched in economic language or in terms of an early hypersensitivity to stimulation are open to theoretical criticism or are unsatisfying. The author suggests that we focus on the effect of precocious ego development on developing object relations. It is suggested that precocity may lead to early disappointment in parental objects. The inter-relationships of disappointment with early identifications, premature sense of autonomy and anal problems are discussed. A case of an obsessive-compulsive adolescent girl is presented to illustrate the role of precocious ego development and superior intelligence in the formation of the symptoms.

The adaptive significance of destructiveness in primitive personalities

Destructiveness in primitive personalities is not restricted to a segment of the person as it is in the case of neurotics, but is global and pervasive. This destructiveness is meaningfully configured in a manner which cannot fully be accounted for by constitutional factors or be comprehended from the individual, intrapsychic, conflictual viewpoint of classical psychoanalysis. It follows an interpersonally meaningful pattern and therefore has adaptive significance in the contemporary life of the individual. The adaptive model I propose does not violate essential canons of psychoanalytic theory, for it can simultaneously be conceptualized in terms of intrapsychic structure and dynamics. This model holds out the possibility for a therapeutic approach to primitive personality organization which differs in some but by no means all respects from classical analysis.

Learning disabilities and psychological development in childhood and adolescence

The relationship between learning disabilities and psychological development is a complex, ongoing intrapsychic and psychosocial process. The results of two clinical-psychological investigations about a group of learning-disabled children and a group of learning-disabled adolescents is summarized. Although the learning-disabled youngsters were psychologically more heterogeneous than homogeneous, several common configurations emerged that characterized these children and adolescents: (1) problems in work and learning (due to the learning disability itself and to psychogenic factors related directly and/or indirectly to the disability); (2) chronic, low-level depression and relatively high, free floating anxiety; (3) characteristic unconscious concerns about self and others. In addition, learning disabilities organize psychological development in determining strengths, weaknesses, interests, and defensive strategies. And, the intermittent nature of mild to moderately severe learning disabilities seems to contribute to a sense of being traumatized and to character riqidity. The educational and clinical implications are briefly discussed.

Thinking as a narcissistic resistance

Verbal thought occupies a preeminent place in psychoanalytic theory and practice. The patient keeps out of conscious awareness, ultimately, what is unrepresentable, therefore unthinkable. The analyst helps the patient find ways to think about the unthinkable, both to reconstruct the past and free himself from it. The patient's role in this process involves a challenge comparable to the analyst's, in balancing and shifting between free association and objectifying thought. His capacity to progressively adapt his thinking and language to meet these therapeutic needs is a sensitive indicator that the narcissistic disturbance is healing. Conversely, incapacity to do so results in therapeutic stalemate or incomplete treatment.

Psychic trauma and traumatic neurosis. Play therapy with a four-year-old boy

In the introduction to a clinical example of a young boy with a traumatic neurosis, this paper reviews the phenomena of psychic trauma. Freud's contribution to the initial description of the phenomena is discussed with consideration of such factors as the “stimulus barrier”, breaks in this “protective shield” and the development of a “traumatic neurosis”. The elaboration of these concepts is followed in their later development in the literature.

The clinical example presented by the author is a description of the assessment and treatment of a four-year-old boy who had been mauled by a leopard in a suburban pet store. The presenting complaints at the time of assessment were numerous and of precise onset to the time of the mauling. The boy exhibited disturbance in sleep, clinging, fearful, apprehensive behaviour and marked separation anxiety. All such symptoms appeared as a marked regression in the boy's formerly normal development.

The child's course in play therapy is detailed. This highlighted the existence of a number of intrapsychic conflicts involving anger, guilt and the fear of retaliation. The fact that such conflicts predated the traumatic event is postulated to be a determinant of the traumatic process.

Possible sequelae of trauma and somatic disorder in early life

All children experience trauma. The age, state of development and constitutional factors will determine whether some children will have a traumatic effect. Trauma occurring before the age of three, at a time when the ego has not developed its synthetic and integrative functions, may be reproduced in later life as an isolated symptom, by selected sensations involved in a sensory imprint or screen sensation of the trauma as a simple recording. After the age of three, under the influence of a more mature ego, excessive traumatic stimuli will be integrated and elaborated in symptom formations as phobias or other conditions and extended as part of the total personality. Recurrence in later life is triggered by events related not only to the original experience, but also to the content of its elaboration. The earlier in life the trauma occurs, the more likely that somatic imprints of primitive physiological symptoms would result as an archaic, biological defense or screen sensations. Recurrent sensory imprints or screens may appear as organic illness or functional somatic symptoms. Diagnostically, a detailed early life history is necessary to uncover the presence of a sensory screen memory of a trauma and so avoid diagnostic medical search for organic causation. Case material illustrating the two groups are presented. Indications for psychoanalysis and for supportive psychotherapy are discussed from our theoretical framework as well as from the literature.

The replacement child--a developmental tragedy: some preliminary comments

Some of the clinical and theoretical issues thought to be involved in the psychology of "replacement children" are discussed. A developmental framework is proposed within which to view such children. The replacement child is becoming an identifiable clinical syndrome, and a developmental framework is sorely needed to encourage more systematic research. A replacement child perceives his status differently on both a cognitive and emotional level within the context of each developmental phase, and the affective and associative links need to be reworked each time. We view the status of being a replacement child as a developmental interference insofar as demands are placed on the child's immature ego which he might not yet be equipped to cope with.