Introduction

The
purpose of this essay will be an attempt to define, and to critically discuss
the nature of trauma. As well as my own interpretation of trauma, I will be referring
to: Garland (2002), Nicholson (2010), and McNally (2003). When considering the
definition of trauma, I will further look to Freud’s five primary anxieties, as
I feel that these anxieties hold a firm foundation around the nature of trauma.
By examining these primary anxieties, and looking at examples of trauma, I will
argue that McNally’s criteria for diagnosing Post Traumatic Stress Disorder is
insufficient, impersonal and unduly generic.

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I
aim to provide insights as to why it can be difficult to work therapeutically with
adolescents through trauma, and will give examples of potential hurdles, and
things that need to be considered. Although there are many concepts that will
need to be reflected upon regularly throughout treatment, my focus will be on
Negative Therapeutic Reaction and Double Deprivation. When explaining these
concepts, I will refer to Tindle (2006), Henry (1974), Kegerreis (1995), and
Sandler, Dare and Holder (1992). Subsequently, I will show a link between
Negative Therapeutic Reaction and Malan’s (1979) Triangle of Conflict.

 

Nature of trauma

Trauma
can be thought of as an individual experiencing an unendurable response to a
traumatic event. Garland (2002) describes trauma as ‘A kind of wound’ (p.9),
and further explains that ‘When we call an event traumatic, we are borrowing the word from the Greek where it refers
to a piercing of the skin, a breaking of the bodily envelope’ (p.9). To elaborate, it is the mind that is
seen to be wounded, and the exclusive reaction and feelings of an individual
that may, or may not, denote trauma.

A
traumatic event, cannot be assumed traumatic for all. As infants, ideally, we
are protected and rescued by our primary care-giver. When we are hungry, in
pain or lonely, our care-giver will respond to our needs by feeding, soothing
or engaging with us. The stability and continuity of this containment is
essential for healthy development later in life.

Nicholson
(2010) explains that ‘Trauma could be defined as a serious violation of the
expected rhythm and continuity of the individual’s life’ (p.43).

As
adults, we still rely on the continuity and expectedness of life. For example,
we wake every morning expecting our home to be thereabouts in the same
condition as we left it the night before, we have already made presumptions as
to what we expect to see when we look out of the window, we expect to be able
to carry out our usual routine, be that the way we travel to work, or dropping
our children to school. If these expectations were disturbed by external
forces, one’s response to this would depend heavily upon their own experience
of continuity and containment. The person that was neglected as an infant and
was not fed sufficiently, may find themselves experiencing trauma if there were
to be a temporary situation in the outside world, meaning they were unable to
get food. The person that was provided for sufficiently as an infant, may experience
the same situation with an entirely different response. He will have learned
the ability to self-contain, and would be able to draw upon this to filter
through his feelings.

 

Freud’s Primary Anxieties

Looking
at Freuds revaluation on the origins of anxiety in the late 1920’s, we see a common
denominator between each of his stated primary anxieties. Birth, castration
anxiety, Loss of the loved Object, Loss of the Objects love, and annihilation
anxiety, can all be detrimental to one’s sense of security and survival in life.  Garland (2002), speaks of these anxieties as
having ‘a single crucial feature in common: they consist of the separation
from, or the loss of, anything that is
felt to be essential to life, including life itself’ (p.19).

In
1926, Freud explained different types of anxiety, Automatic anxiety and Signal
anxiety. Automatic anxiety is an automatic reaction to a real, external threat,
whereby the ego is overwhelmed and diminishing. Signal anxiety, however, is a
warning of a potentially traumatic situation, a ‘heads-up’ to the ego that
unless something changes fast, it (the ego) is under threat of diminishment.
Garland (2002), warns that ‘the ego, once
traumatised, can no longer afford to believe in signal anxiety in any situation
resembling the life-threatening trauma: it behaves as it were flooded with
automatic anxiety’ (pp 16-17).

 

The
following is an example of signal anxiety being responded to as though it were
automatic anxiety.

A child spent many weekends at her grandparent’s home,
and often baked cakes with her Grandmother. The child was sexually abused for a
three to four-year period by her Grandfather.          

Once an adult, the sight, thought or taste, of thick,
sickly icing, would send her into a ‘frenzy’, and would result in numerous
panic-attacks and night-terrors.

 

The
link between the cake making (icing), and the sexual abuse proceeding it, is
clear. Although contact with icing may not be classed as a traumatic event on
its own, this example shows how the signal – ‘It’s icing, this could mean that real danger is
imminent’, has become confused and distrusted by the ego, and ‘flooded’ with an
automatic anxiety response, ‘This taste, smell or sight, means that I am
already in trouble, I am overwhelmed’.

 

McNally’s
criteria for diagnosing PTSD

In
a presentation given by Nicholson (2017), speaking of Richard J. McNally’s
(2003) critique of psychodynamic approaches to trauma, he states:

“McNally
(2003), defines traumatic stressors as events involving ‘actual or threatened
death or serious injury, or a threat to the physical integrity of the self and
others’ that produces ‘intense fear, helplessness, or horror.’ (APA 1994: 427,
428). Unless a person has been exposed to a stress meeting these criteria, a
diagnosis of posttraumatic stress disorder (PTSD) cannot be made, regardless of
how distressed the person happens to be’ (p.79).” (slide 14 of 68).

I
feel that McNally’s criteria does not take into consideration one’s personal
experience of continuity or containment. When looking at the scenario I gave
above of the two individuals whom were unable to get food, although this
temporary situation could cause distress, it may not be classed as traumatic.
However, when we look further into the history of the individual’s earlier
experiences, we see that although this single temporary circumstance may not
have caused a traumatic response on its own, but when it is combined with other
previous distressing, or even unconscious memories of traumatic events, a
traumatic response is entirely conceivable. The same theory applies to the
example given of the sexually abused child. Although encountering icing is not
in itself traumatic for most, when we look at this as a trigger from a previous
trauma, we can understand how this individual could find themselves feeling
overwhelmed and traumatised.

Taking
into consideration the age range of children that tend to be sexually abused
the most, are those under 12 months, I feel it is fair to say that they would
not have any conscious memories of this later in life. This does not however,
imply that they are not traumatised. Be it repression, denial, or being too
young to consciously recollect it, so that ‘actual or threatened death or
serious injury, or a threat to the physical integrity of the self and others’,
cannot be confirmed, does not mean that unconscious triggers, or transference
for instance, will not result in traumatism.

 

Difficulties in working with Trauma

 

Negative
Therapeutic Reaction

When
working with adolescents through trauma, we need to be aware of the potential
implications of their recovery. Unfortunately, self-destructive behaviour is
possible when an individual can feel, or is made aware of, progress concerning
their mental health. There are many reasons for this, including fear of letting
go of their ‘safe’ and well-known identifications, the desire for fusion with
an internalized object, the new expectations of them, from those around them
and themselves, and saying goodbye to their current institutions and
professional help. It could also be an act of defiance, a way to eliminate any
self-satisfaction in those (parents or professional workers) whom could reap
the rewards of fulfilling their ‘duties’, by repairing the ‘broken’.

One
may fear ‘letting go’ of damaging identifications, due to an unconscious guilt.
If a negative identification has been made with a punitive father for example,
an adolescent may feel traitorous to ‘cut ties’ with the identification.
Sandler, Dare and Holder (1992), state that ‘It is likely that the experiencing
of guilt at the idea of abandoning the tie to the figure of early childhood
plays a significant role in bringing about a Negative Therapeutic Reaction’
(p.128).

There could be ambivalent feelings to be part of/fused with
the internalized mother/object. This fusion can become under threat as the
therapist begins to show the patient that it may be an unhealthy identification
or attachment, therefore deriving anxiety that this fusion may be severed.

Some
adolescents that have experienced progress with their mental health, may find
or feel themselves to be expected to behave differently. The pressure of this,
and of maintaining it, may prove too strong for some.  For example, if an adolescent has low self-esteem,
or a higher functioning super-ego, critical and self-attacking, they may feel
as though they couldn’t possibly be ‘better’. Kegerreis (1995), explains that
‘doing well can create such anxiety over ‘keeping it up’ that it feels better
to ‘blow it’ straightaway’ (p.102).

Adolescents
experiencing trauma, may attend or reside in special schools or institutions
that cater for their needs. Some may be overwhelmed at the thought of starting
over again at a mainstream school, and the anxiety of this could cause them to
deteriorate. When progress has been made, and they are faced with their goal of
attending a mainstream school being realised, their fears around what this
means for them – saying goodbye to friends, staff and having to re-establish
their identity, can become too annihilating. When speaking of children leaving
a special school to attend a mainstream school, Kegerreis (1995), states that
it ‘carries with it all the problems familiar to primary school children on
secondary transfer magnified many times’ (p.102). She goes on to explain that
‘They also have to deal with complex feelings about leaving a place which
simultaneously symbolises both their problems and the kind of nurturing they
need’ (p.102).

Adolescents
with emotional or behavioural problems, may have unconscious hatred towards
their parents. To progress from their difficulties may mean to them that they
forgive their parents for their perceived or even factual shortcomings. Remaining
with their issues can be a way to punish their parents for their ‘failures’. It
is as though they are playing the role of a spoilt child, whom despite being
given their desires (treatment), still want to ‘sulk’ with their parents by
behaving in an ungrateful and unsatisfied manner. We could see there to be a
link with projection here. The child may feel frustrated, disappointed, or in
anguish, and to disassociate themselves with these feelings, they could be
attempting to split and project these feelings into another (parents).

The
examples given above are just some possibilities of why an adolescent may have
a negative therapeutic reaction. Tindle (2006) explains that ‘the term
‘negative therapeutic reaction’ has been used by psychoanalysts and
psychotherapists to define the phenomenon of improvement followed by
deterioration of a client’s psychological or symptomatic condition, apparently
in response to their therapist’s intervention’ (p.99).

 

 

Double
Deprivation

Double deprivation is explained in a paper written by Henry
(1974), in which she gives a detailed example in the form of a case study
concerning a traumatised child whom she was treating. The child was placed into
residential care from 2 months old, and had no contact with his biological
parents since then. At 12 years old at the time of his referral, he would be
consumed in his appearance, and showed no emotions to those around him, even
when after a 10-year relationship, one of his foster placements broke down.

The child had strong identifications with an idealised
internal object, and although this object was damaging for him, he was fiercely
reluctant to cut ties with it. This object seemed to be a phantasy mother, with
no physical or emotional time for a child, one whom only cared for herself, and
prioritized her appearance over her child. This could be his views on the
reasoning behind his original placement in residential care.

The child had established unconscious defences including a
very powerful mechanism of splitting and projection. The way in which he
separated himself from feelings of neediness, and induced in other’s feelings
of inadequacy and insignificance, shows how overwhelming he finds these
feelings. By ‘passing’ these feelings to another and by being unable to
acknowledge them in himself, shows how he is looking for a ‘container’. To withstand
these feelings, he is non-verbally asking for someone to experience them, and
demonstrate how they can be survived. Once this process has been recognised and
trusted, he would be able to accept the feelings as his own, knowing that he too,
could endure them.

Henry (1974) describes the double deprivation in her
patient’s case as ‘one inflicted upon him by external circumstances of which he
had no control what-so ever, secondly the deprivation derived from internal
sources: from his crippling defences and from the quality of his internal
objects which provided him with so little support as to make him an orphan
inwardly as well as outwardly’ (pp.15-16).

Double deprivation could be explained as one being primarily
deprived by external situations, then due to the resulting trauma of this and
the defences that come into place, are deprived for a second-time round, but on
this occasion, they are unconsciously depriving themselves.

In the case of Henry’s patient, I see how the defences that were in place to protect
himself from further hurt, anguish or trauma, could have felt to be under
threat of diminishment at an interpretation showing him how his identification
with his phantasy mother, is causing him to be deprived again. The intervention
may have triggered anxiety that the issues the defences kept at bay, will
resurface.

 

Triangle of
conflict

Malan
(1979) describes ‘The triangle of conflict’ (pp13-14), as a way to ‘Spell out
to the patient the three aspects of the mechanism going on inside her – defence, anxiety, and hidden feeling – the triangle of conflict.’ (Malan, p14).

An
individual may have developed defences to eliminate the anxieties surrounding
their ‘hidden feeling’.

To
use the example of Henry’s patient above, his ‘hidden feeling’ could be his
wish for fusion with his mother/bad object, and his anxiety of this fusion
being severed or harmful for him, and perhaps his guilt in this desire, has led
to defences of splitting, projection and attacks on linking.

 

 

Considerations

It
is a concern that a therapist may mistake a ‘set back’ in progress from a
patient to be a Negative Therapeutic Reaction. A premature interpretation can also
cause regression in therapy. One would need to regularly reflect upon the
countertransference, and in personal analysis, look to the motives around
offering a premature interpretation.

Rosenfeld
(1975) states:   

‘A
great deal of confusion could be created if our understanding of the pathology
of the negative therapeutic reaction were to become confused with
transference/countertransference reactions, which have obviously more to do
with the pathology of the therapist than with the patient’ (p. 104).

 

Conclusion

I
have described Trauma with the hope to have left a visualization of a
laceration on the mind, a mental injury that is felt to be too much to bear.
The feeling that this injury is too engulfing, is a unique response, dependent
upon one’s exclusive internalisation of their earlier experiences.

By
giving examples of how single events may not fit McNally’s criteria for PTSD,
then showing how once these are combined with previous trauma, recollected or
not, can result in traumatism, I hope to have illustrated the deficiency of
McNally’s report.

Negative
Therapeutic Reaction is described by Rycroft (1968) as an ‘exacerbation of the
patient’s symptoms in response to precisely those interpretations which are
expected to alleviate them’ (p.108). By explaining some of the reasons why one
may experience a NTR, I anticipate to have increased awareness of possible
obstacles when working with trauma.

Double
Deprivation is an important concept to be aware of. It involves the deprivation
from both internal and external sources. The development of incapacitating
defences is the result of the external deprivation. Double deprivation needs to
be recognised and worked with to attain and maintain successful results in
psychotherapy.     

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