Introduction Thepurpose of this essay will be an attempt to define, and to critically discussthe nature of trauma. As well as my own interpretation of trauma, I will be referringto: Garland (2002), Nicholson (2010), and McNally (2003). When considering thedefinition of trauma, I will further look to Freud’s five primary anxieties, asI 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 willargue that McNally’s criteria for diagnosing Post Traumatic Stress Disorder isinsufficient, impersonal and unduly generic.Iaim to provide insights as to why it can be difficult to work therapeutically withadolescents through trauma, and will give examples of potential hurdles, andthings that need to be considered. Although there are many concepts that willneed to be reflected upon regularly throughout treatment, my focus will be onNegative Therapeutic Reaction and Double Deprivation. When explaining theseconcepts, I will refer to Tindle (2006), Henry (1974), Kegerreis (1995), andSandler, Dare and Holder (1992). Subsequently, I will show a link betweenNegative Therapeutic Reaction and Malan’s (1979) Triangle of Conflict.
Nature of traumaTraumacan be thought of as an individual experiencing an unendurable response to atraumatic 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 refersto a piercing of the skin, a breaking of the bodily envelope’ (p.9). To elaborate, it is the mind that isseen to be wounded, and the exclusive reaction and feelings of an individualthat may, or may not, denote trauma. Atraumatic event, cannot be assumed traumatic for all.
As infants, ideally, weare protected and rescued by our primary care-giver. When we are hungry, inpain or lonely, our care-giver will respond to our needs by feeding, soothingor engaging with us. The stability and continuity of this containment isessential for healthy development later in life. Nicholson(2010) explains that ‘Trauma could be defined as a serious violation of theexpected rhythm and continuity of the individual’s life’ (p.43).
Asadults, we still rely on the continuity and expectedness of life. For example,we wake every morning expecting our home to be thereabouts in the samecondition as we left it the night before, we have already made presumptions asto what we expect to see when we look out of the window, we expect to be ableto carry out our usual routine, be that the way we travel to work, or droppingour children to school. If these expectations were disturbed by externalforces, one’s response to this would depend heavily upon their own experienceof continuity and containment. The person that was neglected as an infant andwas not fed sufficiently, may find themselves experiencing trauma if there wereto be a temporary situation in the outside world, meaning they were unable toget food. The person that was provided for sufficiently as an infant, may experiencethe same situation with an entirely different response.
He will have learnedthe ability to self-contain, and would be able to draw upon this to filterthrough his feelings. Freud’s Primary AnxietiesLookingat Freuds revaluation on the origins of anxiety in the late 1920’s, we see a commondenominator between each of his stated primary anxieties. Birth, castrationanxiety, Loss of the loved Object, Loss of the Objects love, and annihilationanxiety, can all be detrimental to one’s sense of security and survival in life. Garland (2002), speaks of these anxieties ashaving ‘a single crucial feature in common: they consist of the separationfrom, or the loss of, anything that isfelt to be essential to life, including life itself’ (p.19).
In1926, Freud explained different types of anxiety, Automatic anxiety and Signalanxiety. Automatic anxiety is an automatic reaction to a real, external threat,whereby the ego is overwhelmed and diminishing. Signal anxiety, however, is awarning of a potentially traumatic situation, a ‘heads-up’ to the ego thatunless something changes fast, it (the ego) is under threat of diminishment.Garland (2002), warns that ‘the ego, oncetraumatised, can no longer afford to believe in signal anxiety in any situationresembling the life-threatening trauma: it behaves as it were flooded withautomatic anxiety’ (pp 16-17). Thefollowing is an example of signal anxiety being responded to as though it wereautomatic anxiety.A child spent many weekends at her grandparent’s home,and often baked cakes with her Grandmother. The child was sexually abused for athree 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 numerouspanic-attacks and night-terrors. Thelink between the cake making (icing), and the sexual abuse proceeding it, isclear. Although contact with icing may not be classed as a traumatic event onits own, this example shows how the signal – ‘It’s icing, this could mean that real danger isimminent’, has become confused and distrusted by the ego, and ‘flooded’ with anautomatic anxiety response, ‘This taste, smell or sight, means that I amalready in trouble, I am overwhelmed’. McNally’scriteria for diagnosing PTSDIna 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 threateneddeath or serious injury, or a threat to the physical integrity of the self andothers’ that produces ‘intense fear, helplessness, or horror.’ (APA 1994: 427,428).
Unless a person has been exposed to a stress meeting these criteria, adiagnosis of posttraumatic stress disorder (PTSD) cannot be made, regardless ofhow distressed the person happens to be’ (p.79).” (slide 14 of 68).Ifeel that McNally’s criteria does not take into consideration one’s personalexperience of continuity or containment.
When looking at the scenario I gaveabove of the two individuals whom were unable to get food, although thistemporary situation could cause distress, it may not be classed as traumatic.However, when we look further into the history of the individual’s earlierexperiences, we see that although this single temporary circumstance may nothave caused a traumatic response on its own, but when it is combined with otherprevious distressing, or even unconscious memories of traumatic events, atraumatic response is entirely conceivable. The same theory applies to theexample given of the sexually abused child. Although encountering icing is notin itself traumatic for most, when we look at this as a trigger from a previoustrauma, we can understand how this individual could find themselves feelingoverwhelmed and traumatised. Takinginto consideration the age range of children that tend to be sexually abusedthe most, are those under 12 months, I feel it is fair to say that they wouldnot 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 tooyoung to consciously recollect it, so that ‘actual or threatened death orserious injury, or a threat to the physical integrity of the self and others’,cannot be confirmed, does not mean that unconscious triggers, or transferencefor instance, will not result in traumatism. Difficulties in working with Trauma NegativeTherapeutic ReactionWhenworking with adolescents through trauma, we need to be aware of the potentialimplications of their recovery. Unfortunately, self-destructive behaviour ispossible when an individual can feel, or is made aware of, progress concerningtheir mental health. There are many reasons for this, including fear of lettinggo of their ‘safe’ and well-known identifications, the desire for fusion withan internalized object, the new expectations of them, from those around themand themselves, and saying goodbye to their current institutions andprofessional help. It could also be an act of defiance, a way to eliminate anyself-satisfaction in those (parents or professional workers) whom could reapthe rewards of fulfilling their ‘duties’, by repairing the ‘broken’.Onemay 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 experiencingof guilt at the idea of abandoning the tie to the figure of early childhoodplays a significant role in bringing about a Negative Therapeutic Reaction'(p.128).There could be ambivalent feelings to be part of/fused withthe internalized mother/object.
This fusion can become under threat as thetherapist begins to show the patient that it may be an unhealthy identificationor attachment, therefore deriving anxiety that this fusion may be severed.Someadolescents that have experienced progress with their mental health, may findor 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 feelas though they couldn’t possibly be ‘better’. Kegerreis (1995), explains that’doing well can create such anxiety over ‘keeping it up’ that it feels betterto ‘blow it’ straightaway’ (p.102).Adolescentsexperiencing trauma, may attend or reside in special schools or institutionsthat cater for their needs.
Some may be overwhelmed at the thought of startingover again at a mainstream school, and the anxiety of this could cause them todeteriorate. When progress has been made, and they are faced with their goal ofattending a mainstream school being realised, their fears around what thismeans for them – saying goodbye to friends, staff and having to re-establishtheir identity, can become too annihilating. When speaking of children leavinga special school to attend a mainstream school, Kegerreis (1995), states thatit ‘carries with it all the problems familiar to primary school children onsecondary transfer magnified many times’ (p.102). She goes on to explain that’They also have to deal with complex feelings about leaving a place whichsimultaneously symbolises both their problems and the kind of nurturing theyneed’ (p.
102). Adolescentswith emotional or behavioural problems, may have unconscious hatred towardstheir parents. To progress from their difficulties may mean to them that theyforgive their parents for their perceived or even factual shortcomings. Remainingwith their issues can be a way to punish their parents for their ‘failures’. Itis as though they are playing the role of a spoilt child, whom despite beinggiven their desires (treatment), still want to ‘sulk’ with their parents bybehaving in an ungrateful and unsatisfied manner.
We could see there to be alink with projection here. The child may feel frustrated, disappointed, or inanguish, and to disassociate themselves with these feelings, they could beattempting to split and project these feelings into another (parents).Theexamples given above are just some possibilities of why an adolescent may havea negative therapeutic reaction. Tindle (2006) explains that ‘the term’negative therapeutic reaction’ has been used by psychoanalysts andpsychotherapists to define the phenomenon of improvement followed bydeterioration of a client’s psychological or symptomatic condition, apparentlyin response to their therapist’s intervention’ (p.99). DoubleDeprivationDouble deprivation is explained in a paper written by Henry(1974), in which she gives a detailed example in the form of a case studyconcerning a traumatised child whom she was treating. The child was placed intoresidential care from 2 months old, and had no contact with his biologicalparents since then.
At 12 years old at the time of his referral, he would beconsumed in his appearance, and showed no emotions to those around him, evenwhen after a 10-year relationship, one of his foster placements broke down.The child had strong identifications with an idealisedinternal object, and although this object was damaging for him, he was fiercelyreluctant to cut ties with it. This object seemed to be a phantasy mother, withno physical or emotional time for a child, one whom only cared for herself, andprioritized her appearance over her child. This could be his views on thereasoning behind his original placement in residential care.The child had established unconscious defences including avery powerful mechanism of splitting and projection. The way in which heseparated himself from feelings of neediness, and induced in other’s feelingsof inadequacy and insignificance, shows how overwhelming he finds thesefeelings. By ‘passing’ these feelings to another and by being unable toacknowledge them in himself, shows how he is looking for a ‘container’.
To withstandthese feelings, he is non-verbally asking for someone to experience them, anddemonstrate how they can be survived. Once this process has been recognised andtrusted, 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 herpatient’s case as ‘one inflicted upon him by external circumstances of which hehad no control what-so ever, secondly the deprivation derived from internalsources: from his crippling defences and from the quality of his internalobjects which provided him with so little support as to make him an orphaninwardly as well as outwardly’ (pp.15-16).Double deprivation could be explained as one being primarilydeprived by external situations, then due to the resulting trauma of this andthe defences that come into place, are deprived for a second-time round, but onthis occasion, they are unconsciously depriving themselves.In the case of Henry’s patient, I see how the defences that were in place to protecthimself from further hurt, anguish or trauma, could have felt to be underthreat of diminishment at an interpretation showing him how his identificationwith his phantasy mother, is causing him to be deprived again.
The interventionmay have triggered anxiety that the issues the defences kept at bay, willresurface. Triangle ofconflict Malan(1979) describes ‘The triangle of conflict’ (pp13-14), as a way to ‘Spell outto the patient the three aspects of the mechanism going on inside her – defence, anxiety, and hidden feeling – the triangle of conflict.’ (Malan, p14).Anindividual may have developed defences to eliminate the anxieties surroundingtheir ‘hidden feeling’.Touse the example of Henry’s patient above, his ‘hidden feeling’ could be hiswish for fusion with his mother/bad object, and his anxiety of this fusionbeing severed or harmful for him, and perhaps his guilt in this desire, has ledto defences of splitting, projection and attacks on linking. ConsiderationsItis a concern that a therapist may mistake a ‘set back’ in progress from apatient to be a Negative Therapeutic Reaction.
A premature interpretation can alsocause regression in therapy. One would need to regularly reflect upon thecountertransference, and in personal analysis, look to the motives aroundoffering a premature interpretation.Rosenfeld(1975) states: ‘Agreat deal of confusion could be created if our understanding of the pathologyof the negative therapeutic reaction were to become confused withtransference/countertransference reactions, which have obviously more to dowith the pathology of the therapist than with the patient’ (p.
104). Conclusion Ihave described Trauma with the hope to have left a visualization of alaceration 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, dependentupon one’s exclusive internalisation of their earlier experiences.Bygiving examples of how single events may not fit McNally’s criteria for PTSD,then showing how once these are combined with previous trauma, recollected ornot, can result in traumatism, I hope to have illustrated the deficiency ofMcNally’s report. NegativeTherapeutic Reaction is described by Rycroft (1968) as an ‘exacerbation of thepatient’s symptoms in response to precisely those interpretations which areexpected to alleviate them’ (p.108). By explaining some of the reasons why onemay experience a NTR, I anticipate to have increased awareness of possibleobstacles when working with trauma.
DoubleDeprivation is an important concept to be aware of. It involves the deprivationfrom both internal and external sources. The development of incapacitatingdefences is the result of the external deprivation. Double deprivation needs tobe recognised and worked with to attain and maintain successful results inpsychotherapy.