Thursday, April 15, 2010

Emotional Trauma in Review - Part 3

The Dialectical Opposites of Emotional Trauma
Herman (1992) says that in the fallout of emotionally traumatizing experiences, “the two contradictory responses of intrusion and constriction establish an oscillating rhythm. This dialectic of opposing psychological states is perhaps the most characteristic feature of [emotional trauma]. Since neither the intrusive nor the numbing [manifestations] allow for the integration of traumatic [emotions], the alternation between the these two extreme states might be understood as an attempt to find a satisfactory balance between the two. But balance is what the [emotionally] traumatized person lacks. She finds herself caught between the extremes of amnesia or of reliving the [experiences], between floods of intense, overwhelming feeling and the arid states of no feeling at all, between irritable, impulsive action and complete inhibition of action. The instability produced by these periodic alternations further exacerbate the traumatized person’s sense of unpredictability and helplessness. The dialectic of trauma is therefore potentially self-perpetuating.”
“In the course of time,” Herman explains, “this dialectic undergoes a gradual evolution. Initially, the intrusive reliving of the traumatic [experiences] predominate, and the victim remains in a highly agitated state … as the intrusive symptoms diminish, numbing or constrictive symptoms come to predominate. The traumatized person may no longer seem frightened and may resume the outward forms of her previous life. But the severing of the [experiences] from their ordinary meanings and the distortion in the sense of reality persist. She may complain that she is just going through the motions of living, as if she were observing the events of daily life from a great distance. Only the repeated reliving of the moments of horror break through the sense of numbing and disconnection.”
Herman concludes, “The constraints upon the traumatized person’s inner life and outer range of activity are negative symptoms. They lack drama; their significance lies in what is missing. For this reason, constrictive symptoms are not readily recognized, and their origins in [traumatic experiences] are often lost. With the passage of time, as these negative symptoms become the most prominent feature of [emotional trauma], the diagnosis becomes increasingly easy to overlook. Because [emotional trauma] symptoms are so persistent and so wide-ranging, they may be mistaken for enduring characteristics of the victims personality. This is a costly error, for the person with unrecognized [emotional trauma] is condemned to a diminished life, tormented by memory and bounded by helplessness and fear.”
”Thus, the very “threat of annihilation” that defined the traumatic moments may pursue the survivor long after the danger has passed. No wonder Freud found, in the traumatic neurosis, signs of a “daemonic force at work.” The terror, rage, and hatred of the traumatic moments live on in the dialectic of trauma.”
In treatment, the dialectical opposites of emotional trauma can be solved in the process of making sense together with our patients and reaching a deeper, clearer emotional understanding of the problems at hand (Orange, 1995; Frie & Orange, 2009).

E - Shame - A Blow Falling Upon a Bruise
From the perspective of intersubjective systems theory (as articulated by Stolorow & Atwood, 1979; Atwood & Stolorow, 1984; Stolorow, Brandchaft, & Atwood, 1987; Stolorow & Atwood, 1992; Orange, 1995; Orange, Atwood, & Stolorow, 1997; Stolorow, Atwood, & Orange 2002; Stolorow, 2007; Frie & Orange, 2009), “developmental emotional trauma consists in the shattering of our world of experience, a world that exists always in the relational context of interaction with other such worlds; emotional trauma results from the experience of intesubjectively derived unbearable affect…”
“…Painful or frightening affect becomes traumatic when the attunement that the person needs to assist in its tolerance, containment, and modulation is profoundly absent.” One of the consequences of developmental emotional trauma is that “traumatic affect states can take on enduring crushing meanings.” Another consequence is “a severe constriction and narrowing of the horizons of emotional experiencing, so as to exclude whatever feels unacceptable, intolerable, or too dangerous in particular intersubjective fields.”
Herman’s (1992) account of emotional trauma provides evidence to support the notion that what the above authors theorize about emotional trauma in early life also applies to the experience of trauma at any age.
One of the “traumatic affect states can take on enduring crushing meanings” is shame. And it is to its complexity, to ‘the many faces of shame’ (Nathanson, 1987) that I now turn.
The experience of shame
The experience of shame is described poetically by Silvan Tomkins(1963): “Shame is felt as an inner torment. No other affect is more disturbing. If distress is the affect of suffering, shame is the affect of indignity, of defeat, of transgression, and of alienation. Though terror speaks to life and death, and distress makes of the world a vale of tears, yet shame strikes deepest into the heart of man. While terror and distress hurt, they are wounds inflicted from outside which penetrate the smooth surface of the ego; but shame is felt as an inner torment, a sickness of the soul. It does not matter whether the humiliated one has been shamed by derisive laughter or whether he mocks himself. In either event he feels himself naked, defeated, alienated, and lacking in dignity or worth.”
With eloquence, Gershen Kaufman (1996) echoes Tomkins. I have consolidated Kaufman’s descriptions as follows: Shame is the affect of inferiority and of exposure. To experience shame is to feel inherently bad, fundamentally flawed as a person. To feel shame is to feel seen in a painfully diminished sense. Whether all eyes are upon us or only our own, we feel fundamentally deficient as individuals, diseased, defective. To live with shame is to experience the very essence of oneself as wanting. It is the most poignant self-experience, whether felt in the humiliation of cowardice, or in the sense of failure to cope successfully with a challenge.
Shame is inevitably alienating, isolating, and deeply disturbing. Shame is alienating because it compels us to hide, separating us from others. Indeed, shame is derived from an Indo-European root, SKAM or SKEM, which means to hide, and from which also derive our words SKIN and HIDE, the latter in both its meanings: the hide that covers us naturally, and that within which we seek cover. We learn to hide first for the sake of shame, and later for protection from physical danger.
The exposure inherent in shame creates the sense of nakedness before an audience: it feels as if others can see inside us or actually read our thoughts. In the experience of shame we feel exposed, which opens us further to painful inner scrutiny. When the attention turns inward, we are suddenly watching ourselves, scrutinizing critically the minutest detail of our being. The excruciating observation of oneself that results, this torment of self-consciousness, becomes so acute as to create a binding, almost paralyzing effect. Sudden, unexpected exposure, coupled with binding inner scrutiny, characterize the essential nature of the affect of shame.
Shame is loss of face, whether at the hands of a bully or a parent. Shame is hanging the head, whether in response to, "You should be ashamed of yourself' or "I'm so disappointed in you." Shame is exquisitely painful, it feels like a wound made from the inside by an invisible hand. Shame is dishonor, fallen pride, a broken spirit.
Shame is felt as an interruption, and it functions to further impede verbal communication. However, the physical experience of shame itself is communicated non-verbally. The individual whose head hangs, or whose eyes lower, or whose gaze is averted, however briefly, is directly communicating shame. The beaten, humiliated individual, whether defeated as a child by a brutalizing parent or defeated as an adult by a dead end career or marriage, has been defeated by shame.
Repeated experiences of shame can engulf the whole of our being, immersing us deeper into despair. To live with shame is to feel alienated and defeated, never quite good enough to belong. And secretly we feel we are to blame; the deficiency lies within. Shame is without parallel a sickness of the soul. The source of low self-esteem, poor self-concept, or diminished self-image is shame. That is the affective source of later feelings of inadequacy or inferiority.
In the early years of life, shame is predominantly a wordless experience irrespective of its duration. Later, shame experiences become transformed by language, becoming a partially cognitive, self-evaluative experience. (Kaufman, 1996).
The unfolding of shame
Jones (1995) articulates the evolution of shame as follows. The presymbolic roots of shame lay with experiences of inefficacy during the first 18 months of life as we try to acquire competence and mastery over our body and our environment. Shame is further refined when our competence is tested in the crucible of competition between 6 and 12 years of age. During this period we learn the rules of engagement in a very tough and competitive world. We also learn to socialize our affects and develop increasingly complex emotional convictions. A third layer of shame complexity starts to emerge during adolescence and continues for the rest of our lives as we develop and refine ideals which guide our being-in-world.
Shame and the sense of self
Kaufman (1996) interprets Erickson’s (1950) eight stages or identity crises as “linguistic transformations of shame. The negative pole of each crisis is actually an elaboration of shame, given a new or wider meaning. Each subsequent crisis involves, at least in part, a reworking of shame.”
Kaufman goes on to say: “Consider the poles of each identity crisis more closely: basic trust versus basic mistrust, autonomy versus shame and doubt, initiative versus guilt, industry versus inferiority, identity versus role confusion, intimacy versus isolation, generativity versus stagnation, ego integrity versus despair. The affect most critical to the development of mistrust, guilt, inferiority, isolation, and so on, is shame... Certainly, other affects may become fused with shame in the formation of these recurring crises, but the one affect central to the sense of identity is shame.”
Shame as psychobiological dysregulation
Introduced in 1987 by McGuire and Troisi, regulation-dysregulation theory studies the effect intersubjective attunement and misattunement on physiological states. It is an approach derived from an evolutionary analysis of social behavior that emphasizes the psychobiological nature of intersubjectivity and of intersubjective sequences.
Similar to the medical notion of homeostasis, the term regulation refers to a state of steady attuned responsiveness in which physiological and psychological systems function optimally. In a regulated state one feels well, has the energy and confidence to do what one wants to do, thinks clearly, feels in control of one’s own thoughts and emotions, and is free of symptoms.
The term dysregulation refers to disorganized physiological and psychological states caused by erratic, misattuned responsiveness, and associated with symptoms, and reduced capacities to concentrate and act efficiently. The degree of dysregulation varies along a continuum. In moderate to severe instances, we are unable to control our emotions and thoughts. Examples include the demobilized, fretful state of the infant whose mother does not respond to his or her facial signals; the fearful anticipation of a parent waiting for a child to return home when he or she is late; the pining and distress of grief; a quarrel between lovers; and of course, the anxious, withdrawn, ruminative states of the shamed.
In posts number 2 and 3 of this series, I examined the affective-symbolic disintegration and the psychobiological dysregulation inherent in emotional trauma, a dysregulation which, according to Gilbert and McGuire (1998), we can now understand as shame.
E - A personal account of emotional trauma
In the last few years I have experienced two intertwined and devastating professional losses. My emotional surround throughout was inhospitable, and that, at least initially, rendered my predicament unbearable.
In the words of Gershen Kaufman (1996), the loss of my Medical License felt “like a wound made from the inside by an invisible hand.” Evelyn Waugh’s (1945) words from his novel ‘Brideshead Revisited’ are fitting to describe the second loss, for it felt like “a blow falling upon a bruise,” and was for me of far greater import than the first one, since it exiled me from this community to a life of relative isolation.
These two emotionally crushing experiences had two shame themes in common. The first theme had to do with a disconcerting sense of emotional and bodily disorganization, of dysregulation as described above, which brought on a feeling of incompetence, of disability, of not being to stand on my own two feet. The second theme was that of a loss within each of these losses: I felt dispossessed of the esteem of others; that is, deemed, seen as diminished, dishonored, and no longer good enough to belong; and my self-esteem began to organize around this harrowing sense of diminishment. These experiences radically altered for a while my way of being-in-the-world. Eventually, my therapist and his consulting room afforded me refuge and opportunity for understanding and healing.
The work of Douglas L. Cairns (1993, 2009) was also illuminating in my effort to arrive at a clearer understanding of the dynamics involved in the experiences I just described. As a Classicist, Professor Cairns works on ancient society and ethics, especially the emotions, and especially as they are reflected in early poetry and classical tragedy. He has delineated the linguistic, psychological, social, and ethical contexts in which the term aidos appears in Greek literature of the classical period. Aidos is a very complex Greek word, truly a concept, which encompasses the notions of shame, honor and morality, identity, respect, modesty, and integrity, and their dialectical opposites in community life.
Cairns’ conclusions about how these complex emotions operate in the emotional life of individuals and communities are remarkably similar to some of the conclusions that appear in contemporary psychoanalytic thinking (relational theories, intersubjective systems theory, for example). The individual does not exist in isolation but ‘intricately bound’ with other individuals (today we speak of interacting subjective worlds of experience, and of mutual recognition, for example); individual identity is bound up with group membership; self-esteem depends, in part, on the esteem of others; ideas of selfhood are mediated through the concept of aidos, comprising all the meanings indicated above, and at every step of development, the sense of self upon which aidos rests is promoted and maintained by a focus on the standing of self and others as the bearers of honor; the crucial point is that aidos includes the notion that the honor of the individual and that of the group are reciprocally bound.
It was very helpful to be reminded that one’s honor, as so much else in human life, is inextricable from that of others; that transgression affects both the transgressor as well as the community; and that certain measures taken in these situations are meant to restore at least some equilibrium to both. As I regained this perspective, I felt more grounded. I was able then to reach out to this community, and to my surprise some of you began to guide my return here. Why was I surprised, I wondered. Well, in my befuddlement, I had overlooked yet another important consideration.
In the early 1990s, I attended a 3-day summer seminar on shame Don Nathanson (1996) gave in Cape Cod. In his last lecture he examined some aspects of narcissistic injuries and shame, and the not-uncommon self-protective stance of pride, indicating that in this predicament “the reciprocity of shame was to pride,” one of the possible outcomes in what he called ‘the compass of shame.’ He concluded the seminar movingly and memorably with this suggestion: “… the reciprocity of shame is to be not to pride but to love; for only true love, a love rooted in the will to affirm the value of the other, can absorb shame!” And so it is to be, I believe, with emotional trauma as well.
What I have encountered both in being helped to return, as well as in being in this community is true love.
I am grateful to you all…

Ernesto Vasquez, MD
April 14, 2010

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