The PANY Bulletin

Psychoanalytic Association of New York
Volume 43, #2 Summer 2005

Living with Terror, Working with Trauma
A Clinician’s Handbook

by Danielle Knafo
2004 New York: Aronson
Reviewer: Arlene Kramer Richards, Ed. D.

No one knows when the next trauma will come to destroy the orderly processes of life. A terrorist attack, a catastrophe of nature, a sudden illness can leave one helpless, fearful, traumatized. Some people, especially those who choose or are chosen to be police officers, soldiers, National Guards, firefighters or emergency service providers have to face the possibility of disaster as part of their daily work . They walk into potentially traumatizing situations as routinely as analysts walk into our safe comfortable offices. Or maybe our offices are not so safe and comfortable. Maybe we face traumatizing situations every time we invite patients to tell us their thoughts and feelings. This way of thinking about our work leaves us with a special understanding of how and why trauma is so fascinating to analytic thinkers. The professional is personal. Our work is our life. Danielle Knafo carefully weaves together the disparate essays from different theoretical and experiential perspectives by means of art, both visual art and that of poetry. Art becomes the way to overcome trauma by encoding the catastrophic experience, thus turning the passive into the active.

This handbook is meant to provide a way of dealing with trauma that will allow the clinician to heal the other rather than become infected by the patient's symptoms. It begins with a definition of trauma by Harold Blum that restricts trauma to the experience that disorganizes a person and cannot be explained by concepts of compromise formation and conflict. It is not limited to object loss, but can occur with it. Judith Lewis Herman emphasizes the role of continuous trauma in causing feelings of despair, helplessness and loss of interest in human relationships. She uses domestic abuse and incarceration as prototypes of the kind of trauma. As she sees it, the clinician needs to be careful not to miss this etiology when working with seemingly apathetic or characterologically passive patients. Marvin Hurvich points to fears of being annihilated as symptoms resulting from trauma. Henry Krystal recalls Nelly Sachs admonition that survivors of trauma should be aided by gradual introduction of freedom, gradual establishment of new ties to groups and to other individuals and the gradual return from the shame of helplessness and the anger of thwarted love to the loving connections that make human life rewarding. Mordechai Benyaker and Danielle Knafo suggest that "Mental health professionals should be present at the moments and in the locations in which disasters take place." By being there, the mental health professional can assess the need for treatment before the trauma becomes chronic.

In another context, Robert J. Lifton suggests that what enabled some peole to survive the catastrophe of Hiroshima was the presence of foreign aid workers who healed by compassion. David J. Kinzie concludes from his treatment of Cambodians, Somalis and Central Americans that both individual and group therapy have places in the treatment of those isolated and estranged by brutality. In another contribution Benyakar points to the frame of the treatment setting as a source of stability and safety for the person recovering from trauma. Herbert Hendin and Ann Poliger Haas use their experience with Vietnam veterans to conclude that a sense of purpose is key to avoidance of crippling guilt after military service. Ofra Ayalon works with children who have been traumatized by war and terrorism and has devised a story telling device that enables children to express their fears in metaphors that heal but she concludes that teaching children to coexist with others, to be part of a peace process rather than a war is the best therapy for them. The implication is that this is the best, or perhaps the only way to end the cycles of revenge and retaliation that otherwise result from the trauma of war. Taking the Palestinian perspective, Elia Awwad brings to the discussion a particularly resonant explication of the shame that leads to personification of conflict. Thus anything that deprives the person of a sense of power or competence is experienced as the intent of the aggressor. Awwad agrees with Benyakar that dealing with trauma is best done by having mental health workers present on the front lines: at the site of each catastrophe. Group sessions for parents, expectant mothers, teachers and others who will have to be caregivers in emergencies is important. Also crucial is support for Emergency Medical Services personnel who are constantly exposed to catastrophe.

The question of whether to intervene early after catastrophes is still an open one. Despite evidence that one session debriefing can be harmful to survivors; the advantage of early intervention in preventing formation of chronic symptoms is persuasive. Rony Berger advocates a model of short term intervention in which the patient recounts the events just prior to the catastrophe, then the terrorizing events and then the resolution. Support is provided in noting bodily changes during the telling of the story. This is done after the patient is asked to recall previous experiences of coping with stress. Success at these experiences is regarded as supportive of hope that the current experiences will also be coped with successfully. The author is candid in stating that she does not know the likelihood that this procedure improves the survivor's prognosis. Bessel van der Kolk advocates adding to this form of treatment imagining new possibilities. Henry Krystal describes treatment by promoting recognition, verbalization and toleranceof bad feelings. Nina K. Thomas discusses revenge as an undesirable outcome of trauma and suggests that expressing the rage generated by trauma by means other than revenge is necessary to promoting the mourning that allows healing psychic wounds. One way of doing this is to allow the victims to express their horror in the presence of witnesses. Trials in which victims can confront the perpetrators are important for this reason. Another kind of witnessing is the presence of an emotionally attuned listener. This is the therapeutic modality for treatment of trauma advocated by Ilene Serlin and John T. Cannon. But such attuned listening, John P. Wilson admonishes, inevitably leads to counter-transference stress in the therapist. He rejects Serlin and Cannon's method of making each therapeutic encounter unique. Instead he creates a scheme that lists fifteen markers to be aimed at in each encounter. Attunement is the outcome of hitting the markers. Helping the helpers is also the focus of an essay by B. Hudnall Stamm, Craig Higson-Smith, and Amy C. Hudnall. They underline the importance of seeing the position of the helper in the culture in which treatment is taking place in order to restore faith that the person is effective and the world benevolent.

And so we come to the specific effect of 9/ 11 on American culture. Martin Bergmann addresses the chasm in the American sense of confidence caused by the terrorist attack. He revives the generally unpopular idea of the death instinct to understand the behavior of terrorists. He says "The battle is on, and we are enlisted on the side of life and survival." His strong rallying cry contrasts with the sadness and humiliation characterizing the essays by Charles Strozier and Katie Gentile, the cautious optimism of Bennett Roth, the reminder of re-traumatization by Maria V. Bergmann and the focus on the reparative value of art, custom and memorials advocated by Issac Tylim.
How can trauma be prevented? Is it possible to avoid at least the trauma committed by people on people? Vamik Volkan describes his working program for having mental health professionals engage in social action by leading groups to allow warring factions to speak to each other and convey their points of view as well as their feelings. Some small group meetings occur between members of one ethnic group; other meetings groups in conflict with each other. The aim is to promote healing within and between the groups. A variant of this technique was developed from post Holocaust healing groups. Dan Bar-On and Fatima Kassem use the storytelling technique with groups from Northern Ireland, South Africa and now Israelis and Palestinians. The authors conclude that many issues are particular to the specific conflict and that the method needs to be adapted anew to each set of local conditions. A darker side of trauma work is underscored by Michael Eigen in his essay on the shame induced by trauma and by Robert Karen in his account of the enormous pressure to hate those who murder one's children and the difficulty of reaching forgivness when this has happened. By describing the healing that several women artists have been able to build for themselves and for the viewers and hearers of their art, Danielle Knafo brings the book to a close that embodies what she advocates: the gentle touch that makes the wound heal. We are indebted to her and her contributors for this thoughtful book.