CRITICA

What does psychoanalysis have to contribute in times of actual trauma-times that fundamentally disrupt lives? 

This is the question voiced by many analysts at the outset of the pandemic. Usually it was some version of the question: is analytic work really possible in the face of so many concrete life and death concerns?

Today’s program will not only provide essential interventions for dealing with frontline workers, patients and families, it will remind us that we already rely on many of these interventions under another name. As we learn from Laura, I invite you to use your everyday trafficking in the unconscious as a template for navigating these disruptive times.

For the purpose of this morning’s conference, I’m going to briefly describe the phenomenon of trauma especially as relates to the body, describe what happens to the patient. what happens to the analyst and or caregiver and propose that psychoanalysis has plenty to contribute in times like these.

About trauma
Each person has a personal narrative that is part of a reciprocal process of making meaning out of experience. This narrative is an evolution of the earliest experiences of continuity of being- or, in Winnicott’s terms, of going on being.

Trauma sets in when a person is confronted with experiences so overwhelming that the capacity to make meaning from experience is replaced with massive arousal without the capacity for discharge. Quoting Steven Reisner: “Being overwhelmed by sheer actuality without one’s having a say either in what ’s happening or what has happened”.

Because trauma interrupts going on being, it is experienced as the psychic equivalent of maternal abandonment. Our earliest sense of somatic wellbeing is grounded on the maternally constructed stimulus barrier, later on the family and on society’s organizational foundation. In my own practice, I have noticed that patients who are the most terrified of contracting the virus are those with the greatest quotient of maternal misattunement.

One of the frequent comments I’ve heard from colleagues is that they feel like they are doing more supportive than depth work. Taking the experience of maternal abandonment into account, I hope that this is true since it stands to reason that our interventions will resemble those of Winnicott’s environmental mother–not symbolic but all about provision. 

When there is a sudden assault to the stimulus barrier-the personal narrative by which we recognize ourselves- the continuity of a representation of a good object -is jeopardized. In fact, in this time of COVID 19, quoting Mario Perini, we find ourselves orphans – “ we are both ‘motherless’ and ‘fatherless,’” because all social institutions turned out to be unable to offer maternal protection against a threatening world as well as a paternal guidance oriented by a shared reliable knowledge.” Much of the fate of the damage from trauma will rest on the preservation or restoration of a good internal object. This is what we try to do everyday.

Let’s turn to what happens to the patient.
In good enough circumstances, individuals are able to transform global anxiety into manageable pieces or nameless dread into defensive strategies. In somatic trauma, self cohesion is undone by feelings of falling, shattering and fragmenting. Perceptions that encompass our usual mode of everyday life: logical thought, secondary process, temporal spatial dimensionality are atomized and replaced by random disconnected sensations. Circumstances that defy time and space defy logical, symbolic thinking threatening – the usual landscape of psychoanalysis leading us to doubt our capacity as analysts.

Yesterday in a webinar, a person asked: “When speaking about feelings, we symbolize them but doesn’t ‘traumatic’ mean not being able to symbolize?” I would say to this, remember that speech, verbalization is compromised in a crisis. Even though a person may name fear, contagion, death doesn’t mean that those states are digested. They are more like what Ogden would call an autistic – contiguous phenomenon–naming something familiar in an attempt to hold on to some personal continuity.

So What happens to the Care Givers
I’m using the term care giver as analogous to analyst here to underscore an identity that is familiar to us as therapists–to suggest that we already have many commonalties with health care workers.

Dealing with a traumatized person or situation acts on the care giver in a real way. It requires bearing terrible events, hearing horrible stories, facing the loss of the patient. Personally, watching televised scenes of intubated patients, masked and exhausted health care workers has plunged me back into my earlier career as the head nurse of a pediatric intensive care unit. I value that experience and the sense of competence it gave me as a much younger person. At the same time, I’ve managed to foreclose the tension of constant urgency, of how hard it is to watch someone struggle to breathe, of never being able to do enough. All of the media has triggered a return of that hypomanic existence I thought I left behind. Often caretakers don’t have the luxury of steady, thoughtful responses. For analysts, thinking usually trumps action but in times of trauma that dichotomy often can’t be maintained.

One of the issues we’ll be talking about today is when front-line workers are most able to use support. Time is tricky here. It may be the case, as we know from PTSD, that while healthcare workers are in the heat of a crisis, they may be too exhausted to seek or use help – but as they get some distance are more impacted by what they experienced and in need of support.

A traumatized person elicits in the analyst projected elements of their own early representations. Bodily representations that have long been established as cohesive begin to fray. Freud’s paper the Uncanny comes to play here. Primitive images of disconnected body parts, feeling lost, not being able to stand up, torn skin provoke anxiety and the impulse to turn away.

Additionally, in these situations, the analyst has a sense that what is/has happened to the patient, could/has happened to me. One of most unusual aspects of COVID is that we are caught up in the same dangers and possibilities as our patients. It‘s easy for boundaries between the caretaker and patient begin to blur– they become a double of one another. We often speak of and work from our countertransference but here it’s a bigger challenge for the analyst to convert their own terrors into something usable for the patient.

Coming back to the original question of what psychoanalysis has to offer in times of acute crisis, I’ll mention just three possibilities. First, the analysts modulate between somatic regulation and the world of the imagination competing for the patient from the thrall of fragmented sensations with gestures that preserve relatedness. Then, by telling stories from our countertransference, we provide language imagining out loud new possibilities. Finally, we hold in trust a sense of the future even in the face of experiences that represent a negation of life.