February 25, 2003 8:33 AM
Trauma counseling retraumatizes_Repress Yourself_NYT
“Repress Yourself” an article in Sunday’s New York Times magazine provides Congress with very good reasons for taking back public funds from the mental health trauma industry that it infused with cash after 9/11.
A scientific study conducted in Israel found that NOT dwelling on traumatic experiences is better for your health than mental health therapies. Mental health counseling for trauma victims seems to prolong the agony.
Similarly, Professor Richard Gist, a community psychologist and trauma researcher, along with a growing number of colleagues, has become highly critical of these debriefing procedures. Trauma therapy made people worse: “They were either unhelped or retraumatized by our interventions.”
THE NEW YORK TIMES
February 23, 2003
By LAUREN SLATER
You’ve been in therapy for years. You’ve time-traveled back to your childhood home, to your mother’s makeup mirror with its ring of pearl lights. You’ve uncovered, or recovered, the bad baby sitter, his hands on you, and yet still, you’re no better. You feel foggy and low; you flinch at intimate touch; you startle at even the slightest sounds, and you are impaired. Hundreds of sessions of talk have led you here, back to the place you started, even though you’ve followed all advice. You have self-soothed and dredged up; you have cried and curled up; you have aimed for integration in your fractured, broken brain.
This is common, the fractured, broken brain and the uselessness of talk therapy to make it better. A study done by H.J. Eysenck in 1952, a study that still causes some embarrassment to the field, found that psychotherapy in general helped no more, no less, than the slow passing of time. As for insight, no one has yet demonstrably proved that it is linked to recovery. What actually does help is anyone’s best guess — probably some sort of fire, directly under your behind — and what leads to relief? Maybe love and work, maybe medicine. Maybe repression. Repression? Isn’t that the thing that makes you sick, that splits you off, so demons come dancing back? Doesn’t that cause holes in the stomach and chancres in the colon and a general impoverishment of spirit? Maybe not. New research shows that some traumatized people may be better off repressing the experience than illuminating it in therapy. If you’re stuck and scared, perhaps you should not remember but forget. Avoid. That’s right. Tamp it down. Up you go.
The new research is rooted in part in the experience of Sept. 11, when swarms of therapists descended on New York City after the twin towers fell. There were, by some estimates, three shrinks for every victim, which is itself an image you might want to repress, the bearded, the beatnik, the softly empathic all gathered round the survivors urging talk talk talk. ”And what happened,” says Richard Gist, a community psychologist and trauma researcher who, along with a growing number of colleagues, has become highly critical of these debriefing procedures, ”is some people got worse. They were either unhelped or retraumatized by our interventions.” Gist, who is an associate professor at the University of Missouri and who has been on hand to help with disasters from the collapse of the Hyatt Regency pedestrian skywalks in Kansas City, Mo., in 1981 to the United Airlines crash in Sioux City, Iowa, in 1989, has had time to develop his thoughts regarding how, or how not, to help in times of terror. ”Basically, all these therapists run down to the scene, and there’s a lot of grunting and groaning and encouraging people to review what they saw, and then the survivors get worse. I’ve been saying for years, ‘Is it any surprise that if you keep leading people to the edge of a cliff they eventually fall over?”’
Based in part on the findings that encouraging people to talk immediately after a trauma can actually emblazon fear more deeply into the brain, researchers began to question the accepted tenets of trauma treatment, which have at their center the healing power of story. In Tel Aviv, three researchers, Karni Ginzburg, Zahava Solomon and Avi Bleich, studied heart-attack victims in an effort to determine whether those who repressed the event fared better in the long run. ”Repression” is a word that radiates far beyond its small syllabic self; it connotes images of hysterical amnesiacs on magic mountains or mist-swaddled Viennese streets. But in experimental psychology, as opposed to psychoanalysis, repression has far more mundane meanings; it is used to describe those who minimize, distract, deny. Is it possible that folks who employ these techniques cope better than the rest of us ramblers? In order to address this question, Ginzburg and her collaborators followed 116 heart-attack patients at three hospitals in Israel with the aim of assessing who developed post-traumatic stress disorder and who went home whistling. Ginzburg’s team was particularly interested in exploring the long-term effects of a repressive coping style; some earlier research demonstrated that those who deny are, in fact, better off in the short term. But there remained the larger questions: What happens to these stern stoics over time? Do they break down? Do memories and symptoms push through? Ginzburg’s team assessed its subjects within one week of their heart attacks and then seven months later. During the first assessment, the team evaluated, among other things, the patient’s general coping style using a series of scales that reflect the tendency to avoid and to deny. The researchers defined repressors as those who exhibited ”a specific combination of anxiety and defensiveness” as measured on the self-reported scales.
They found that those patients who had high anxiety and low defensiveness — in other words, those patients who had a lift-the-lid approach to their experience, thinking about it, worrying about it, processing it — had a far poorer outcome than their stiff-lipped counterparts. Specifically, of the stiff-lipped stylers, only 7 percent developed post-traumatic stress disorder seven months after the infarction, compared with 19 percent of the voluble ones.
The Israeli study hypothesizes at one point that repression may work as a coping style because those who ignore have a uniquely adaptive perceptual style. Repressors, others posit, may be protected by their presuppositions regarding — and subsequent perceptions of — stressful events, meaning that where you see a conflagration, they see a campfire, where you see a downpour, they see a drizzle. Still other researchers suggest that repressors are good at repressing because they can manipulate their attention, swiveling it away from the burned body or the hurting heart, and if that fails, they believe that they can cope with what befalls them. They think they’re competent, those with the buttoned-up backs. Whether they really are or are not competent is not the issue; repressors, Ginzburg suggests, think they are, and anyone who has ever read ”The Little Engine That Could” knows the power of thinking positively when it comes to making it over the mountain.
George Bonanno, an associate professor of psychology at Columbia University Teachers College, has found similar results in his many inquiries into the role of repression and avoidance in healthy coping styles. And, unlike the Israeli researchers, Bonanno has used scales that go beyond self-report to determine who’s repressing what and how that person fares. For instance, in a study of bereaved widows and widowers, Bonanno used a technique called verbal autonomic association. He had people talk about their loss while he looked at autonomic arousal (heartbeat, pulse rates and galvanic skin responses). What he saw: a subgroup of mourners who consistently said they weren’t distressed while displaying high heart rates. ”These are the repressors,” Bonanno says. ”And these people, the ones who showed this pattern, had less grief over time and had a better overall life adjustment, and this has been consistent across studies.” Bonanno has recently completed a study involving adolescent girls and young women who are sexual-abuse survivors. ”The girls who chose not to talk about the sexual abuse during the interview, the girls who measured higher on repression scales, these were the repressors, and they also had fewer internalizing symptoms like depression and anxiety and fewer externalizing symptoms like hostility and acting out. They were better-adjusted.”
Bonanno pauses. ”I’ve been studying this phenomenon for 10 years,” he says. ”I’ve been deeply troubled. My work’s been in top journals, but it’s still being dismissed by people in the field. In the 1980’s, trauma became an official diagnosis, and people made their careers on it. What followed was a plethora of research on how to heal from trauma by talking it out, by facing it down. These people are not likely to believe in an alternative explanation. People’s intellectual inheritance is deeply dependent upon a certain point of view.”
George Bonanno works in New York City, while Richard Gist works in Kansas City; the doctors have never spoken, but they should. They share a lot. Gist told me: ”The problem with the trauma industry is this: People who successfully repress do not turn up sitting across from a shrink, so we know very little about these folks, but they probably have a lot to teach us. For all we know, the repressors are actually the normal ones who effectively cope with the many tragedies life presents. Why are we not more fascinated with these displays of resilience and grace? Why are we only fascinated with frailty? The trauma industry knows they can make money off of frailty; there are all these psychologists out there turning six figures with their pablum and hubris.”
Gist, who speaks with a Midwestern twang and knows how to turn a rococo phrase, also insists on plain figures to back up whatever he says. According to Gist, meta-analyses of debriefing procedures, a subset of trauma work that encourages catharsis through talk, simply do not support the efficacy of many of the interventions. Both Gist and Bonanno say they believe that the accepted interventions, like narrative catharsis, remain in use for pecuniary, political and historical reasons, reasons that have nothing to do with curing people.
And the history of these reasons? The trauma field is broad and might have begun at any of a number of points: there was Freud, who originally believed that female hysteria was caused by childhood sexual abuse, only to abandon the idea later in favor, perhaps, of something less jarring to Victorian sensibilities; even before Freud, there was Jean Martin Charcot, who posited his patients’ fits of hysterics to be somatic expressions of buried traumatic memories. But for modern-day purposes, the trauma industry seems to have started sometime in the early 1980’s, when the women’s movement asserted that post-traumatic stress disorder did not belong to Vietnam veterans alone; it belonged also to the legions of women who were abused in domestic situations. Mostly middle-class, well-educated women seeing private therapists began to whisper their stories, stories that contradicted the dominant belief in most psychiatric textbooks that incest occurred in one family per million. And yet here were Ph.D.’s and Ed.D.’s and Psy.D.’s and L.C.S.W.’s hearing that no, it happened here, and here, and here, behind this bedroom door, in this dark night, under the same shared suburban sky where we do not live safely. Thus, from their very inception, incest accounts were subversive stories, and their telling became acts of political and personal rehabilitation. Silence, as far as sexual abuse was concerned — and this quickly radiated out to all forms of trauma — was tantamount to toxic conformity. Only speech would save.
It makes sense, therefore, that the tools deployed to help survivors were largely verbal and emphasized narrative reconstruction. Trauma (the word means ”wound” in Greek) is seen as a rupture in the long line of language that constructs who we are. The goal of treatment has traditionally been, therefore, to expand the story so that it can accommodate a series of unexpected scenes. By the early 1990’s, neurological models of broken narratives were being developed. Dr. Bessel van der Kolk, for instance, hypothesized that repressed trauma has very specific neural correlates in the brain. The event — say, the rape, the plane crash — is isolated, flash-frozen in a nonverbal neural stream, where it stays stuck, secreting its subterranean signals of fear and panic. The goal of trauma treatment has been to move memories from nonverbal brain regions to verbal ones, where they can be integrated into the life story.
This, to my mind, is a beautiful theory, one that blesses the brain with malleable storage sites and incredible plot power — but whether it’s true or not, no one knows. More to the point, whether it’s true for all people, no one knows. While storying one’s life is undoubtedly an essential human activity, the trauma industry may have overlooked this essential fact: not all of us are memoirists. Some of us tell our stories by speaking around them, a kind of Carveresque style where resolution is whispered below the level of audible language. Then again, some of us are fable writers, developing quick tales with tortoises and hares, where right and wrong have a lovely, simple sort of sound. If we are all authors of our experience, as the trauma industry has so significantly reminded us, we are not all cut from the same literary cloth. Some of us are wordy, others prefer the smooth white space between tightly packaged paragraphs. Still others might rather sing over the scary parts than express them at all.
Here’s the question: at what cost, this singing? Jennifer Coon-Wallman, a psychotherapist based in Lexington, Mass., asks, ”By singing over or cutting off a huge part of your history, aren’t you then losing what makes life rich and multifaceted?” I suppose so, but let me tell you this. I’ve had my fair share of traumas — I’m sure you have, too — and if I could learn to tamp them down and thereby prune my thorny lived-out-loud life a little, I’d be more than happy to. Go ahead. Give me a lock and key.
Girvani Leerer of Arbour-H.R.I. Hospital in Brookline, Mass., doesn’t necessarily agree with my lock-and-key longings. ”Facing and talking about trauma is one of the major ways people learn to cope with it. They learn to understand their feelings and their experiences and to move out, beyond the event.” On the one hand, Gist told me, referring to the work done in Israel, ”Ginzburg’s study, despite its limitations, is right on and has done us a great service.” On the other hand, Dr. Amy Banks, a faculty member at the Jean Baker Miller Training Institute at Wellesley College, says: ”Ginzburg’s study is interesting, but it’s weak. It’s saying repression is useful for repressors. Is repression useful for those of us with different styles? I doubt it. I think it’s probably harmful.”
Banks’s sentiments ultimately win out with doctors and patients, professionals and lay people. ”The Courage to Heal,” a book by Ellen Bass and Laura Davis about trauma and talk, has sold more than 700,000 copies. Dr. Judith Herman, the director of training at the Victims of Violence Program at Cambridge Hospital, in her updated book ”Trauma and Recovery,” continues to advocate narrative and catharsis. And a quick scan of trauma Web sites shows that plebeians like you and me are still chatting up a brutal bloody storm.
Beyond the general reactions, there are some specific methodological criticisms clinicians have with the Ginzburg study, one of which is its implicit comparison of sexual-abuse survivors to heart-attack victims. Banks says: ”Trauma that happens at the hands of another human being has a much greater psychological impact than trauma that happens from a physical illness, accident or even natural disaster. There’s a bigger destruction in trust and relationships. And to further complicate things, sexual abuse usually happens over time, in a situation of secrecy, to what may be a preverbal child. A heart attack is a public event that involves fully verbal adults who have so much more control over their world.” Yes and no. Certainly, sexual abuse has an element of shame that medical events don’t tend to carry. But as Ginzburg notes at the start of her study, a heart attack is ”a stressful life-threatening experience.” The death rate is high, the rate of recurrence higher still, and if that doesn’t do it for you, consider the symbolic meaning of the heart, that central valentine in its mantle of muscle. Consider the fear when it starts to fibrillate, and then the pain, and afterward, you’ll never trust that tired pump again. In both sexual abuse and devastating medical events, the sense of self is shattered, and this commonality may unite the disparate traumas in essential ways.
And yet clinicians still resist the relevance of the Ginzburg findings. Bononno says, ”We just don’t want to admit they could be true,” and that’s true. The repression results appear to insult more than challenge us, and this feeling of insult is almost, if not more, interesting than the findings themselves. We are offended. Why?
Alexis de Tocqueville might know. In 1831, when he came to this country, he observed as perhaps no one has since its essential character. Tocqueville saw our narcissism, our puritanism, but he also saw the romanticism that lies at the core of this country. We believe that the human spirit is at its best when it expresses; the individualism that Tocqueville described in his book ”Democracy in America” rests on the right, if not the need, to articulate your unique internal state. Repression, therefore, would be considered anti-American, antediluvian, anti-art and terribly Teutonic. At its very American best, the self is revealed through pen and paint and talk. Tocqueville saw that this was the case. So did Emerson and Thoreau and of course Whitman, who upheld the ideas of transcendentalism, singing the soul, letting it all out.
But the resistance to repression goes back even further than the 19th century. Expression as healing and, consequently, repression as damaging can be found as far back as the second century, when the physician and writer Galen extended Hippocrates’s theory that the body is a balance of four critical humors: black bile, yellow bile, phlegm and blood. Disease, especially emotional disease, Galen suggested, is the result of an internal imbalance among these humors, and healing takes place when the physician can drain the body, and soul, of its excess liquid weight. Toward this end, purging, emetics and leeches were used. Wellness was catharsis; catharsis was expression. It’s easy to see our current-day talking cures and trauma cures as Galenic spinoffs, notions so deeply rooted in Western culture that to abandon them would be to abandon, in some senses, the philosophical foundations on which medicine and religion rest.
To embrace or even consider repression as a reasonable coping style is a threat to the romantic ideals so central to this culture, despite our post-modern sheen. Postmodernism, with its pesky protestations that there is no ultimate history or total truth, inadvertently ends up underscoring just these things. We’re still all Walt Whitman at heart. Our response to the research illuminates this.
And of course, practically speaking, there are real reasons why we would not want to embrace the current findings. Our entire multimillion-dollar trauma industry would have to be revamped. There are in this country thousands of trauma and recovery centers predicated upon Whitman-esque expression, and sizable portions of the self-help industry are devoted to talking it out. While there wouldn’t be a countrywide economic crash if repression came back into vogue, there would be some serious educational, political and medical upheavals. Federally financed programs would go down. Best to avoid that. Best to just repress the thought.
What would therapy look like if repression came back into vogue? Here’s Dusty Miller. She lives and works in Northampton, Mass. She’s well into her 50’s, with blue eyes and moccasins. Her office is small and spartan. On the wall there is a picture of Audre Lorde and the words ”When I dare to be powerful — to use my strength in the service of my vision — than it becomes less and less important whether I am afraid.” Miller knows this to be true.
Before Miller was a psychologist, she was a patient. Before she was a patient, she was a victim, visited nightly by her father, who she says physically and sexually abused her, and this for years and years. At Cornell, where she was an undergraduate, Miller went into therapy, first to be told in the early 1960’s that her memories were wishes and then to be told in the 1980’s that they were true and that her job was to be Nancy Drew, shining a flashlight into all the dark places.
Which is what Miller did in the 1980’s. She went back over and over the memories of trauma and got sicker and sicker. ”After many therapy sessions I’d be a quivering ball, and then I’d leave the office and take my credit card and go out and spend $500 on clothes I didn’t need.” A year or so into her recovered-memory therapy, Miller developed chronically aching joints and a low-grade fever. She could barely move, she was so fatigued. Months passed. Snow fell. Skies cleared. Miller knew she had to make a change. She had gone back to her memories for healing and wound up with a chronic disease. ”You know that saying ‘It has to get worse before it gets better’?” Miller says to me. ”Well, I used to believe that, but I don’t anymore. That just leads you to fall apart. And you know the saying ‘It’s never too late to have a happy childhood’? Well, guess what? It is.”
So she quit her Nancy Drew therapy. One day, she told her therapist, ”I’m not coming back anymore.” Then what did she do? Among other things, she took up . . . tennis.
Yes, tennis. Keep your eye on the ball, stay inside the bright white lines and hit hard. ”Tennis was so grounding and taught me so much grace and helped me to regulate my anxiety. It was tennis, not talk, that really helped.”
Miller’s own self-styled ”cure” fueled her work as a clinician. She began to consider directing her clients away from their traumas and toward the parts of their lives that ”gave them more juice.” She found that it worked. With trauma survivors, Miller now never begins a group session by asking, ”How are you feeling?” ”Oh, my God, that would just be a disaster,” she says. ”All I’d get was, ‘Terrible, fearful, awful.’ Instead I say, ‘What strengths do you need to focus on today?”’ In one session, Miller hands out paper dolls and bits of colored paper. Trauma survivors are told to glue the colored paper onto body parts that hurt or have been hurt, ”but then,” Miller says, ”we don’t stop there. We turn the dolls over, onto a fresh side, and participants use the same bits of paper to design a body of resilience.”
Miller’s form of psychotherapy emphasizes doing, not reflecting. The actions at once block and dilute memories. She, along with other colleagues, has started a trauma resource treatment center in western Massachusetts for low-income women and their children, predicated in part upon the virtues of repression. At the center, there is a kitchen full of utensils, so women can stir and chop instead of sitting and talking, a computer room where women can type up resumes and query letters and, maybe best of all, an attic full of professional clothes so if a job interview is landed, the woman can don a second skin, a sleek suit, a pair of pumps. It’s exhilarating.
Miller tells me: ”I worked with this woman named Karen, who said she was a sexual-abuse survivor and a schizophrenic. She had been in so much therapy and told her story so many times, and it reinforced her feelings of being sick. She’d been terribly infantilized by the mental health system, a system that tells women to recover by walking around clutching teddy bears and crying.” Miller pauses. ”With this woman, we never asked her about her past. We saw it would be bad for her. Instead, we put her right on the computer. And then, when she’d learned the computer, we had her do some research work for us, interviewing. And it was incredible.” Miller stares up at the ceiling, recalling. ”Karen did so well with the work we gave her. She learned to send e-mail, and that thrilled her.” Consider this: teaching a schizophrenic sexual-abuse survivor how to press a button and hurl the self through space with cyber-specificity. Who wouldn’t feel empowered?
”And then,” Miller says, ”the feds came out to inspect our program like they do every year or two, and everyone had to go around the room and say, you know, like, ‘Hi, I’m Dusty Miller, psychologist.’ And when it was Karen’s turn, instead of saying, ‘Hi, I’m Karen, I’m a schizophrenic sexual-abuse survivor,’ she said, ‘Hi, I’m Karen, and I’m the lead ethnographer for the Franklin County Women and Violence Project.’ I was so proud of her. We got her to stop telling her story, and she improved. There were tears in my eyes.”
And today? Karen is feeling better several years later. She has earned enough money at her part-time job to buy a ”used used car,” and she sings in a community chorus. ”I think she sings mostly peace songs,” Miller tells me, and what are peace songs, really, but pleas and wishes, pictures of perfection, the wreckage wiped away. Karen, schizophrenic, sexually abused, rarely discusses her memories anymore; she looks to her future, not to her past. Who wouldn’t be happy to hear that? And yet, who wouldn’t worry as well? Will the trauma treatment of the future be something simplistically saccharine, down by the riverside, or maddeningly upbeat? Or will the trauma treatment of the future be done in small square rooms where no tears are allowed, where the ceiling is lidlike, the walls the color of clamp?
Within the expression-versus-repression debate lurk ancient, essential questions and the oldest myths. In the fifth century B.C., Socrates claimed that an unexamined life was not worth living. Score one for the trauma teams. Around the same time, however, Sophocles described how a raging Oedipus, on a quest for knowledge, gouged out his own eyes when he finally learned the terrible truth; he would have been better off never asking. Score one for the Ginzburg findings. Who’s to say which side is right, and when? There are times when a person would be better off diverted; just get a job, for God’s sake, we want to say to the endless explorer who keeps reliving and revising the painful past. But then there are those folks with mouths as stern as minus signs, their faces like fists; they could use a little expressive therapy, for sure. In the end, we may need to parse repression, nuance it, so that we understand it as a force with potentially healthful and unhealthful aspects. Freud once defined repression quite benignly as a refocusing of attention away from unpleasant ideas. Of course there are times, in an increasingly frantic world, when we need to do that; repression as filter, a screen to keep us clean. So turn away. But run away? Therein lies the litmus test.
If you’re breathless, knees knocking, and life is a pure sprint from some shadow, I say go back. Slow down. Dwell. As for the rest of us, let’s do an experiment and measure the outcome. Let us fashion our lids; let us prop them proudly on top of our hurting heads.
Lauren Slater is the author of ”Opening Skinner’s Box: Great Psychological Experiments of the 20th Century,” to be published by W.W. Norton in 2004.
FAIR USE NOTICE: This may contain copyrighted (© ) material the use of which has not always been specifically authorized by the copyright owner. Such material is made available to advance understanding of ecological, political, human rights, economic, democracy, scientific, moral, ethical, and social justice issues, etc. It is believed that this constitutes a ‘fair use’ of any such copyrighted material as provided for in section 107 of the US Copyright Law. In accordance with Title 17 U.S.C. Section 107, this material is distributed without profit to those who have expressed a prior general interest in receiving similar information for research and educational purposes. For more information go to: http://www.law.cornell.edu/uscode/17/107.shtml If you wish to use copyrighted material for purposes of your own that go beyond ‘fair use’, you must obtain permission from the copyright owner.