Trauma Inevitably Equates to Baggage

Jo Frasca

Of the prolific criteria for a diagnosis of chronic post-traumatic stress disorder (PTSD), regrettably, she met most. The diagnosis was determined, using the internationally recognised reference in mental health, The Diagnostic and Statistical Manual of Mental Disorders Ill (1994).

In training, we were encouraged to think beyond the rigorous parameters of the DSM. While diagnosis is important and a useful tool, it is not always definitive. ‘A patient is more than a series of diagnoses and words’, our trainers would remind us. To keep the formal diagnosis in context we were encouraged to do our DSM reading and study in not-so elaborate a place such as a toilet, thereby limiting its overrated esteem. My trainers’ caution has proved to be prudent. I use the past tense to refer to the DSM which, while still used by many, due to its controversial content has fortunately lost much of its power, control and the stronghold bestowed on it by the mental health profession. The currency of this document is now being plagued with contention around who might be driving the text’s extensive diagnoses and disorder lists in order to profit financially (Greenberg, 2010, 2013; Reese, 2013; Frances, 2013). It is the preferred tool in the United States on account of its affiliation with psychiatry, mental health, and the insurance and pharmaceutical companies, though its predominance here is also wavering (ibid). It is not my intention to explore the controversy and arguments in this chapter, but only to note that there is a shift away from the use of the DSM as an exclusive diagnostic tool.

Referring in this case, however, to that very DSM, the following features described her behaviour: ‘Experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others’ (DSM-1II, 1994, p. 427). Many of her symptoms extended beyond those required to meet the diagnosis of PTSD. I noted with apprehension that she also suffered acute hypervigilance, an exaggerated startle response which I later learnt was caused by people smashing up her family home, and an avoidance of certain people, places and things, especially where there appears to be a re-enactment of a threat, or possible threat, aggression and/or violence. She constantly cowered when faced with unfamiliar locations and people, and she would flee the scene at the slightest sound.

This was the introduction to my new, incidental canine companion, Saydee.

When Saydee began realising that my home was her new home and that 1 was now her human mother, she appeared to find it distressing to have me out of her sight and she tended to become upset and agitated if I was not in her direct line of view. It was disheartening to see that in the list of symptoms she also met a diagnosis of separation anxiety. Freud considered babies as having instinctual impulses, where ‘something inherent, wired in, prestructured, is pushing from within’ (in Mitchell, 1988, p. 3). Mind for Freud emerges in the form of‘endogenous pressures’ (ibid), that contribute to the trauma when the baby is left alone, while Bowlby (1973), and ultimately Mitchell (1988) suggest that the infant’s habit of seeking proximity to the main carer is ‘fundamentally dyadic and interactive’ and that ‘above all else [it] seeks contact ... and ... engagement with other minds’ (1988, p. 3).

Bowlby (1973) explains that when the child is separated for longer than tolerable periods or finds themselves in unfamiliar and uncomfortable environments without the mother, they become anxious. If this period is brief the child can recover, re-attach and avoid a lifetime of emotional detachment. However, if the reverse occurs and the mother is unavailable for longer periods the child passes through three developmental phases: protesting the missing mother; despairing she will ever return, and finally, becoming detached. If the mother’s absence becomes a pattern for the child, the child develops a more acute anxiety, often developing the symptoms in line with separation anxiety (ibid). Such was the case with Saydee. Saydee would pace and fret even if a short distance separated us and even if I was still in full view. She did not like being left anywhere, except with the people who had originally rescued her. Saydee was also a bed-wetter, although the people who rescued her told me she had only wet in fear. In our home, this also occurs when I am gone for longer than tolerable periods. It has not been a difficult task to overlay Saydee’s anxious and distressed behaviours onto the developmental stages of children where separation creates many and varied symptoms, such as anxiety, bed-wetting, nightmares, cowering and acting out. Often these behaviours occur in apparently normal living environments, which nevertheless are experienced by the child (or dog) as unsafe. The parallels in Saydee’s behaviour to those of my patients were confronting.

In Bowlby’s (ibid) writing on separation, anger and anxiety, he discusses the likelihood of a fearful and anxious response to the threat of actual harm and how that response is replicated even when it is unlikely harm will occur. It did not matter what I did behaviourally to create safety for Saydee, her

Trauma inevitably equates to baggage 109 response was always the same. 1 often experience the same phenomenon when using CBT with clients to help them feel safe using strategies. At a very early stage of development, as mammals we can internalise the fear associated with many situations and that that fear will not budge with a strategy.

In Bowlby’s (ibid) exploration of mammals and their avoidance of danger, he discusses how animals will not only remain in areas that are familiar and that meet their needs, such as for food, water, climate and safety, but will also narrow that area down to a relatively small and familiar locale. It is only when the basic needs in that area are threatened that the animals will move further afield. He is clear also about how remaining close to that which sustains and keeps the animals physically safe also influences the regulation of the vulnerable young and how this sphere of safety plays a vital role in the psychological state of the dependant. 1 was therefore resigned to the prospect that I may never be able to assist Saydee in a life totally free from anticipated and perceived fear, with anxious behaviours, just as 1 might not be able to do with a patient.

Watching her behaviour, I also began to wonder if I was overly optimistic about patient outcomes. One patient, enraged and lacking trust in our work, which was carried out from within a stark psychoanalytic frame which she felt replicated her life with her own absent mother, once accused me of needing ‘a crisis in faith’ in the psychotherapeutic process. This response was possibly precipitated by the failure of an earlier psychotherapeutic treatment with another practitioner and by her doubt in my capacity to help her. It was not until my practice work began to shift as a result of my exposure to, and integration of, a relational sensibility that we were able to dialogue about both her experiences of her previous practitioner and her experience of the barrenness she felt as a patient within that purist psychoanalytic frame with me. I felt the accusation of that client might have been stimulated by Mitchell’s (1988, p. 295) description of the analyst as a ‘coactor’ in the patient’s drama, in the case of this patient, a drama from all aspects of her developmental life, in which the psychoanalytic frame had created the circumstances for an enactment with me as her unavailable mother. In light of my work with such patients, I had begun to question the wisdom of Saydee’s adoption - not so much for me, but for her (and by deduction, my evaluations about some of my patients). Was I capable of giving her (or them) the attachment experience she required to recover? Would I become the object that Saydee (or they) still feared and thus disable my ability to influence her much needed recovery? Fairbairn (1952) explains how the patient forces the psychotherapist to occupy that patient’s antilibidinal state, a state that has had a rejecting experience through an experience of a neglectful and abusive (parental) home. As the antilibidinal ego is obsessed and consumed at the early stage of child (puppy) development, the resilience of the psychotherapist/dog mother would need to be potent.

In an attempt to create a safe environment, 1 did find myself tiptoeing around my own life after her arrival. Simple things were done with morecare and thought, like emptying the dishwasher, putting cutlery away, opening the saucepan drawer, not slamming bin lids, closing doors and more, in the hope that she might begin to integrate her post-traumatic development and start to feel safe in her present home. For me, it was an interesting time as I noted how much calmer I felt moving about my home more slowly, more deliberately, about being more thoughtful when moving things and doing things. 1 too had begun to slow down, in harmony with our environment. Using neuroscience, Schore (2015) reconsiders the Winnicottian (1960) notion that there is no baby without a mother, in his consideration of the psychobiological structure supporting socioemotional functioning at the earliest stages of development. He discusses how the growth and development of the infant’s brain occur in direct correlation with its environment and explains how the parenting process is both affected by and impacts upon the infant, creating its self-regulatory capacity. I hoped this was occurring with Saydee.

As with patients, it took me quite some time to learn the depth and complexity of the issues Saydee presented and was struggling with. Adding to a long list of those emotional symptoms, there were also many physical concerns. Physically, it was obvious she had not learnt how to eat properly because when she arrived, she was exceedingly thin and was somewhat averse to eating healthy dog food. Her tiny legs had little muscle mass and when I ran my fingers over them, I could feel the bony structure bulging from beneath the thin layer of skin, unprotected by the muscle 1 knew she needed to avoid sarcopenia as she aged. The major weight-bearing bones, and her little joints, already felt significantly vulnerable without adequate muscle. Around this time, 1 began frequently thinking about a patient with osteomalacia (previously referred to as rickets) who had a history of severe domestic violence. As with Saydee, it had become imperative that we attend to his physical health issues as much as his psychological issues. While this had been a complex and often problematic journey, at the time of termination we had obtained a satisfactory physical outcome for him. 1 had once traversed this territory and 1 guessed that I could again.

Urgency became a factor as Saydee was now three years old, with the muscle mass of a tiny puppy. If she were to lead an injury-free life, we needed to make routine changes, rapidly. I began a boot-camp-style exercise regime and unlike some human participants (including the patient mentioned), Saydee took to her new programme with zeal. While the patient was sent off to a local, well-known trainer, 1 became Saydee’s personal trainer. On one of these early outings, I was disturbed to discover that she did not know how to run. The moment 1 let her off the lead she would run, inordinately fast, her part-Cavalier ears flying like joyous flags, trying to stay attached to her head in her lightning speed. 1 noted, with some disbelief, however, that she kept falling over. I was incredulous that a dog could fall over while running. Having grown up on a farm, watching cattle dogs run very fast over long distances, 1 had not ever seen a dog fall over while running. In fact, I had not

Trauma inevitably equates to baggage 111 ever seen a dog fall over. While her falls were sometimes simple stumbles, frequently they were full and complete tumbles. As impossible as this was to believe, from the little 1 knew of her history of having grown up in a back garden filled with a swimming pool and pavers, 1 could surmise that she may never have had the opportunity to run, perhaps rarely, if ever, having been taken out to run in a park, or perhaps even for a walk. Though not deterred now, tail always wagging, tongue hanging out, she would jump up and keep running, at full capacity. After about eight to nine months of her exercise routine, I observed discernible growth in her muscle mass. Simultaneously 1 noted she fell much less often. To date, she might still stumble and perhaps only occasionally fall when in full flight.

Another symptom, suggestive perhaps of an incomplete intrapsychic developmental process, or of trauma, was Saydee’s dislike of water. Teaching her to swim became a part of her recovery treatment plan, while at the same time was an attempt to give her a full range of ‘dog-life’ experiences, much as I might have done with a human patient’s treatment plan. Saydee’s usual routine while at the beach would be, barking loudly to intermittently run up to me, just clear of the water’s edge to where I had waded. She came to love the beach but was having no part of the water. It clearly evoked some traumatic fear. Later I was to learn why this was so. I knew this turf well. 1 had had my own water phobia until my late 20s. I knew my fear stemmed from a frequently narrated family story, from which I became vicariously traumatised, in contrast to Saydee’s experiential water trauma and phobia. Mine was a story of an uncle, who had only just immigrated to Australia, following other family members to this land of opportunity and new experiences. One glorious summer day he was put in very deep water, with a floatation device he had no idea how to manoeuvre. As it slipped from his grasp he began to flail, then panicking he became submerged. Fortunately for all concerned, an observant bystander recognised the gesticulations of a drowning citizen and fished him out. Though true, this story has been recounted as a jolly family fable in which I still find no humour. Hence my deep respect for Saydee’s reticence. When I told Saydee’s rescuers about her dislike of water, they told me a story, relayed to them by her departing previous owner as he left on a business trip from which he never returned: ‘Oh of course Saydee would hate water; my ex-wife used to randomly toss her in the pool and someone would have to dive in to get her’.

On one particular, relatively warm day on our beach walk, I was lured into the swell, though remaining in the shallows with Saydee looking on. While she watched she paced and barked, paced and barked, paced and barked. I called her name, knowing she loathed not joining in a game. But this game meant water, getting wet, and she was having none of it. Her anxiety was palpable. I was always vigilant not to push her, much as with a patient, when exploring fear and unfamiliar territory and activities. Rothschild (2000) talks about not pushing patients into traumatic material until they are emotionally equipped to manage their ability to recall, and be backin touch with, their trauma. ‘With judicious application of the brakes to gradually relieve the pressure, the whole process of trauma therapy becomes less risky’ (p. 80). It became imperative that 1 use this same process with Saydee. I knew if she were ever to find her way into the water, she would do so in her own time again, much like patients; it does not matter how often we ‘tell’ the patient, change is created by their own awareness that develops over time. 1 pondered that with children and patients our anxiety to get them to a certain phase can and will undermine their progress. 1 also knew that she, like many patients, might never find a way into the water, such was her/their traumatic experiences. It was a curious waiting game, as might have been the case with a child learning a new behaviour or a patient exploring their history in the psychotherapy setting. Then, one random beautiful autumn weekend we were down on the south coast of New South Wales, a location where even the most water-phobic person could find something inviting. I ran from the stairway leading down to the beach, straight into the water, the heat of summer receding, though still warm enough for a dip. As I launched myself into the water 1 looked down and there she was, right on my heels, in the water. With smallish waves splashing about us, 1 crouched down and played with her. She was barking, running to and fro, frolicking in the water as it lapped her belly, without doing anything specific at that moment she had triumphed over another trauma-related phobia. In terms of change, Lasker (2000) identifies that

both Bowlby and Kohut acknowledge the crucial role of the psychotherapist in the provision of a safe, secure therapeutic environment from which the patient can explore their life and all its aspects, including relationship biases and the relationship between each other, the impact of the patient’s history on their current perceptions and how appropriate or otherwise these may be (p. 7).

It appeared Saydee had traversed some such security in her life with me.

As a reflection of that day 1 was left wondering whether, if at the moment, she even knew she was in the water or had she prevailed over so many other traumas that the water phobia was no longer a fear. As with patients, there may be change ‘without an event’ (as one patient often says to me), and that at that moment, Saydee, as happens in the case of patients, may have felt the naturalness of psychological resolution that in turn changes behaviour.

As a psychotherapist and Saydee’s mother, I am satisfied with this phase of the treatment.

In the case of Saydee’s traumatic responses, I have the feeling she has made considerable inroads into what Berne (1980) refers to as ‘cure’. This definition of cure has three main elements. The first is a reduction in symptoms, and is evidenced by people noting and commenting socially on change in the patient; the second is where the patient has introjected the psychotherapist; and the third is where the patient’s developing awareness of their own

Trauma inevitably equates to baggage 113 unconscious process becomes more apparent to them and includes overt observable change. 1 am never lulled into a false sense of security around Saydee’s recovery, however, as something as simple as dropping a pen will still have her scuttling off to find safety from the perceived threat, much like us humans. If a patient had reported such a development, it would certainly feel like a psychological change. In terms of Berne’s (ibid) ‘cure’, Saydee had not only had a reduction in symptoms, but it had been noted by others as well as myself that she had had overt observable change. From that day on Saydee has never been afraid of beach water. She will go into the ocean, quite deeply for a height-challenged dog, especially in my company.

At this point in our treatment plan, the majority and immediacy of the trauma responses were relieved enough for us to relax into a harmonious life where we settled into a normal routine. Saydee learns how to hang out with people and other dogs, to ride in the car, go to the shops and much more. She is a polite, well-socialised and well-adjusted canine unless something goes crash, or people raise their voices.

Once my concern about these more overt issues with Saydee began to subside, I noticed other interesting phenomena. I noticed, for example, her reaction to people sneezing. When anyone sneezed Saydee would exhibit an exaggerated startle response, depicting significant distress. She would sit up if she had been lying down or appear from nowhere (by then, she had begun to tolerate being out of my sight) and stare for long periods of time, shrinking and trembling, but always staring, not taking her eyes off the person who sneezed, as if waiting. I would stare back, waiting. Her response was puzzling. Eventually, I would go to her, pick her up and hug her, explaining that it was only sneezing, simulating sneezing in a playful gesture, attempting to familiarise her with it and calm her nervous system.

One day, and I will never really know why, perhaps I was falling into some sort of sync with the trauma patterns of this dog, but all the pieces fell into place. It was like an epiphany. I was sitting up in bed reading, she was dozing nearby, I began staring at her. Many thoughts were stirred and flashed through my mind around her story and our tumultuous time together. I guess in hindsight at some level a part of me was still in the treatment planning phase. I began imagining what it must have been like to live in that house, for any person, especially a dog and a child (there had, in fact, been a child in the house until she, too, was rescued), living in such violence. I began thinking about my patient who grew up in not dissimilar circumstances, a volatile violent home. At that moment I recalled that Saydee’s previous owners had been drug users, by their own admission, cocaine having been the drug of choice. I wondered if Saydee had correlated a series of events, just as she had done with many others - in our lives together, for example, lip balm and sunglasses usually meant a walk. According to this theory, was sneezing a prelude to violence? In my practice, I frequently work with cocaine users. The early days of my practice brought with it an interest in this area. In those days I researched and read much about such drug use and its symptomsespecially to better assess patients while they were withdrawing. It was often cocaine use that brought people to my rooms. Cocaine was of particular interest to me due to the lack of overt, early side effects. This research revealed a plethora of information on the subject; nose-related symptoms top the list. Cocaine and sneezing cohabit. It would appear that, in Saydee’s former home, around the time of sneezing, yelling and arguing would likely have intensified into physical and verbal violence which usually progressed to smashing the home and contents, to axing furniture, and on one occasion, axing every panel of a luxury car, smashing cabinets full of crystal, photo frames, trashing cupboards, anything in their path (behaviour reported by the neighbours who would eventually rescue Saydee and give her up to me for adoption). Drug use escalated violence. At that moment, in bed, it dawned on me. No wonder she had been staring at sneezers. She was waiting for us to turn into the familiar human monster, the unpredictable beast that could love in one moment, then unleash madness in the next. While the phenomenon of her weird staring at sneezing people is no longer a mystery in our life together, it still holds a tight rein over her response to anyone sneezing, perhaps not to be transformed, if we consider the consistency and degree of violence in her previous home.

I was unable to escape the constant reflection on how it must be for traumatised children, and people generally, living in violent homes. Living with Saydee was and always is a stark reminder. It leaves me thinking about how much thought and care it takes to create safety, and how many of our patients might not have had that privilege. This little dog was giving me a first-hand experience of what growing up and living in what often appears externally to be a ‘normal’ middle-class home and how greatly these events impact children and others, creating the early lives that eventually bring those children, as adults, into our consulting rooms.

This little dog was also teaching me that as much as her trauma occurred in relationship with her previous owners, so does the potential for healing reside within our relationship. Bowlby (1969) contends that the behavioural patterns we develop come unquestionably from how we develop our mental abilities with our early main carers and how we are in relationship. He emphasises that the infant’s overarching desire is proximity to its main carers and that if this is attained at an early enough stage and with consistency a healthy developmental attachment will parallel a healthy psychological state. When this does occur, the child, can and will recover and reattach, as has Saydee. Bowlby (ibid) also suggests that a child separated for longer than tolerable periods, or with a mother in unfamiliar and uncomfortable environments, is unable to recover and reattach. In my care, Saydee has not reexperienced the trauma of separation, of ‘protesting the missing mother’ (Bowlby, 1973) or of despairing that she will never return. With consistent mothering from her human mother, Saydee has shown me how recovery is made possible. She has, in the process, also taught me about patients in the therapeutic setting.

Trauma inevitably equates to baggage 115

Note

1 This chapter has been adapted from Delving Deeper: Understanding Diverse Approaches While Exploring Psychotherapy by Jo Frasca, self-published in 2016.

References

American Psychiatric Association. (1994) DSM-III: Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Association.

Berne, E. (1980) Transactional analysis in psychotherapy. London: Souvenir Press.

Bowlby, J. (1969) Attachment and loss, Volume 1: Attachment. London: Hogarth Press and the Institute of Psychoanalysis.

Bowlby, J. (1973) Attachment and loss. Volume 2: Separation, anger and anxiety. London: Hogarth Press and the Institute of Psychoanalysis.

Fairbairn, W.R.D. (1952) Psychoanalytic studies of the personality. London: Routledge & Kegan Paul.

Frances, A. (2013) The new crisis of confidence in psychiatry diagnosis. Annals of Internal Medicine, American College of Psychiatrists, acponline.org. Accessed 03/02/2020.

Greenberg, G. (2010) Manufacturing depression: The secret history of a modern disease. New York: Simon & Schuster.

Greenberg, G. (2013) The book of woe: The DSM and the unmaking of psychiatry. New York: Blue Rider Press Penguin Group.

Lasker (Silbert), J. (2000) “Ao man is an island": A comparison between the relational theories of Heinz Kohut and John Bowlby. Unpublished.

Mitchell, S. (1988) Relational concepts in psychoanalysis: An integration. Cambridge, MA and London, UK: Harvard University Press.

Reese, H. (2013) The real problems with psychiatry. The Atlantic - Health, https://www.theatlantic.com/health/archive/2013/05/the-real-problems-with-psychiatry/275371/. Accessed 03/11/19.

Rothschild, B. (2000) The body remembers: The psychophysiology of trauma and treatment. New York: WW Norton & Company, Inc.

Schore, A.N. (2015) Affect regulation and the origin of the self: The neurobiology of emotional development. London and New York: Taylor & Frances Group.

Winnicott, D.W. (1960) The theory of the parent-infant relationship. International Journal of Psychoanalysis, 41, pp. 585-595.

 
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