Safety Security and Attachment Psychodynamic Approaches to PTSD

Most students of psychology are familiar with psychodynamic theories of human psychological functioning, from the works of Sigmund Freud to W. Bion. Psychodynamic is the modern name for what most people would recognize as psychoanalytic. Psychodynamic theories are bound together by their rich history and tradition as well as by their core themes and conceptual focus. Psychodynamic theories of psychopathology have in common a focus on the internal struggle of the mind for the expression and management of impulses, wishes, fears, and instincts by the defensive functions and other mental operations.

According to Ulman and Brothers (1988), there are three main schools of psychoanalytic or psychodynamic thought on trauma: (1) classical, (2) neoclassical, and (3) revisionist.

The classical school begins with Sigmund Freud, who recognized that traumatic events could produce traumatic neuroses, conditions recognized by Freud to consist of intrusive imagery, physiological hyperactivity, active reliving the event as if it was recurring in the here and now (Wilson, 1995). A traumatic event threatens the ego with destruction or annihilation, and in order to cope with this threat, repression is employed as a defense. Freud characterizes traumatic stressors as overwhelming for the protective shield of the ego. There is a disruption in normal functioning and the ability to cope effectively with current stressors. Traumatic stressors and current stressors combine to overwhelm the ego and its defenses, thus leading to symptom expression. The strong affects related to the trauma press for expression in emotional or behavioral form.

Freud developed a second model of trauma that served as an important predecessor to the neoclassical and revisionist schools. In this model, trauma is viewed as a stimulus that activates deep unconscious processes and memories of deep conflict. A traumatic event has meaning and power only in that it activates and is subsequently derived from dormant pathology and repressed memories. As unconscious memories and conflicts become activated by the intrusiveness of the traumatic stimulus, it results in overstimulation and symptomatic breakthroughs.

The work of Phyllis Greenacre (1969) and Edith Jacobson (1949) characterize the neoclassical school. Both theorists rely heavily on Freud's second model. For Greenacre, trauma results from stimulation of deep unconscious conflict, but she adds that the response is organized as a sadomasochistic fantasy. That is, the trauma is dealt with as a purely mental phenomenon as it is connected to deep unconscious processes. The drama of the traumatic stress reaction is played out, coped with, and resolved as our mental defenses transform it into a fantasy that is both out of our control and simultaneously under our control.

Edith Jacobson (1949) proposed that traumatic stressors represent an assault on our ego and result in a "narcissistic disturbance inside the ego involving conflicts between self-representations" (Ulman & Brothers, 1988, p. 52). Conflict arises between views of oneself as safe and secure versus being weak and unsafe. There are problems with the formulation and maintenance of a healthy self-image. Decompensation and regression develop as responses to the assault on a person's dignity and pride. There is an unacceptable and painful sense of self or a self that has been "degraded, humiliated, and worthless" (Ulman & Brothers, 1988, p. 53). This can lead to dissociation. Again, the key point to remember in the works of Freud, Greenacre, and Jacobson is that trauma comes not directly from the event but from a stimulation of unconscious conflict and our coping and defensive responses to the conflict.

Big names from the revisionist school are Rado (1942), Kardiner (1941), and Kelman (1945). For both Rado and Kardiner (1941), trauma is characterized as a disturbance in adaptational functioning in which there is a pathological alteration in one's sense of self and how it relates to the outer world. For Kelman, trauma is caused by the loss of and failure to revive a neurotic character- or personality-organizing structure that gives rise to a core sense of self. Symptoms come from extreme personality decompensation, and some people are more vulnerable than others due to underlying character pathology that is overly focused on a view of oneself as strong, unique, inviolate, invulnerable, and having a strong need for self-control and external control of the environment. Trauma is the result of these images of oneself breaking down.

Ulman and Brothers (1988) have developed a self-psychology model of trauma based to a large degree on the work of psychoanalyst Heinz Kohut. In essence, trauma shatters the self, with the self defined as the "subject's experience of mental being and physical existence" (Ulman & Brothers, 1988, p. 5). With trauma, there is a disturbance in self-functioning that contributes to the sense of trauma, there is damage to one's view of the self, and there is a failure to restore the self to the center of one's psychological organization of the world. One's ability to maintain an organized sense of experience breaks down. This, in part, may account for the disorganized and fragmented nature of traumatic memories and cognitions. Trauma is a significant challenge to narcissistic fantasies of personal uniqueness, entitlement, and invulnerability. As a victim responds to these insults and features of disorganization, symptoms ensue.

Lemma and Levy's Perversion of Loss

Allessandra Lemma and Susan Levy (2004) give us a very contemporary psycho-dynamic approach to understanding PTSD. At its core, PTSD is about loss-symbolic loss, actual loss (e.g., death or almost dying), or both. Exactly how the experience of loss is processed is crucial as are the relationships between traumatic responses and a victim's capacity to mourn the loss in question. A traumatic stressor presents a victim with a very powerful and unbelievable experience. The normal mourning process used in coping with loss is altered in response to traumatic stress as a way to manage the "unbearable and unthinkable nature of the traumatic loss" (Lemma & Levy, 2004, p. xvi). Internal and unconscious mental functioning is altered.

The mental representation and symbolism of interpersonal relations and representations of self are critical components in this theory. There is a breakdown in the symbolic functioning of the mind and its identifications that result in the trauma victim's being locked or stuck in a chronic state of melancholia or a related unresolved posttraumatic response. With the onset of a traumatic stressor, an individual engages in defensive functioning, central to which is one's connection to an attachment figure or object. With trauma, there is an attack on attachment in which both internal mental representations and external relationships at the time of the trauma are taxed and challenged. A trauma is experienced as an attack on this symbolic mental representation and the quality of one's identifications with attachment figures. It is as if traumatic stressors lead to one questioning his or her very connection to the people they feel closest to and safest with. Further, a trauma is an attack on one's sense of identity and security in relation to the world. The world is experienced as having turned against the victim, leaving them perpetually afraid and hyperresponsive to everything. The ego and its functioning is compromised as the trauma's severity breaks through and breaks down typical defenses. The ego and the self are penetrated and can no longer be trusted for protection. Hypervigilance results, and perceptual and other stimuli cease to be mere symbols but are mistaken as actual signals of danger.

There are four main themes to Lemma and Levy's (2004) work. The first theme, mentioned earlier, is that trauma is an attack on attachment. There is an attack on and damage done to one's ability to share and engage with others. There is also an attack on one's ability to mentally structure a story or narrative about the event—an attack on one's ability to put what happened into words, "both in relation to another person and also in terms of the construction of an inner dialogue with our subject" (Levy & Lemma, 2004, p. 5).

The second theme holds that there is a breakdown in the ability to adequately mourn the loss in question. This process leads to the perversion of loss in which emotional pain and guilt overwhelm the victim and result in identifying with the perpetrator of the trauma as a means to control or cope with these powerful emotions. Also, a current trauma can reshape memories of attachment and give a victim a sense that good objects (i.e., mental representations of people) will not endure or prevail under the stress and strain. This is the breakdown in the capacity to mourn.

The third theme involves consequent oscillating identifications between internal psychological themes of goodness, survival, and safety and the destructive identification or perverted loss identification. The fourth and final theme involves the breakdown of symbolic functioning in which the traumatic stressor undermines the facility to think and reflect on current, conscious, lived experience. Posttrauma images, thoughts, and feelings are represented in a manner that distorts reality testing and are not stored as typical memories. They emerge in concrete form as flashbacks and intrusive thoughts, and the mind is vulnerable to overstimulation.

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