Charcot conducted meticulous studies of the physiological and neurological correlates of hysteria in both men and women, all of which emphasized embodied memory and a lack of language. For example, in 1889 he published the case of a patient named LeLog, who developed paralysis of the legs after being involved in a traffic accident with a horse-drawn cart. Although Lelog fell to the ground and lost consciousness, his legs appeared unhurt, and there were no neurological signs that would indicate a physical cause for his paralysis. Charcot discovered that just before Lelog passed out, he saw the wheels of the cart approaching him and strongly believed he would be run over. He noted that “the patient . . . does not preserve any recollection. . . . Questions addressed to him upon this point are attended with no result. He knows nothing or almost nothing.”13 Like many other patients at the Salpêtrière, Lelog expressed his experience physically: Instead of remembering the accident, he developed paralysis of his legs.14
PAINTING BY ANDRE BROUILLET
Jean-Martin Charcot presents the case of a patient with hysteria. Charcot transformed La Salpêtrière, an ancient asylum for the poor of Paris, which he transformed into a modern hospital. Notice the patient’s dramatic posture.
But for me the real hero of this story is Pierre Janet, who helped Charcot establish a research laboratory devoted to the study of hysteria at the Salpêtrière. In 1889, the same year that the Eiffel Tower was built, Janet published the first book-length scientific account of traumatic stress: L’automatisme psychologique.15 Janet proposed that at the root of what we now call PTSD was the experience of “vehement emotions,” or intense emotional arousal. This treatise explained that, after having been traumatized, people automatically keep repeating certain actions, emotions, and sensations related to the trauma. And unlike Charcot, who was primarily interested in measuring and documenting patients’ physical symptoms, Janet spent untold hours talking with them, trying to discover what was going on in their minds. Also in contrast to Charcot, whose research focused on understanding the phenomenon of hysteria, Janet was first and foremost a clinician whose goal was to treat his patients. That is why I studied his case reports in detail and why he became one of my most important teachers.16
AMNESIA, DISSOCIATION, AND REENACTMENT
Janet was the first to point out the difference between “narrative memory”—the stories people tell about trauma—and traumatic memory itself. One of his case histories was the story of Irène, a young woman who was hospitalized following her mother’s death from tuberculosis.17 Irène had nursed her mother for many months while continuing to work outside the home to support her alcoholic father and pay for her mother’s medical care. When her mother finally died, Irène—exhausted from stress and lack of sleep—tried for several hours to revive the corpse, calling out to her mother and trying to force medicine down her throat. At one point the lifeless body dropped off the bed while Irène’s drunken father lay passed out nearby. Even after an aunt arrived and started preparing for the burial, Irène’s denial persisted. She had to be persuaded to attend the funeral, and she laughed throughout the service. A few weeks later she was brought to the Salpêtrière, where Janet took over her case.
In addition to amnesia for her mother’s death, Irène suffered from another symptom: Several times a week she would stare, trancelike, at an empty bed, ignore whatever was going on around her, and begin to care for an imaginary person. She meticulously reproduced, rather than remembered, the details of her mother’s death.
Traumatized people simultaneously remember too little and too much. On the one hand, Irène had no conscious memory of her mother’s death—she could not tell the story of what had happened. On the other she was compelled to physically act out the events of her mother’s death. Janet’s term “automatism” conveys the involuntary, unconscious nature of her actions.
Janet treated Irène for several months, mainly with hypnosis. At the end he asked her again about her mother’s death. Irène started to cry and said, “Don’t remind me of those terrible things. . . . My mother was dead and my father was a complete drunk, as always. I had to take care of her dead body all night long. I did a lot of silly things in order to revive her. . . . In the morning I lost my mind.” Not only was Irène able tell the story, but she had also recovered her emotions: “I feel very sad and abandoned.” Janet now called her memory “complete” because it now was accompanied by the appropriate feelings.
Janet noted significant differences between ordinary and traumatic memory. Traumatic memories are precipitated by specific triggers. In Julian’s case the trigger was his girlfriend’s seductive comments; in Irène’s it was a bed. When one element of a traumatic experience is triggered, other elements are likely to automatically follow.
Traumatic memory is not condensed: It took Irène three to four hours to reenact her story, but when she was finally able to tell what had happened it took less than a minute. The traumatic enactment serves no function. In contrast, ordinary memory is adaptive; our stories are flexible and can be modified to fit the circumstances. Ordinary memory is essentially social; it’s a story that we tell for a purpose: in Irène’s case, to enlist her doctor’s help and comfort; in Julian’s case, to recruit me to join his search for justice and revenge. But there is nothing social about traumatic memory. Julian’s rage at his girlfriend’s remark served no useful purpose. Reenactments are frozen in time, unchanging, and they are always lonely, humiliating, and alienating experiences.
Janet coined the term “dissociation” to describe the splitting off and isolation of memory imprints that he saw in his patients. He was also prescient about the heavy cost of keeping these traumatic memories at bay. He later wrote that when patients dissociate their traumatic experience, they become “attached to an insurmountable obstacle”:18 “[U]nable to integrate their traumatic memories, they seem to lose their capacity to assimilate new experiences as well. It is . . . as if their personality has definitely stopped at a certain point, and cannot enlarge any more by the addition or assimilation of new elements.”19 He predicted that unless they became aware of the split-off elements and integrated them into a story that had happened in the past but was now over, they would experience a slow decline in their personal and professional functioning. This phenomenon has now been well documented in contemporary research.20
Janet discovered that, while it is normal to change and distort one’s memories, people with PTSD are unable to put the actual event, the source of those memories, behind them. Dissociation prevents the trauma from becoming integrated within the conglomerated, ever-shifting stores of autobiographical memory, in essence creating a dual memory system. Normal memory integrates the elements of each experience into the continuous flow of self-experience by a complex process of association; think of a dense but flexible network where each element exerts a subtle influence on many others. But in Julian’s case, the sensations, thoughts, and emotions of the trauma were stored separately as frozen, barely comprehensible fragments. If the problem with PTSD is dissociation, the goal of treatment would be association: integrating the cut-off elements of the trauma into the ongoing narrative of life, so that the brain can recognize that “that was then, and this is now.”
THE ORIGINS OF THE “TALKING CURE”
Psychoanalysis was born on the wards of the Salpêtrière. In 1885 Freud went to Paris to work with Charcot, and he later named his firstborn son Jean-Martin in Charcot’s honor. In 1893 Freud and his Viennese mentor, Josef Breuer, cited both Charcot and Janet in a brilliant paper on the cause of hysteria. “Hysterics suffer mainly from reminiscences,” they proclaim, and go on to note that these memories are not subject to the “wearing away process” of normal memories but “persist for a long time with astonishing freshness.” Nor can traumatized people control when they will emerge: “We must . . . mention another remarkable fact . . . namely, that these memories, unlike other memories of their past lives, are not at the patients’ disposal.
On the contrary, these experiences are completely absent from the patients’ memory when they are in a normal psychical state, or are only present in a highly summary form.”21 (All italics in the quoted passages are Breuer and Freud’s.)
Breuer and Freud believed that traumatic memories were lost to ordinary consciousness either because “circumstances made a reaction impossible,” or because they started during “severely paralyzing affects, such as fright.” In 1896 Freud boldly claimed that “the ultimate cause of hysteria is always the seduction of the child by an adult.”22 Then, faced with his own evidence of an epidemic of abuse in the best families of Vienna—one, he noted, that would implicate his own father—he quickly began to retreat. Psychoanalysis shifted to an emphasis on unconscious wishes and fantasies, though Freud occasionally kept acknowledging the reality of sexual abuse.23 After the horrors of World War I confronted him with the reality of combat neuroses, Freud reaffirmed that lack of verbal memory is central in trauma and that, if a person does not remember, he is likely to act out: “[H]e reproduces it not as a memory but as an action; he repeats it, without knowing, of course, that he is repeating, and in the end, we understand that this is his way of remembering.”24
The lasting legacy of Breuer and Freud’s 1893 paper is what we now call the “talking cure”: “[W]e found, to our great surprise, at first, that each individual hysterical symptom immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affect into words (all italics in original). Recollection without affect almost invariably produces no result.”
They explain that unless there is an “energetic reaction” to the traumatic event, the affect “remains attached to the memory” and cannot be discharged. The reaction can be discharged by an action—“from tears to acts of revenge.” “But language serves as a substitute for action; by its help, an affect can be ‘abreacted’ almost as effectively.” “It will now be understood,” they conclude, “how it is that the psychotherapeutic procedure which we have described in these pages has a curative effect. It brings to an end the operative force . . . which was not abreacted in the first instance [i.e., at the time of the trauma], by allowing its strangulated affect to find a way out through speech; and it subjects it to associative correction by introducing it into normal consciousness.”
Even though psychoanalysis is today in eclipse, the “talking cure” has lived on, and psychologists have generally assumed that telling the trauma story in great detail will help people to leave it behind. That is also a basic premise of cognitive behavioral therapy (CBT), which today is taught in graduate psychology courses around the world.
Although the diagnostic labels have changed, we continue to see patients similar to those described by Charcot, Janet, and Freud. In 1986 my colleagues and I wrote up the case of a woman who had been a cigarette girl at Boston’s Cocoanut Grove nightclub when it burned down in 1942.25 During the 1970s and 1980s she annually reenacted her escape on Newbury Street, a few blocks from the original location, which resulted in her being hospitalized with diagnoses like schizophrenia and bipolar disorder. In 1989 I reported on a Vietnam veteran who yearly staged an “armed robbery” on the exact anniversary of a buddy’s death.26 He would put a finger in his pants pocket, claim that it was a pistol, and tell a shopkeeper to empty his cash register—giving him plenty of time to alert the police. This unconscious attempt to commit “suicide by cop” came to an end after a judge referred the veteran to me for treatment. Once we had dealt with his guilt about his friend’s death, there were no further reenactments.
Such incidents raise a critical question: How can doctors, police officers, or social workers recognize that someone is suffering from traumatic stress as long as he reenacts rather than remember? How can patients themselves identify the source of their behavior? If their history is not known, they are likely to be labeled as crazy or punished as criminals rather than helped to integrate the past.
TRAUMATIC MEMORY ON TRIAL
At least two dozen men had claimed they were molested by Paul Shanley, and many of them reached civil settlements with the Boston archdiocese. Julian was the only victim who was called to testify in Shanley’s trial. In February 2005 the former priest was found guilty on two counts of raping a child and two counts of assault and battery on a child. He was sentenced to twelve to fifteen years in prison.
In 2007 Shanley’s attorney, Robert F. Shaw Jr., filed a motion for a new trial, challenging Shanley’s convictions as a miscarriage of justice. Shaw tried to make the case that “repressed memories” were not generally accepted in the scientific community, that the convictions were based on “junk science,” and that there had been insufficient testimony about the scientific status of repressed memories before the trial. The appeal was rejected by the original trial judge but two years later was taken up by the Supreme Judicial Court of Massachusetts. Almost one hundred leading psychiatrists and psychologists from around the United States and eight foreign countries signed an amicus curiae brief stating that “repressed memory” has never been shown to exist and that it should not have been admitted as evidence. However, on January 10, 2010, the court unanimously upheld Shanley’s conviction with this statement: “In sum, the judge’s finding that the lack of scientific testing did not make unreliable the theory that an individual may experience dissociative amnesia was supported in the record. . . . There was no abuse of discretion in the admission of expert testimony on the subject of dissociative amnesia.”
In the following chapter I’ll talk more about memory and forgetting and about how the debate over repressed memory, which started with Freud, continues to be played out today.
CHAPTER 12
THE UNBEARABLE HEAVINESS OF REMEMBERING
Our bodies are the texts that carry the memories and therefore remembering is no less than reincarnation.
—Katie Cannon
Scientific interest in trauma has fluctuated wildly during the past 150 years. Charcot’s death in 1893 and Freud’s shift in emphasis to inner conflicts, defenses, and instincts at the root of mental suffering were just part of mainstream medicine’s overall loss of interest in the subject. Psychoanalysis rapidly gained in popularity. In 1911 the Boston psychiatrist Morton Prince, who had studied with William James and Pierre Janet, complained that those interested in the effects of trauma were like “clams swamped by the rising tide in Boston Harbor.”
This neglect lasted for only a few years, though, because the outbreak of World War in 1914 once again confronted medicine and psychology with hundreds of thousands of men with bizarre psychological symptoms, unexplained medical conditions, and memory loss. The new technology of motion pictures made it possible to film these soldiers, and today on YouTube we can observe their bizarre physical postures, strange verbal utterances, terrified facial expressions, and tics—the physical, embodied expression of trauma: “a memory that is inscribed simultaneously in the mind, as interior images and words, and on the body.”1
Early in the war the British created the diagnosis of “shell shock,” which entitled combat veterans to treatment and a disability pension. The alternative, similar, diagnosis was “neurasthenia,” for which they received neither treatment nor a pension. It was up to the orientation of the treating physician which diagnosis a soldier received.2
More than a million British soldiers served on the Western Front at any one time. In the first few hours of July 1, 1916 alone, in the Battle of the Somme, the British army suffered 57,470 casualties, including 19,240 dead, the bloodiest day in its history. The historian John Keegan says of their commander, Field Marshal Douglas Haig, whose statue today dominates Whitehall in London, once the center of the British Empire: “In his public manner and private diaries no concern for human suffering was or is discernible.” At the Somme “he
had sent the flower of British youth to death or mutilation.”3
As the war wore on, shell shock increasingly compromised the efficiency of the fighting forces. Caught between taking the suffering of their soldiers seriously and pursuing victory over the Germans, the British General Staff issued General Routine Order Number 2384 in June of 1917, which stated, “In no circumstances whatever will the expression ‘shell shock’ be used verbally or be recorded in any regimental or other casualty report, or any hospital or other medical document.” All soldiers with psychiatric problems were to be given a single diagnosis of “NYDN” (Not Yet Diagnosed, Nervous).4 In November 1917 the General Staff denied Charles Samuel Myers, who ran four field hospitals for wounded soldiers, permission to submit a paper on shell shock to the British Medical Journal. The Germans were even more punitive and treated shell shock as a character defect, which they managed with a variety of painful treatments, including electroshock.
In 1922 the British government issued the Southborough Report, whose goal was to prevent the diagnosis of shell shock in any future wars and to undermine any more claims for compensation. It suggested the elimination of shell shock from all official nomenclature and insisted that these cases should no more be classified “as a battle casualty than sickness or disease is so regarded.”5 The official view was that well-trained troops, properly led, would not suffer from shell shock and that the servicemen who had succumbed to the disorder were undisciplined and unwilling soldiers. While the political storm about the legitimacy of shell shock continued to rage for several more years, reports on how to best treat these cases disappeared from the scientific literature.6
The Body Keeps the Score Page 23