Twenty-two years later, between 1985 and 1990, the social fabric of everyday life of the families whose raped/and or abused children Tsaltas sees has so deteriorated that she has altogether shifted her goals ‘from direct efforts at unconscious conflict resolution to the more indirect but more effective method of re-establishing maturational tracks’. In other words, her psychiatric work has become directly remedial: families are involved, dialogue with the children in trying to establish a narrative of their lives may accompany play, and certainly take more of the treatment time; education and future planning about how they can return to school and cope forms part of the psychiatric plan. The children are designated as ‘traumatized’. They come to the psychiatrist on a referral from a rape crisis centre and their assailant has usually already been dealt with by the criminal courts and is locked up.
In the world in which they live, single-parent families, absent jailed fathers, step-boyfriends are the norm. Poverty is endemic. Aids makes sex even more dangerous. And between 1988 and ’89, crack cocaine use has doubled the murder rate. Even at the start of this period, so prevalent are fears of abuse that mothers tell her that they must be present when she interviews their children–just in case. The doctor is now also a potential abuser–a fear that had become so widespread in the USA at this time that polled university students said they would prefer to have therapy with a computer program than with an analyst. Tsaltas in fact finds that the parent’s presence diminishes the child’s anxiety and, in turn, the child is shored up by the shrink’s presence. She can divulge the family ‘secret’ in front of a parent who has promised not to react. Five of the girls she saw during this time had been not only raped, but sodomized, and one of them had been gang-raped by her father and his druggy friends. Another had been prostituted for drug money.
The level of violence, associated with sex or not, has risen incrementally. In this urban world, brutalized by poverty, mind-doctoring feels like a plaster applied to an arterial haemorrhage. The psy worker can provide a little remedial help, can educate in emotions and social values–as, for instance, lessening the child’s continuing fear by reducing the rapist ‘to the emotionally disturbed, sexually immature figure he really is’ and showing her appropriate adult behaviour, so that she understands how ‘her formerly beloved assailant deviated from that role and those behaviors’.
What is at issue here is not psychic disorder so much as social deterioration of a radical kind. One of the problems of our time is that mind doctors are called upon to deal with ills that have to do with endemic poverty and social breakdown. The theorization of trauma that grows out of this period–with its origins in war neurosis–may have not a little to do with the psy professionals’ own terror at what is being asked of them during a peacetime in which the brutalization and distress of poverty, displacement and drugs take the emotional toll of war.
NEW DIAGNOSTIC CATEGORIES
In 1976, the Comprehensive Textbook of Psychiatry by A.M. Freedman, H.I. Kaplan and B.J. Saddock still claimed that the rate of father–daughter incest was one in a million. Anyone who recognized this text as authoritative would, of course, doubt the reality of a patient’s claims of sexual abuse. Little wonder that women trainees in the therapeutic professions during these years rebelled against the received wisdom. The new generation were not afraid to voice issues their teachers and supervisors would have found too shameful to speak. Following Jeffrey Masson’s lead in The Assault on Truth, many attacked Freud’s shift from an early understanding of sexual seduction as real and traumatic to a focus on fantasy and the psychic life. They mutinied against analysts who refused to give enough weight to the ‘real’ of their lives and turned to his disciple Ferenczi, who in a late paper, ‘The Confusion of Tongues,’ upheld the importance of distinguishing the real from the fantasized both in childhood and in the consulting room.
Amongst this new generation was Judith Herman, who had a background as a civil rights and women’s movement activist. Moulded by consciousness-raising, which she said taught her to trust the personal testimony of women, and her experience as a Harvard-trained psychiatrist working within a ‘victims of violence’ unit, Herman had the authority to contest the ways in which the psychiatric establishment tended to misdiagnose abused women by seeing their ills as a function of their character: a fundamental masochism coupled with promiscuity, for instance, would be said to elicit violence from the male. The perpetrator’s crimes and behaviour were thus repeatedly laid at the feet of the victim.
Herman recounts how in the eighties when the DSM was coming up for revision, a group of male psychoanalysts proposed a diagnosis of ‘masochistic personality disorder’ to be applied to a person ‘who remains in relationships in which others exploit, abuse, or take advantage of him or her, despite opportunities to alter the situation’. Women’s organizations protested, as did Herman, who participated in the DSM revision process. Many of the male psychiatrists failed to see what the women, who during this period worked with the battered and abused in crisis centres and the courts both in America and Europe, learned: that chronic abuse renders a victim passive and dependent on the perpetrator, who often has also isolated her from the rest of society.
Like captive to kidnapper, or prisoner to warder, the relationship between battered wife or child and her abuser generates helpless passivity, robs initiative, and induces that numbness which is also a means of enduring repeated violence. Since for the woman and child what is at issue here is a dismantling of the nature of love, the ability to trust is fundamentally damaged. In front of medics or courts, a perverse loyalty may make her unwilling or too ashamed to reveal the full scale of abuse. As the campaigning barrister Helena Kennedy has also argued, male judges, alongside doctors, trapped in an old double standard about sexuality, were used to blaming the victim for the crime, whether it was rape or repeated abuse, and slow to see the nature of the psychological damage inflicted.
Herman and her women colleagues won a victory over the ‘masochistic personality disorder’ diagnosis and its stigmatization of the victim. The compromise diagnosis, now relegated to the appendix of the DSM, became ‘self-defeating personality disorder’, and the criteria stopped it being applied to anyone who had been physically, sexually or psychologically abused.
In line with one school of feminists, Herman’s major book of 1992, Trauma and Recovery, attacked Freud for reducing psychoanalysis to psychic and unconscious determinants, and so ensuring that the dominant psychological theory of the twentieth century was founded in the ‘denial of women’s reality’. Drawing on clinical work with the victims of sexual and domestic violence, combat veterans and the victims of war and terror, Herman’s book has the zeal of a political campaign. The elision of battered women and political prisoners, rape survivors and combat veterans, of ‘the survivors of vast concentration camps created by tyrants who rule nations and the survivors of small, hidden concentration camps created by tyrants who rule their own homes’, is rhetorically powerful. There is no doubt that the book ‘validates’ women’s experience of sexual violence and raises it to a top-grade category of suffering where the worst and most heroic forms of degradation certainly belong. But the very notion of ‘validation’, like that of empowerment of victims, may sit more readily in a human rights court or a political campaign than within a psychiatric environment.
However, since diagnoses do make their way into court in the form of expert witnesses, since they do affect divorce, custody or the rarer murder trials and also serve to release insurance expenditure for treatment, the battle to find a diagnosis for the abused of the private sphere had a sense of justice about it. The diagnosis which Herman and her colleagues battled to attach to abused women was PTSD–post-traumatic stress disorder. PTSD has a dramatic history of its own, which brings together hysteria, the disputed war neuroses, the search for reparations from the Germans after Nazi atrocities, and the protracted campaigning by Vietnam veterans for compensation for the debilitating psychic after-effects of w
ar. PTSD found its way into the DSM in 1980.
Classified as an anxiety disorder, its criteria were expanded in the revised DSM III-R of 1987:
a. The individual has experienced a traumatic event that (1) is ‘outside the range of usual human experience’ and (2) would be ‘markedly distressing to almost anyone’.
b. The traumatic event is persistently reexperienced in at least one of the following ways: (1) recurring and intrusive distressing recollections of the event; (2) recurring distressing dreams of the event; (3) sudden acting or feeling as if the traumatic event were recurring; (4) intense psychological distress when exposed to events that symbolize or resemble an aspect of the traumatic event.
c. The individual persistently avoids stimuli associated with the trauma or experiences a numbing of general responsiveness. To meet this criterion, a person has to evidence at least three of the following: (1) efforts to avoid thoughts or feelings associated with the trauma; (2) efforts to avoid activities or situations that arouse recollection of the trauma; (3) an inability to recall an important aspect of the trauma; (4) a markedly diminished interest in significant activities; (5) feelings of detachment or estrangement from others; (6) a restricted range of affect; (7) a sense of foreshortened future.
d. The individual experiences persistent symptoms of increased Autonomic arousal not present before the trauma. The person must exhibit at least two of the following: (1) difficulty falling or staying asleep; (2) irritability or outbursts of anger; (3) difficulty concentrating; (4) hypervigilance; (5) exaggerated startle response; (6) physiological reactivity when the individual is exposed to events that symbolize or resemble an aspect of the traumatic event.
On the committee to help write the definition of PTSD for DSM IV, Herman succeeded in having the phrase ‘outside the range of usual human experience’ removed, as well as ‘would be markedly distressing to almost anyone’. This left the way open for the sexually abused and battered wives to be diagnosed as sufferers of PTSD, an affliction that had already gone to court on numerous occasions, particularly with war veterans in America, and won compensation. It is said that the diagnosis has risen by some 50 per cent since the definition was enlarged. Breslau and Davis, who have also carried out gender-based research on PTSD, say that women are at greater risk than men as a result of ‘assaultive violence’ and that because of their helplessness, suffer far longer from its effects.
There is now a movement afoot for the new edition of DSM-IV and the ICD (International Classification of Diseases) to contain a ‘complex’ version of the diagnosis, which would make further reference to the effects of chronic or persistent abuse. Herman argues that victims of prolonged and repeated trauma such as Holocaust survivors, or those who have been subject to totalitarian control–which can include totalitarian systems in sexual and domestic life–hostages, survivors of some religious cults, ‘develop characteristic personality changes, including deformations of relatedness and identity’. They may withdraw from others, disrupt their intimate relationships, suffer from persistent distrust, despair of life, be preoccupied by suicide, fail to protect themselves, be jumpy, and see threatening situations or recurrence of the traumatic events as possible everywhere. They suffer from numbing, insomnia, nightmares and hyperarousal, part of the disorder of the fear/flight mechanism.
Victims of prolonged abuse in childhood develop similar problems and in addition are ‘vulnerable to repeated harm, both self-inflicted and at the hands of others’. Most dramatically, perhaps, they suffer from ‘alternation in consciousness’, not only in the form of the intrusive recall of traumatizing event(s), but in the form of transient dissociative episodes during which amnesia sets in. The standard explanation of this is to do with the abused child coping with repeated brutalization by blocking out existing experience and entering a trance state. This defence is learned; what is called a vertical splitting becomes habitual (rather than the horizontal notion of a Freudian repression into the metaphorically buried unconscious). During this splitting, alternative personalities or alters can emerge–or so they have been interpreted in the literature ever since Janet described his hysterics and Morton Prince his Miss Beauchamp.
Herman’s battle to include abused women alongside survivors of war, disaster and terror under the diagnosis of PTSD did indeed elevate women from the much maligned implication of hysteria or, often, from that classification so loathed by psychiatrists and analysts, Borderline Personality Disorder. But a concept of dissociation, linked with a presumption of incest which could be remembered, had side-effects: it rendered suffering symptomatic and a signal of a psychiatric disorder. ‘Suffering from intimacy, an inability to create safe and appropriate boundaries between the self and others, having a tendency to idealize or denigrate’, could, after all, more or less describe any woman at the end of an affair.
Herman’s therapy for recovery, inspired by the cases that human rights lawyers build with torture victims, involved providing a safe environment in which the patient could trust the therapist. In that safe haven, remembering and reliving horror could occur. The cathartic effect was enabled by the scripting of a trauma narrative which filled in the patient’s missing moments. In putting together the details over many sessions, the therapist acted as prompt and ghost writer. What the patient didn’t remember, the therapist filled in to provide coherence. At all points, the therapist’s role was actively to believe the patient’s story and encourage it.
Since traumatic events re-invade the patient’s mind as images, are incoherent and inarticulate flashes, putting words to these images, providing them with context, sense, history would offer relief. Where there were amnesiac gaps, hypnotherapy, the truth drug sodium amytal or drama therapy were used. Throughout, the therapist acted as a trusting and ‘compassionate witness’. There was one further stage to the therapy: the trauma document validated the patient’s experience and suffering fully only once it was made public as testimony–and perpetrators confronted. Abusers, like war criminals, need to be taken to court.
Herman’s technique is part psychological, part political. The mixture of the two, the use of recovered memory to indict sexual abusers, went against the grain of the more psychoanalytically based part of the profession. Freud had long ago said that the logic of the unconscious, with its uncertain differentiation between the imaginary and the real, and its lack of punctuated time, had no place in the courtroom. The truths of the psyche were not the same as legal evidence. Recovered-memory therapy was based on the assumption that they were.
MULTIPLES
Dissociated memory with its roots in trauma was linked to that other great illness epidemic of the last part of the century, Multiple Personality Disorder, or MPD, which came into the DSM in 1982 and was later revised as Dissociative Identity Disorder, or DID, in 1992. Based again on the prolonged horrors of child abuse from which the victims dissociate, the florid sufferers of MPD, like Charcot’s earlier hysterics, performed an acrobatics of alteration, moving between good and bad, male and female personae. At least two distinct alters were necessary for the DSM classification, but in the lore of what Ian Hacking has described as a ‘down home’, ‘egalitarian’ movement, as many as thirty-two alters have been documented in the same person. An illness of both identity and memory which made the vulnerable all too susceptible to the suggestions of therapists, MPD travelled America remembering satanic abuse and a whole vivid string of horrors which far outranked anything Miss Beauchamp had managed to remember in Prince’s consulting room.
The popularizing of illness descriptions, particularly where the drama of multiples was concerned, was ripe for unconscious mimicking by the vulnerable, often depressed, possibly self-harming and suicidal, certainly suggestible: the behaviour could then become all too real. Human beings are complicated creatures, subject to being ‘made up’ by medical and psychological inquiry, authoritative group or institutional descriptions, so that they can be changed or bettered or simply emulated. Since people are not static, they intera
ct with their own classifications, through support groups or lobbies, and in a ‘looping effect’ create new kinds of people. The 1990s multiple with her support groups and websites was a different being from the mediums or hysterics investigated by the psychologists of the turn of the nineteenth century. What remained the same was that the behaviour needed a little learning, just as had the various acrobatic postures of Charcot’s arc of hysteria.
As Hacking observes in Rewriting the Soul (1995), fewer than fifty cases of multiples had been noted in the medical literature between 1922 and 1972. In 1973 Sybil appeared, Dr Cornelia Wilbur’s case of a grande hystérie, and captured the public imagination, eventually becoming a popular movie. Sybil–as told by her psychiatrist to the journalist Flora Rheta Schreiber who came to live with Sybil, Wilbur and her other multiple patients–is a multiple with sixteen alters whom Wilbur treated first in Nebraska, then took along to New York as a graduate student when she moved there to do a psychoanalytic training, and who finally followed Wilbur to Kentucky.
An intelligent young woman, Sybil suffered from fugue episodes in which she woke up in strange places without knowing how she had arrived there. Amongst Sybil’s warring personalities, some were children; two were men. Some remembered childhood: they had emerged to cope with the terror of a perverse mother, who punished the little Sybil with cold water enemas tied so as to prevent expulsion, sharp objects in her vagina and a sordid list of other tortures. Wilbur went on to confirm that the implements existed in Sybil’s childhood home. Whether–as Hacking underlines–they had been used in the manner Sybil’s alters remembered did not really matter by the time the story had percolated and then been dramatically recreated in the public arena. The links between dissociation, multiple personality and childhood abuse had been made. The swell of abuse findings and narratives over the coming years would mostly change the sex of the abusing parent.
Mad, Bad, and Sad: A History of Women and the Mind Doctors Page 51