ou'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.
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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.
eorge 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.
ere'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.