As a psychoanalytic psychologist, I have been puzzled by the over-reliance of some clinicians to focus on childhood events as being primarily meaningful. Although childhood events and family dynamics can be an important focus of clinical attention, as I said in my last article medical illness, when it occurs in healthy adults, can be traumatic.

Medical patients can feel misunderstood when a therapist intentionally or unintentionally downplays aspects of the powerful impact of adult on-set medical illness.

Trauma has historically been associated with child abuse, cumulative losses, overstimulation, fear of abandonment, and feelings of helplessness. Herman (1992) described traumatic events as those that “overwhelm the ordinary systems of care that give people a sense of control, connection and meaning” (p. 33). Yet thinking about adults who experience adult-onset trauma is relatively new to psychoanalytic theory.

In her ground-breaking book, Boulanger (2007) takes up this problem directly and states that adults who experience trauma are difficult to categorize, especially given the metapsychology of traditional psychoanalysis, which has historically privileged meaning as being related to early childhood events, with less of an impact of adult-onset events.

As I implied in my last blog, one reason people are hesitant to engage in therapy is because the symptom of avoidance creates a situation in which people desperately want to not think about traumatic experiences.

It is not just avoidance that makes talking about trauma difficult. Dissociation helps defend against the overwhelming feelings that are associated with traumatic events. (Check out this Psych Central article on dissociation.) Essentially, dissociation is when we become disconnected from our feelings and occurs normally. People who have experienced trauma, however, are more prone to dissociation and it can make it hard to connect with others.

Putnam (1992) described dissociation as the “escape when there is no escape.”(p. 104). Excessive dissociation does not come without a cost, which includes:

“discontinuity of sense of self; an array of amnesias and gaps in the continuity of memory;  inability to transfer basic conceptual information across dissociative states, leading to a failure to learn from experience and erratic access to knowledge and skills; and inner conflicts and self-sabotage.” (p. 105)

The discontinuous sense of self that results from dissociation makes it difficult to think. Thus, for some medical patients, the cognitive abilities required to benefit from psychotherapy are simply less available. This explains why we need to work differently to engage patients in the therapeutic process and why some traditional psychoanalytic approaches have not been helpful to some people.

Not knowing about something too painful to know serves the function of a basic level of protection. We must be careful to not disrupt the ways people defend themselves. This is often why therapy takes a long time. Therapy for traumatized people ideally, should proceed slowly and with a lot of time for trust and a sense of safety to evolve.

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From Psych Central's website:
PsychCentral (July 27, 2011)

Mental Health Social (July 27, 2011)

From Psych Central's website:
PsychCentral (July 27, 2011)

Cathleen Mackay (July 28, 2011)

Melanie Greenberg (July 28, 2011)

NAMI Massachusetts (July 28, 2011)

Dawn McKinney, MS/RN (July 28, 2011)

    Last reviewed: 27 Jul 2011