Inner trauma and outer trauma.
A psychoanalytic approach

by Arnaldo Novelletto

(Presented to the 4th International Congress of ISAP - Athens, July 1995)

What I would like to do is giving ad introduction, or rather a general frame of reference, to the clinical papers that will follow. In doing this, however, I would let you know the work that our group, the Roman Association for Adolescent Psychotherapy, has made in the last two years on the subject of the psychic trauma in adolescence.
I shall put in connection three arguments that at first sight could seem heterogeneous, but I hope that putting them side by side will make clear our views on psychic trauma.
1) My first argument is the relationship between infantile neurosis and psychic trauma in the psychoanalytic theory.
It has been said that Freud too obstinately insisted on linking together, in his theory of psychic trauma, two basically different psychopathologic paradigms. On one side there was the dynamic -genetic paradigm based on the unsuccessful repression of unconscious fantasies of seduction (as in the hysteric transference neuroses). On the other side the economic paradigm based on the so called "unbearable state", it is the Ego's inability to cope with any overwhelming and sudden input of inner and/or outer stimuli, as in war neuroses and in traumatic neurosis.
In 1925, with his second theory of anxiety, Freud seemed convinced of having been able to attain a satisfying synthesis of the two paradigms. Nevertheless many authors went on thinking that each one could function on its own, giving rise to psychic disturbances that were different in each of the two cases. In these authors' opinion, for instance, the "reaction to exceptional events", mentioned in DSM, can be fully understood by the economic paradigm, whereas transference neuroses can be better explained by the conflict paradigm. However even those psychoanalytic groups which maintain a relative wholeness of freudian methapsychology admit an essential difference in terms of mental functioning according to whether the psychic apparatus has to cope with external events or with an inner conflict between intrapsychic agencies.
All that is generally true, but to what extent does it apply to adolescence? The confusion of boundaries between inner and external reality, between dream and action, between oneself and the other, between past and present, are intrinsic characteristic of the adolescent mind. To assume the task of organising inner chaos without beeing obliged to give up the vital push of instinctual drives, that's the everyday problem of adolescents. We all perfectly know that repressed wishes of childhood use to take advantage of the least inefficiency of the Ego for breaking through into unconsciousness. In spite of this we do not feel it necessary to separate the two parts of the freudian theory of trauma, even though we think that the organisational task of the adolescent mind is set in motion by external stimuli and traumata quite often and in a peculiar way, different from the so called reviviscence of the infantile neurosis. We already felt that the economic point of view had a major role in understanding adolescent psychology at large, but studying and discussing traumatised adolescents we gradually came to believe that trauma can learn us much on the functioning of adolescent mind.

2)My second argument has to do with all that every adolescent feels having left behind himself, I mean his past. I am referring to all the contributions which have been given about trauma in childhood and, more recently, in adolescence. Those papers have shown that the developmental state of some parts of the psychic apparatus, as long as adolescence is going on, can explain many differences between the classical adult postraumatic syndrome and what can be observed in the course of development. Immaturity can affect mental functioning in many ways, as for instance:
a) automatic anxiety has not changed into signal anxiety yet, so that possible traumatic events cannot be clearly foreseen nor easily avoided.
b) affects are still precursors of adult affects, as far as they are undifferentiated, unverbalized and mostly somatic.
c) memory traces are still rudimentary, not apt to be recalled. Therefore traumatic suffering cannot be easily represented, neither set up into temporal courses of a story.
d) unconscious fantasies which contribute to the development of the self are grandiose, unrealistic, difficult to integrate in a suffering image of self.
e) the unconscious part of the Ego is poorly differentiated. Defence mechanism, particularly splitting, are primitive.
f) mourning process is poor, therefore trauma cannot be worked through as a loss, and retains a character of narcissistic wound.
All these immature conditions suggest that conflictual, neurotic paradigm and traumatic, economic paradigm must not be imagined as operating at the same level of mental functioning. On the contrary there is between them a relationship of cognitive hierarchy, in so far they correspond to different stages of psychic organisation. They therefore demand different therapeutic techniques, as we shall see.

3) My third argument id of clinical order. It concerns all that adolescent will meet before him, in the future. I mean his becoming an adult.
The change that psychic disturbances have met in the last decades has brought with it the large amount of narcissistic pathology that all we know. This state of things compels us to review many clinical tenets about the analysability of patients, the effectiveness of therapeutic technique, even the training of therapists. More and more often we find ourselves with patients who, without being overtly psychotic, suffer because of their impossibility to exist, to represent themselves, to recognise their own wishes, to fill in their inner emptiness, in a word because of their narcissistic immaturity and vulnerability.
Western culture urges adolescents to become responsible adults, but at the same time it is a parading values and ideals which, as far narcissism and omnipotence are concerned, correspond to those same levels that responsible adults should have been able to abandon. We wonder whether the lack of symbolisation and poverty of identity that we observe in so many adults can be the final results of those immature aspects of the adolescent mind we were speaking of some minutes ago. In other words, we wonder whether, once our traumatised adolescents will have become adults, they will possibly suffer with psychic disturbances not of neurotic order, but rather of the same narcissistic order we are saying.
The bridge I am trying to build between the three arguments I just touched on, aims to a precise goal. We believe that studying today's adolescent suffering could allow us not to remain too fixed to the point of view of neurotic pathogenesis, even taking into account that this point of view had a big role in our training formation for good, historical and didactic reasons. May be what we can learn when treating traumatised adolescents helps us not only in better understanding today's adult pathology, but also in preventing in youngsters future pathology of the same kind.
What evidences can we bring up to support such an hypothesis? Since trauma was chosen as the main theme of this congress, we proposed to the different Italian group working in the field of adolescence to share a common space in order to discuss our experiences. So we were able to hold in Milan, in October '94, a precongress whose proceedings have been collected in this book, just published.
It is based on the psychotherapies of about forty patients who had suffered with traumatic psychic process following to various events (sexual abuse, incest, death or separation of parents, severe diseases, car accidents etc.).I shall not dwell on clinical results that were generally satisfactory.
I would rather stress - as concisely as possible - two points.
A) The therapeutic approach to traumatic pathology in adolescence. In the literature on this subject we usually find that the concept of trauma has two different meanings. In the first sense trauma is understood as a second time (après coup), a posthumous defensive re-elaboration of infantile trauma. This latter could have been either unique or cumulative, but in any case it is the same that in the past could be considered the starting point of the infantile neurosis. The second meaning applies primarily to the specific reactions of the adolescent to the actual external events e meets with (or sometimes he provokes) even though we know that this actual traumata can be susceptible to reactivate old traumata of childhood.
This distinction may seem pedantic, but it is worth wile in so far as it reveals two different contertransference attitudes in the therapist and therefore two different clinical approaches. The first one aims at going back to the oedipal and pre-oedipal origins of primary trauma. The therapist who follows this kind of approach will necessarily tend to privilege infantile experiences and fantasies. This can lead to undervalue the fact that the adolescent patient is re-enacting his or her traumatic experiences in the light of his or her potentialities, sexual and/or aggressive, of the sexual body.
Such an approach can even produce harmful consequences whenever the reawakening of the infantile past I such to exceed the capabilities of containment of the adolescent Ego.
The second approach, in our view, is more peculiar for an adolescent therapist. he can be rightly aware that the origins of traumatic process lie in the infantile past of the patient, in his "unthought known" (Quoting Bollas). nevertheless he cautiously and patiently will evaluate traumatic process, taking into account all its defensive components and all the psychic resources the patient displays in his or her working through.
The traumatic response to external events determines a further change of the balance between inner and outer reality, that the same balance that can already be unstable in a narcissistic individual because of his relationship to primary objects. After trauma the adolescent patient will regress and will defensively build up a theory and a story of his own about the trauma he has suffered. In this unconscious defensive procedure he employs self representations that have been introjected from meaningful objects in an imitative way. These defences are therefore very rigid, have a postulate-like character and tend to organise themselves as character traits, generally on a depressed mood. Consequently the adolescent patient finds it difficult to recognise signals coming from his own inner world. Uncanny feelings and automatic anxiety are ready to take upper hand. The transitional role of external objects is seriously impaired. External objects tend to become as many targets on which split off parts of himself are projected. The patient clings to his own postulate like an external organiser, a kind of life law that takes the place of thoughts and feelings.
The impact with therapy gives the adolescent patient a second occasion of working through his trauma in a new way. Past traumata had meant to him repetitiveness, immobility, incommunicability. Reliving trauma in the transference situation makes it possible to change it in a shared transformational situation. Let us remember that a certain number of adolescents who cannot organise a neurosis look for traumata because in so doing they hope to meet again those repressed psychic situations that form the core of their infantile traumata.

B) As a second and final point I would say something on the psychotherapeutic technique with traumatic adolescents. As far as the general theory of technique is concerned, we follow psychoanalytic theory. However in our opinion the treatment of traumatic adolescents must have some characteristics on its own. I shall limit myself only to some basic criteria. Treatment must be primarily intended to facilitate the development of subjectivity (I could say of the <self or of the identity), its integration (I could say cohesion) and the functioning of preconscious part of the Ego.
Our attention when offering a psychotherapy stance to this patient goes mainly to all those associative resources that make it possible facilitating word representations, fantasies, activity, symbolisation, figurability, metaphorisation and so on. We do not consider this kind of treatment a supportive therapy, but a psychoanalytical psychotherapy put to the service of self and Ego development as a precondition necessary for further passage to a possible psychoanalysis proper.
In this same transference and countertransference dynamics play a decisive role. The therapist is invested from the beginning by the patient's unconscious wish of finding an endorsement of his own personal interpretation of trauma.
However the immature psychic organisation that made it possible a traumatic response to happen cannot tolerate this wish (as well as self and object representation involved in it) to be interpreted from the start.
Once a good enough analytic relationship to the inner world of the patient has been established, actual trauma will enable the patient to put a distance between himself and his infantile objects. The therapist will be faced with the so called "enlarged psychic space" of the adolescent (quoting Jeammet). In that space the patient will be able to explore his own ability of fantasying, feeling, recognise hidden parts of himself, accept the existence of ambivalence and conflicts. Bit by bit he will be able to replace the external trauma with those inner traumata that the therapist, following the compass of his countertransference, will be able to help him seeing.