• PTSD and fright disorders

TN_frightTobie Nathan, PhD[ii] & Catherine Grandsard, PhD[iii]

PTSD and fright disorders: rethinking trauma from an ethnopsychiatric perspective[i]CG_fright3

 

Introduction: trauma and therapy

DrapeauGBThough the notion of trauma and its present day version of Posttraumatic Stress Disorder (PTSD) allows for wide comparative studies, by standardizing experiences ranging from, for instance, the allergic reaction of a Peruvian farmer to the painful depression of an American soldier home from the front, it proves to be a dull and difficult concept to use for the therapist intent on treating patients. In fact, even in its current rendition, trauma is an exception in modern day psychopathology. It is one of the few disorders which hasn’t been amended by scientific discoveries, neither in terms of comprehending its mechanisms, nor in terms of developing successful treatments. This is not the case of most other diagnostic entities. For example, original psychoanalytic classifications and descriptions of the different neuroses have, over time, been completely revised and broken down into different categories and sub-categories (anxiety disorders, dissociative disorders, mood disorders, etc.), most of which may be successfully treated, or at least alleviated, by medication. Indeed, as a consequence of the discoveries of new and multiple approaches to psychopathology (pharmacological, behavioral-cognitive, genetic, etc…), 19th century categories of mental disorders have for the most part been diffracted into new, more relevant ones. Yet this is not the case of trauma, which remains largely unchanged as a clinical entity since the late 1800’s and early 1900’s, despite the fact that it is now classified as an anxiety disorder. Nevertheless, for this type of disorder, psychotropic medication appears to be of limited help[iv] and psychotherapeutic approaches are oftentimes rather unsophisticated, frequently inspired by concepts from the past such as catharsis — even under the modern form of debriefing — which requires the patient to retell the traumatic event in order to relive it and thereby reprocess it both emotionally and cognitively. We must admit our skepticism regarding this type of method, substantiated in recent years by several publications[v]. In point of fact, according to our own clinical experience with trauma victims, memory activation is in most cases useless and sometimes even harmful, as it reactivates the pain and fright, in effect producing a new trauma. Indeed, as Georges Devereux had already noted in 1966[vi], where trauma is concerned, there is no mithridatic or habituation process. On the contrary, trauma includes a cumulative, potentiating effect which explains the fact that symptoms may sometimes be kindled by a very minor event long after the initial trauma. This point will be further discussed later on in this paper.

TN&CG1

Tobie Nathan & Catherine Grandsard

Turning back to trauma as a psychopathological category, interestingly, it is the only mental disorder for which an external cause is clearly identified in the form of a specific type of event experienced directly or simply witnessed by the patient[vii]. However, as such, it poses a methodological challenge to psychopathology research and theory. Indeed, the challenge is to develop a model which successfully conceptualizes the traumatic event, offering a specific handling of the event itself. Yet most models and interventions focus exclusively on individual characteristics of the trauma victim, his or her psyche, biology or cognitive processes (e.g. debriefing, EMDR, BCT, etc…) thereby excluding the causal, external event and its treatment. Moving beyond the ongoing contoversies pertaining to the relevance and effectiveness — or lack thereof — of the most popular present day approaches to trauma[viii], the central question of the event or events at the root of any traumatic disorder remains, in our view, the most crucial key to understanding trauma and treating its consequences. The following clinical example will illustrate our point.

Clinical observation

TN&CG6In 2000, one of us (9)[ix] travelled to Kosovo with several staff members of our ethnopsychiatry team to give a training seminar on the treatment of psychic trauma caused by war. On this occasion, a young Albanian speaking Kosovar woman of about 20 years of age, suffering from alarming symptoms, was introduced to us. She had been pratically unable to sleep for ten months, wore a fixed hagard expression on her face, and pleaded for medication which would finally enable her to sleep. Over and over, she had repeated the same story: three paramilitary Serbs had come to her village. She had been told many times how the Serbs would kill men and rape women and when she saw the three men, she ran away in terror. The men ran after her and caught up with her inside a barn. There she was, faced by three men in battle fatigues, their frightening faces smeared with black. One of them waived his hand at the young woman and said “You, come over here…”   At that moment, she fainted. How long she had remained unconscious, she didn’t know. What had happened during that time? Had she been sexually abused? She couldn’t really say… Was it because she was ashamed or had she truly forgotten? She preferred to think the men had left her there and gone away. But ever since that day, as soon as she fell asleep, she would see those same three frightening men approaching her and wake up with a start, drenched in sweat. Those first scary minutes of sleep were then followed by a long night of insomnia. The clinicians who treated her were all convinced that during those moments she relived the scene where she had fainted. Yet, when we set out to explore in detail exactly what she experienced during what she referred to as her nightmare — a violent constriction of the throat, suffocation, burning sensations on her neck — she gradually described what she in fact perceived. It wasn’t the paramilitary troops but a strange sort of bird, coming down from the sky, latching on to her neck and causing her to awaken with a start…

Hence, the habit of understanding dreams as containing precious messages about a person’s past had kept the patient’s therapists from solliciting information about her true perceptions. In point of fact, the young woman’s dream contained the following information: the extreme fright caused by the sight of the three paramilitary Serbs had fractured her being, causing a breach in which a mythic being had engulfed itself, a strange bird, a striga, which returned every night since then. Recognizing the existence of this being, exploring in depth with the patient both its nature and technical ways of getting rid of it sufficed for the young woman to find sleep again that very same night. The reason she had not been able to rest for so long was that her therapists had all suspended their investigation the moment the Serbs appeared in the dream. Understanding and treating the traumatic event at the root of traumatic symptoms is therefore not as simple a task as it might seem. After our long interview with the young woman, it was indeed clear that the etiology of her pathology, the origin of the breach in her psyche, was in fact fright. But how and why is fright the cause of disorder? As demonstrated by this particular case, but also by many cultural etiological models of fright found worldwide, fright evidently causes disorder because it puts human beings in the presence of beings from other worlds.

The nature of traumatic events

In terms of etiology, practitioners often note two fundamental emotions in relation to a trauma: fright and experiencing death. In fact, both characteristics are included in the very definition of the traumatic event in the DSM-IV (10) [x]. Thus, a traumatized person is first and foremost someone who has been frightened. Apparently, the reason a new word was created in the field of psychopathology is because the common use of the terms fear or fright had gradually lost their physical connotations. Indeed, the emotional turmoil brought on in a moment of great fright associates sudden and unexpected fear, a physical startle response, an abrupt change in equilibrium, followed by tachycardia and a physical sensation of heaviness in the stomach or chest. The impression, when a frightened person manages to describe the experience, is both one of loss, as if her breath had suddenly been taken from her, and the feeling of an invasion, as though a foreign entity had penetrated by surprise inside her system. And, just as in the Kosovar example given above, such powerful fear is provoked when a person is faced with the experience of her own death. Not merely the fear of dying, but the actual living of one’s death, of an instant where one knows one is dying or sees oneself dead.

Clinical observation

TN&CG5He stands on a high scaffolding in a Parisian suburb, tightening the bolts in a metal sheet held in place by four screws, as he has done many times. The first two are easy but when he goes to tighten the third one, his wrench slips on the bolt. He feels himself falling backwards. He lands on his back after a fall from a height of ten meters. His head and lower back strike the ground first. He feels the strap of his helmet give way and loses consciousness. He awakens on a stretcher. Men clad in white stand around him. He realizes he is in Paradise, in the Muslim Paradise where the dead wear long white gowns. He is X-rayed and tested: aside from several bruises, he presents no alarming symptoms, no broken bones or hurt organs. A week later, he is discharged from the hospital. Ever since, he suffers without respite from splitting headaches, dizziness, nausea, whisling in the ears, lower back pain, visual disorders and insomnia. Three years later, the traumatic pathology which developed in the wake of his encouter with his own death is still acute (11) [xi].

Many clinicians have encountered similar cases. Faced with the endless repetition of the same narrative, of the same traumatic scene, what can be done? The only way a therapist can possibly stand such a feeling of helplessness for weeks, months and sometimes years on end — a reflection of the patient’s experience of his own death — is by asking the question “why?”. Why him? Why then, on that day? Because of whom? By doing so, he or she is once more bound to witness the appearance of beings. For instance, so and so had made love to his wife, and later stored the towel stained with semen under the couple’s mattress, before going to work. That evening, his wife had asked him if he had seen the towel. He told her it was stored in the usual place, but she couldn’t find it. Later, he had forgotten about the incident. A week after, he had had the accident. As it turns out, his sister in law, his wife’s brother’s wife, who lives in the same building, had come over that day to borrow sugar. While her sister in law was busy with a child, she had crept into the couple’s bedroom and stolen the towel stashed under the mattress. Later that day, she had taken it to a sorcerer who had buried it in a cemetery… The point was to harm the couple most certainly out of spite or jealousy. This was in fact what had happened to the Algerian immigrant worker who fell from the scaffolding mentioned above. Now, there is only one way to recover the towel in such a case: the man must turn to a healer, a master of the spirits, for him to send one of his helper Djinns (12) [xii] out into the night to retrieve the missing object and thereby save the man from certain death.

Thus, trauma is one of the only modern notions for which the knowledge conveyed by traditional cultures turns out to be decisive. A short review of the etymology of the word fright in several languages will demonstrate how deeply such concepts are embedded in the culture’s vocabulary (13) [xiii].

Fright

TN&CG4In French, the word frayeur, which comes from the latin fragor (loud noise) refers to a strong emotion, a great fear; it is associated with the notions of surprise (a frayeur is always unexpected) and of physical start (panting, tachycardia, breathlessness). To experience a frayeur is both to be surprised while experiencing intense fear and to jump in fear. The word effroi refers to an even more intense experience of fright which seizes and sometimes even petrifies a person.

Up until the 19th century, it was still a common idea in France that the mere encounter with an epileptic or with a person suffering from tics was enough to transmit to the onlooker, through fright, the same being, spirit or demon which afflicted the person. “Never look at an epileptic having a seizure because you might catch the devil”, was a common saying. But if a human being can be taken over by a being from another world, it is because his own being, his “self” — or maybe one should say his “soul” — has fled under the shock of fear.

In Wolof, sama feet na — which is usually translated as “I’m frightened”— literally means “his or her ‘soul’ (feet = ‘soul’, life principle) has fled or taken leave of his or her body”.

In Bambara, diatiggé (from dia = ‘shadow’ and by association ‘soul’, ‘psyche’ and tiggé = ‘cut’), specifically refers to nightly terror caused by the encounter with a supernatural being such as a spirit (djinna), a sorcerer (subkha) or the soul of a dead person. As in Wolof, the word which expresses the concept of fright means “the soul is cut, or separated from the body of the person”. By extension, diatiggé also refers to the psychic disorders caused by fright, in particular agitation or brief psychotic episodes.

In Arabic, two words can be used to refer to fright. One of them, sar’; though very widespread is rather literary. It is derived from a root which means “to spill”, lose one’s original shape or even lose any kind of shape. The other word, khal’a, more commonly used in the Arabic dialects of the Maghreb, is directly derived from the verb meaning “to uproot”, to extract violently. The first word, sar’, was largely used in Medieval Arabic medicine and, after a series of metonymies, came to refer to disorders including chaotic physical agitation which modern authors identify as epilepsy or hysteria but which are closer to what anthropologists and ethnopsychiatrists describe as possession disorders (14) [xiv]. Once more, then, we are in the presence of a word which refers to both fright and to the etiology of a disorder caused by the occupation of the inner world of a human being by another, non human, being. As for the word khal’a, which can be translated as “uprooted soul”; it is very similar to other traditional etiologies and, as in Bambara or Wolof, is used to describe chaotic pathologies ranging from pediatric autism to psychomotor agitation syndromes and including the entire scope of defensive reactions to the environment such as mutism, echolalia, echopraxia and coprolalia.

In Spanish and Portuguese, susto, or “start”, also means fright and refers — in Spain, Portugal but also in Latin America — to a depressive type disorder the etiology of which is once again an encounter with a being from another world who chases the victim’s soul from his or her body in order to take its place. In Peru, among the Quechua people, the symptoms of susto include the gradual weakening of physical strength, isolation behavior, anorexia and insomnia. According to the Quechua, the disorder, which is common even in big cities, is caused by the capture of the victim’s soul by the Earth or by one of its representative deities (15) [xv].

The Hakka Chinese of Tahiti interpret a series of symptoms as the result of a frightening experience (hak tao) which has separated the person (often a child) from his double (t’ung ngiang tsai) which can therefore no longer reach its original location. The healer must do everything in his or her power to retrieve it, through persuasion, promises, tricks, intimidation or threats (16) [xvi].

In Kirundi, the language spoken in Burundi, the same root, kanga, is found in a series of words related to the notion of fright. Sylvestre Barancira explains the following (17) [xvii]:

Gukanga, means frightened; Kwikanga means to start; Ggukangagurika means to wake up frequently while shivering, to sleep agitatedly, to be on the lookout and to start frequently. [Meanwhile,] “Igikangge refers to an invisible being found in the wilderness, marshes, chasms, bushes or the depths of the earth. Its presence can be detected through smoke rising from bushes in the early morning or evening, or through sparks in the night, or unexpected noises which sometimes resemble cattle sounds, or simply when the vegetation stirs even though there is no wind. [As in many African countries,] the swirls of dust rising from the ground at sundown also indicate the presence of the frightening spirit. People say such swirls are in fact the sign of the spirit from beneath, the sacred python on its way to the drinking trough… A sudden cold, hot or numbing feeling is also a sign. These spirits of the wilderness have their own autonomous lives and, [like the Djinns or Jnun in Arabic cultures,] they also marry, have children, raise cattle and practice the same faith as humans, namely [the traditional religion of the Barundi:] the Kubandwa possession cult… It sometimes happens that an Ibikangge or Ibihume spirit may call out someone’s name as that person passes by, at sundown or in the wee hours of the morning. He or she who answers the call risks illness, madness or even death… Skin allergies, the sudden swelling of joints, paralysis of an arm or a leg, mutism, convulsions, agitation or delusions [are often attributed to the action of these spirits]… The etiology of such pathologies is the encounter with spirits, the victim having been frightened — yarakanzwe — by his or her meeting with bush spririts such as Igikangge, Ibinyamwonga or Iggihume. Iggihume is a frightening ghost, a monster, a wild and malevolant spirit, or the spirit of a person who died a violent death and wasn’t buried and who returns to haunt the living…”

Thus, in Burundi, like in many cultures around the world, the language itself contains the theory of fright with which we are becoming familiar: fright shatters the person’s self and thereby allows the entrance of an invisible non human being. The pathology which ensues — referred to as trauma, traumatic neurosis or PTSD in our own psychiatry — is nothing other than the manifestation of the invisible being inside the person. The therapy should then consist in expelling this being or, at the very least, in taming it.

Clinical narrative

CG_fright2We will turn now to a case where fright indeed caused an invisible being to enter a person albeit one which is both socially acceptable and even valued, at least in the cultural context in question. A brief historical reminder will prove useful in understanding the story.

Since the late 1950’s, Rwanda and Burundi — both of which acquired their independence in 1962 — have been plagued by political instability marked by the assassination of presidents, military putsches and episodic massacres (18) [xviii]. In the 1990’s, such massacres reached the scale of genocides. Among them, the 1994 events in Rwanda remain by far the most ghastly and incomprehensible. They were triggered in the early morning of April 6, 1994 by the shooting down by ground to air missiles of the airplane carrying the president of the country as it was preparing to land at the Kigali airport, the country’s capital. The Presidential Guard and the Interahamwe, a Hutu militia under the government’s command, immediately took over and set out to carry out a plan to physically eliminate every single Tutsi living in Rwanda. Within a few weeks, the country had literally become a blood bath, river waters turning red with th blood of countless bodies, corpses by the tens of thousands littering the roads. Four months later, one eighth of the country’s population had been brutally murdered by organized mobs wielding machetes, clubs, billhooks, and less often, guns (19) [xix].

Six months earlier, similar events — though on a smaller scale — had taken place in Burundi, a country largely made up of the same populations as Rwanda. In October 1993, following the assassination of the first Hutu president, at least three hundred thousand people had been massacred in retaliation, using similar non industrial means.

After the 1994 killings in Rwanda, the United Nations declared that Rwanda had been the site of a genocide perpetrated by the Hutu against the Tutsi, a genocide which took the lives of between eight hundred thousand and one million people. The institutional recognition of the genocide led to the creation by the Security Council of an international criminal tribunal for Rwanda (ICTR) based in Arusha, Tanzania. As for the killings in Burundi, they have yet to receive an international status. Meanwhile, noone has been judged or even accused by the extremely weak Burundian court system. Moreover, in order to downplay daily strife, amnesties have been repeatedly granted by different governments.

The following account was collected in November 2003, in the context of a training session on the psychological treatment of victims of mass trauma organized at the University of Bujumbura (Burundi) (20) [xx]. The speaker is the young man himself, whose name we have changed to Jean-Chrysostome.

“On October 21, 1993, President Ndadayé, who was a Hutu, was assassinated. For the Hutu, he was killed by the Tutsi. Groups of Hutu men set out to kill the Tutsi, barging into houses. I was at home with my brothers and we didn’t really know what was going on. Outside, a group of Tutsi men was formed but it was too small to stop the assailants. When they saw that they were too few, they ran away. I was with my brothers; there were three of us. We decided to flee in different directions. I went out into the street and I met a woman who was on her way to draw water from the well. I asked her where the killers were and when she answered me, I thought she was lying and I decided to run in another direction. I hid in the forest for the entire day. Around seven o’clock in the evening, I thought people weren’t killing anymore because of the quiet. I decided to leave the forest and to walk towards Muranza. The moment I set foot on the road, I ran into a group of thirty to forty men carrying flash lights, machetes, clubs, all sorts of things they were using to kill. They ordered me to stop but I ran into a house and locked myself inside. They followed me and broke down doors and windows. I hid inside to avoid the rocks they were throwing. They entered the house and told me to come to them. I had to obey. They searched every inch of the house; they were looking for other people but I was alone. They ordered me to step outside and once I did, they started to strike me with their machetes. They accused me of not having heeded their orders. They didn’t tie me up as they usually did so I managed to protect my head thanks to which I survived. I avoided some of the machete blows that way. They were all trying to hit me with their machetes. At one point, I heard someone say ‘be careful, don’t let him get away’ and I realized that I had to try. To my left, there were a lot of people but on the other side of me, there weren’t as many and I managed to slip through their legs. Two men ran after me. I fell once, twice and the third time they caught up with me. But one of my attackers also fell and I grabbed him by the throat and pressed as hard as I could. I also grabbed the billhook he wanted to use to kill me, but I caught it by the blade and hurt myself. I thought that if I let it go, he would retrieve it. The other guy was shouting, calling to his friends. A third guy came, he had a club and hit me on the back. I let go of the billhook and lay down on my back. One of them had a torch lamp; he realized I wasn’t dead. My heart was beating very fast.   I’m not sure what happened next, but I lay there without moving and they thought I was dead. They consulted each other to decide where to dispose of my body. They looked for a latrine in which they could throw me. They were saying there shouldn’t be any trace of blood. They picked me up and carried me towards the latrine. Since I was still slightly conscious, I tried to block the entrance with my knee. The club hit me on the leg and I fell to the bottom of the latrine which was about ten to twelve meters deep. When I hit the bottom, I realized the latrine hadn’t been used yet. I was aware that I was bleeding but I didn’t know where. I had lost my shoes but not my socks so I used them to wrap around my wounds. Then I passed out. A night and an entire day went by. Towards evening, I started to dream. In my dream, I saw my friends, the ones I had been with before the whole thing started. I saw someone trying to build a house on top of me, a kind of tower, like a latrine. I called out to him, asking for help and told him I was hungry and cold but the person didn’t budge. I shouted that if I ever managed to get out of this place, he would be sorry. Then I heard a voice saying ‘take a ladder and get out of there’. But there was noone, it was still a dream. Then I saw light from the setting sun. When I reached out for the ladder and saw the light, I regained consciousness. I realized there was no ladder and that I was alone. Gradually, I realized where I was. First I thought I was in a reservoir. When I realized there was no exit, I thought maybe I could use the holes in the walls of the latrine to climb out. That’s what I did. Since I’m a Christian, I prayed to God for His help to climb out of this hole. One of my fingers had been practically torn off but part of it was still attached to my hand. I tried to tear it off completely with my teeth but I didn’t succeed. So I folded it back inside my hand. My wounds were all very painful and I used my elbows to climb. I felt dizzy so I stopped for a while, resting against my back. Then I continued to climb. When I was about to reach the top, I banged myself against some rocks and hurt my shoulder but I managed not to fall back down. Once I was out, I stood still for about five minutes, looking around me, not realizing where I was nor what had happened to me. Then I thought I needed to hide somewhere. The first building I saw was a school, run by nuns. I noticed a small group of sentries watching out for fugitives. I entered the school. I forgot to tell you that my clothes had been torn off and I was in my underwear… I was bloody and covered with mud. A nun closed the gate behind me and told me to hurry inside, but I couldn’t go any faster so she waited for me. The first thing I said was ‘I’m hungry’ But when food was brought to me, I couldn’t eat a thing. So I drank some milk first and gradually I regained some strength.”

We were a group of people in the room specially set up for consultations at the University of Budjumbura. Among the young psychologists, several had lived through the same events but none had been so close to death. Everyone listened closely to Jean-Chrysostome’s story. When someone asked him where he had found the strength to resist, he answered that God had entered him, at the moment of the most intense fright, God who had manifested Himself in the ladder dream and given him the strength to climb out from the latrine. Since then, Jean-Chrysostome, both clinical psychologist and pastor in an Evangelical church, prays and heals, guided by the same being who appeared to him during those twenty four hours spent at the bottom of the latrine…

The cumulative process of trauma

TN&CG3In the three clinical examples provided so far, the traumatic event, through the process of fright described above, caused the victim to come into contact with another, hidden, world. In all three cases, this second, hidden world, was culturally available to the person, even though he or she had paid little attention to it in his or her daily life. In the first example, up until the traumatic event, the world of Strigas had had no direct relevance to the young woman, who had probably heard of these terrifying beings in stories and legends and had never thought she would personnally had anything to do with them. Yet her encounter with the threatening Serbs all at once put her in intimate contact with this hidden world, henceforth forcing her — as well as her therapists — to acknowledge its existence and contend with it. Similarly, as long as the Algerian immigrant worker had been more or less smoothly carrying out his daily routine in France, building a life for himself and his family there, he had little reason to think or care about witchcraft or about the Djinns. Here again, the fright caused by the accident, the experience of waking up in the world of the dead, changed that. His posttraumatic symptomatology was alleviated only once the other world characteristic of his culture of origin had been recognized and he received proper expert treatment within the framework of that other, hidden world. In both these examples, as in many such cases, the traumatic event put the victims in contact with the hidden world within their respective cultural contexts. In terms of therapy, the first step towards curing this type of patient is to give credit to the non human, invisible beings recognized and described as such by the patient’s cultural tradition. In our experience, a single session is often enough to obtain significant improvement.

Though similar to the first two, Jean-Chrysostome’s case, on the other hand, is slightly different. Following his traumatic experience, Jean-Chrysostome did not develop posttraumatic symptoms as did our first two examples. Quite the opposite, as a matter of fact, since after living through his own death and resuscitation, Jean-Chrysostome took on the responsibilities of a public figure, both a healer and a religious leader. In his case, rather than putting him in contact with traditional invisible beings of his cultural world, extreme fright, experiencing death and coming back to life, forced him to contend with forces which are presently taking over Burundi, and to actively participate in the construction of a new social reality. In effect, Christian churches of all imaginable denominations, as well as cults of Christian inspiration are rampant throughout Central Africa and are currently becoming the leading political forces in the region. Incidently, Jean-Chrysostome’s experience suggests the ways in which the traumatic process can be — and very often is — deliberately used as a political tool to bring about radical transformation and set up a new world. Though in his case he was destined to die by his agressors — the very fact that he survived is living proof that Jesus is indeed his personal Saviour ­—, his subsequent transformation or transfiguration nevertheless clearly demonstrates how orchestrating someone’s death and rebirth through the use of fright can be a powerful psychological and political tool allowing for a complete and irreversible transformation of the person. Indeed, for this very reason, trauma is a tool well known to traditional cultures as shown by the structure of numerous initiation rites around the world (21) [xxi]. For the same reason, it is also a tool more and more frequently put to use by present day radical political and religious groups.

The transforming power of trauma pertains to the cumulative aspect of the traumatic process. If we accept the idea suggested by cultural fright etiologies that extreme fright shatters the person, thereby putting him in contact with beings from another, unknown world, then the primary effect of trauma is a breakdown of the person’s former, habitual world. In it’s place, as we have seen, a new, hidden world is revealed. Yet, if and when this process is repeated several times, the culturally accepted hidden or unknown world and beings, revealed by the initial traumatic event, will in turn be shattered, putting the victim in contact with beings and worlds previously unknown not only to him or her but to mankind. This indeed explains the isolating effect of cumulative trauma, the victim, gradually becoming the only person on Earth to know of hidden worlds which noone else can see or perceive. Thus, with each new traumatic event, the person’s usual, everyday world loses meaning until it has become totally senseless and empty, obligating the victim — and also his or her therapists — to construct a “neo-world” in which the succession of events and their implications make some sort of sense. The following account written by an Auschwitz survivor is both a chilling and articulate description of this process (22) [xxii]. At the time of the excerpted incident, the author has been in Auschwitz for some time ; he has run into a man he knew from Paris and followed him to his block hoping to get some extra soup.

“I’m gulping the contents of a dish of soup when lightning strikes me.

A voice announces: ‘Lagersperre!’ Camp closed! Curfew!

What am I doing here? I drop the dish and race out the door.

I won’t make it this time. I’m dead. The reason is simple: I’m not in my own block in time for the curfew. For an SS, if this isn’t an attempted escape, then what is?

…I run and run and run, expecting a burst of machine gun fire from one of the miradors. Noone could avoid it. Each surveillance post watches over a sector within its range and it’s impossible to find cover. The only solution would be to throw myself against the electrified barbed wire fence.

I discover true fear. Not just anxiety, not just heightened imagination but reality. I am the prime target of all the SS machine gunmen. The only question is which one of the miradors will be the first to fire?

At that precise moment, I stopped being part of the “normal” world, acquiring my new skin: the skin of a camp prisoner (23) [xxiii]. Until that instant, I knew intellectually what was going on in the Lager. That evening, I lost all contact with my peers by perceiving relations between human beings from a perspective I hadn’t suspected, namely relations governed by the absence of laws. In effect, I am a solitary participant in an absurd game, the rules of which noone can master since each SS has the right to improvise according to his mood. For me, the name of the game, winner or loser, is death.

From now on, I am a Häftling, a full-fledged convict, a thing with a human face. The SS refer to deportees as a “Stück”, a piece or a part. A piece of wood or metal has value, at least commercially. The Stück I have become has no value whatsoever, be it esthetic, moral or commercial. It can be thrown away or burned. From now on, I am part of this world of spare parts. I am but a very small piece of a new world I couldn’t have imagined even though I am fitted into it.” (24) [xxiv]

Trauma, then, is a process whereby something happens not just to the person but to the world itself, thereby rendering the victim permeable to new ideas, open to the advent of a new order, in search of new meanings. This is one of the primary dangers of cumulative trauma. Once the person has been “opened up” by successive traumatic events, he or she is vulnerable to all sorts of social, political, religious and or esoteric forces and ideas, sometimes simultaneously, sometimes experimenting one proposition after the other in an endless search for meaning. The work of the therapist, in these cases, is to strive to both identify and construct, together with the patient, the new world heralded by the traumatic events and establish the patient’s place in it. Not a simple task…

Conclusion: a philosophy of fright

TN&CG2The concept of fright as an etiology has disappeared from scientific psychopathology, replaced first by the notion of anxiety (in psychoanalysis) or more recently by the idea of a biochemical imbalance of certain substances in the brain such as serotonin or dopamine (pharmacological psychiatry). Yet most traditional cultures continue to turn to it with proven therapeutic success. In effect, interpretations based on the notion of anxiety produce a lone subject with enduring psychic pain. Whereas the concept of fright compels clinicians to conceptualize otherness, true otherness, not our fellow “others” who are in fact identical, but “others from another world”, whose mere encounter causes a breach in our psyches, whose mere presence petrifies us! Taken a step further, cumulative fright compels the therapist to construct a new world for his or her traumatized patient.

The Kashinawa natives of the Amazon forest, who are aware of the advantage of producing individuals curious about other worlds, profess a true apology of fright. They claim that the ability to be frightened is a virtue which makes both a skilled hunter and a skilled shaman. Indeed, a hunter needs to be keenly attuned to the animal world and the shaman to the world of spirits (25) [xxv] and fright is the only way to introduce a person to another world. In order to initiate their professionals to the mastery of fright, apprentices are given a beverage called ayawaska containing juices derived from a liana and from leaves of a specific kind of tree. The Kashinawas provide the subtle explanation that the leaves produce the visions while the liana makes it possible to vomit the terror produced by the visions. The alternation between vision and regurgitation gradually confers to the apprentice the ability to stand his beneficial fright (26) [xxvi]. The ability to cope with being frightened is thus equivalent to the ability to perceive different worlds based on unknown logical principles. This ability can be compared to the curiosity of the researcher who has to be able to tolerate being surprised.

Today, the word “fright” is seldom used by psychopathology professionals who favor words such as “trauma” or “stress”, yet interest is growing in all the notions it subsumes. Recent research in the psychopathology of trauma and in ethnopsychiatry point to its relevance and to the fact that traditional cultures are right to hold on to it.

Reference List

CG_frightAfrican Rights. Not So Innocent: When Women Become Killers. London: African Rights, 1995.

Amercian Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, Amercian Psychiatric Association, 1994.

Barancira, Sylvestre. “Théorie et traitement traditionnel de la frayeur.” Paper presented at the Centre Culturel Français de Bujumbura, Bujumbura, Burundi, March 30, 2004.

Bialot, Joseph. C’est en hiver que les jours rallongent. Paris: Le Seuil, 2002.

Boris, Neil W, Ou, Alan C. and Singh, Rohini. “Preventing post-traumatic stress disorder after mass exposure to violence.” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 3(2) (2005): 164-165.

Crocq, Louis. “Histoire du debriefing.” Pratiques Psychologiques 10(4) (2004): 291-318.

Davidson, Paul. “Eye Movement Desensitization and Reprocessing (EMDR): A Meeta-Analysis.” Journal of Consulting and Clinical Psychology 69(2) (2001): 305-316.

Deshayes, Patrick. “Frayeurs et visions chamaniques : le malentendu thérapeutique.” Psychologie française 47-4 (2002): 5-14.

Deshayes, Patrick. “L’Ayawaska n’est pas un hallucinogène.” Psychotropes 8 (2002): 65-78.

Devereux, Georges. “Dedans et dehors… la nature du stress.” Revue de Médecine Psychosomatique et de Psychologie Médicale 2 (1966): 103-113. Reprinted in Devereux, Georges. Ethnopsychanalyse complémentariste. Paris: Flammarion, 1972, ch. II.

Ehlersa, Anke, and Clarka, David. “Early Psychological Interventions for Adult Survivors of Trauma: A Review.” Biological Psychiatry 53(9) (2003): 817-826

Gelpin, E., Bonne O., Peri T., Brandes, D. and Shalev, Arieh Y. “Treatment of recent trauma survivors with benzodiazepines: a prospective study.” Journal of Clinical Psychiatry 57(9) (1996): 390-394.

Hatzfeld, Jean. Dans le nu de la vie, récits des marais rwandais. Paris: Le Seuil, 2000.

Hatzfeld, Jean. Une saison de machettes. Paris: Le Seuil, 2003.

Hounkpatin, Lucien. “Survivre au génocide… et après ?” Revue Française de Psychosomatique 28 (2005):   99-113.

Lewis, Steve. “Do One-Shot Preventive Interventions For PTSD Work? A Systematic Research Synthesis Of Psychological Debriefing.” Aggression and Violent Behavior 8(3) (2003): 329-343.

Nathan, Tobie. La folie des autres. Traité d’ethnopsychiatrie. Paris: Dunod, 1986.

Nathan, Tobie. L’influence qui guérit. Paris : Odile Jacob, 1994 (reprinted in a pocket edition in 2002).

Nathan, Tobie. Nous ne sommes pas seuls au monde. Paris: Le Seuil-Les Empêcheurs de penser en rond, 2001.

Nathan, Tobie. “Ethnopsychiatrie, complémentarisme, possession.” Ethnopsy: Les mondes contemporains de la guérison 5 (2003): 7-28.

Nathan, Tobie. “The Djinns: A Sophisticated Conceptualization of Pathologies and Therapies.” In Integrating Traditional Healing Practices Into Counseling and Psychotherapy. Edited by Roy Moodley and William West. Thousand Oaks, London, New Dehli: Sage Publications, 2005, 26-37.

Neumeister, Alexander. “What role does Serotonin play in PTSD?” Psychiatric Times 23(4) (April 2006) http://psychiatrictimes.com/showArticle.jhtml?articleId=186700462 (accessed June 4, 2006).

Pury-Toumi, Sybil (de). “Une maladie nommée susto.”  Nouvelle revue d’ethnopsychiatrie 15 (1990): 173-207.

Robertson, Michael, Humphreys, Leanne and Ray, Rebecca. “Psychological treatments for posttraumatic stress disorder: recommendations for the clinician based on a review of the literature.” Journal of Psychiatric Practice 10(2) (2004): 106-118.

Sin Chan, Ernest. “Une étiologie traditionnelle chez les Hakka de Polynésie française : le hak tao ou la théorie étiologique de la frayeur.” Ethnopsy: Les mondes contemporains de la guérison 5 (2003): 181-207.

Taylor, Steven, Thordarson, Dana S., Maxfield, Louise, Fedoroff, Ingrid C., Lovell, Karina, and Ogrodniczuk. “Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training.” Journal of Consulting and Clinical Psychology 71(2) (2003): 330-338.

Van Emmerik, Arnold, Kamphuis, Jan H., Hulsbosch, Alexander M., and Emmelkamp, Paul MG. “Single session debriefing after psychological trauma: a meta-analysis.” The Lancet 260(9335) (2002): 766-771.

Vermeiren, Etienne, and De Clercq, Michel. “Le debriefing psychologique après un événement à caractère traumatique: intérêts et limites. Médecines de catastrophe-Urgences collectives 2(3-4) (1999): 95-99.

Watson, P., Friedman, M., Ruzek J., and Norris, F. “Managing acute stress response to major trauma.” Current Psychiatry Reports 4(4) (2002): 247-253.

Zajde, Nathalie. “Le traumatisme.” Psychothérapies. Edited by Tobie Nathan. Paris: Odile Jacob, 1998, 223-279.

Zajde, Nathalie. Enfants de survivants. Paris: Odile Jacob, 1993 (reprinted in 2005).

Zajde, Nathalie, and Grandsard, Catherine. “Kaddish. Rituel de deuil dans un groupe de parole d’enfants de survivants de la Shoah.” Nouvelle revue d’ethnopsychiatrie 31 (1996): 119-138.

Zajde, Nathalie, and Grandsard, Catherine. “Le groupe de parole d’enfants de victimes de la Shoah: un dipositif de recherche en psychologie clinique.” Psychologie française, 47 (2002): 73-83.

Zajde, Nathalie. Guérir de la Shoah. Paris: Odile Jacob, 2005.

Notes

[i] Paper presented at the Third International Trauma Research Net Conference, Trauma-Stigma and Distinction: Social Ambivalences in the Face of Extreme Suffering, St Moritz, 14-17 September 2006.

[ii] Full Professor of Clinical Psychology and Psychopathology, founder of the Georges Devereux Center at the University of Paris 8, and currently Cultural Counsellor at the French Embassy in Israel.

[iii] Family Therapist, Associate Professor of Clinical Psychology and Psychopathology, Adjunct director of the Georges Devereux Center, University of Paris 8, 2 rue de la liberté, 93526 Saint-Denis, France, website: http://www.ethnopsychiatrie.net

[iv] Neumeister, Alexander. “What Role Does Serotonin Play In PTSD?” Psychiatric Times 23(4) (April 2006) http://psychiatrictimes.com/showArticle.jhtml?articleId=186700462 (accessed June 4, 2006). See also Gelpin, E., Bonne O., Peri T., Brandes, D. and Shalev, A. Y. “Treatment of Recent Trauma Survivors with Benzodiazepines: A Prospective Study.” Journal of Clinical Psychiatry 57(9) (1996): 390-394.

[v] For example Van Emmerik, Arnold, Kamphuis, Jan H., Hulsbosch, Alexander M., and Emmelkamp, Paul MG. “Single Session Debriefing After Psychological Trauma: A Meta-Analysis.” The Lancet 260(9335) (2002): 766-771; Taylor, Steven, Thordarson, Dana S., Maxfield, Louise, Fedoroff, Ingrid C., Lovell, Karina, and Ogrodniczuk. “Comparative Efficacy, Speed, And Adverse Effects Of Three PTSD Treatments: Exposure Therapy, EMDR, And Relaxation Training.” Journal of Consulting and Clinical Psychology 71(2) (2003): 330-338.

[vi] Devereux, Georges. “Dedans et dehors… la nature du stress.” Revue de Médecine Psychosomatique et de Psychologie Médicale 2 (1966): 103-113. Reprinted in Devereux, Georges. Ethnopsychanalyse complémentariste. Paris: Flammarion, 1972, ch. II.

[vii] See diagnostic criterion A in the DSM-IV for both Posttraumatic Stress Disorder and Acute Stress Disorder : “The person has been exposed to a traumatic event in which both of the following were present:

  • the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
  • the person’s response involved intense fear, helplessness, or horror.” (Quoted from Amercian Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, Amercian Psychiatric Association, 1994, 427-428.)

[viii] See for example : Boris, Neil W, Ou, Alan C. and Singh, Rohini. “Preventing Post-Traumatic Stress Disorder After Mass Exposure To Violence.” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 3(2) (2005): 164-165 ; Crocq, Louis. “Histoire du debriefing.” Pratiques Psychologiques 10(4) (2004): 291-318; Davidson, Paul. “Eye Movement Desensitization and Reprocessing (EMDR): A Meeta-Analysis.” Journal of Consulting and Clinical Psychology 69(2) (2001): 305-316 ; Ehlersa, Anke, and Clarka, David. “Early Psychological Interventions for Adult Survivors of Trauma: A Review.” Biological Psychiatry 53(9) (2003): 817-826 ; Lewis, Steve. “Do One-Shot Preventive Interventions For PTSD Work? A Systematic Research Synthesis Of Psychological Debriefing.” Aggression and Violent Behavior 8(3) (2003): 329-343; Robertson, Michael, Humphreys, Leanne and Ray, Rebecca. “Psychological Treatments For Posttraumatic Stress Disorder: Recommendations For The Clinician Based On A Review Of The Literature.” Journal of Psychiatric Practice 10(2) (2004): 106-118 ; Watson, PJ, Friedman, MJ, Ruzek, Josef, and Norris, F. “Managing Acute Stress Response To Major Trauma.” Current Psychiatry Reports 4(4) (2002): 247-253 ; Vermeiren, Etienne, and De Clercq, Michel. “Le debriefing psychologique après un événement à caractère traumatique: intérêts et limites. Médecines de catastrophe-Urgences collectives 2(3-4) (1999): 95-99.

[ix] Tobie Nathan. See Nathan, Tobie. Nous ne sommes pas seuls au monde. Paris: Le Seuil-Les Empêcheurs de penser en rond, 2001.

[x] See above, note 2.

[xi] This case and its treatment were described in Nathan, Tobie. La folie des autres. Traité d’ethnopsychiatrie. Paris: Dunod, 1986.

[xii] In the Muslim tradition, the Djinns are invisible spirits who live alongside humans. See Nathan, Tobie. “The Djinns: A Sophisticated Conceptualization of Pathologies and Therapies.” In Integrating Traditional Healing Practices Into Counseling and Psychotherapy. Edited by Roy Moodley and William West. Thousand Oaks, London, New Dehli: Sage Publications, 2005, 26-37.

[xiii] See also Nathan, Tobie. L’influence qui guérit. Paris: Odile Jacob, 1994, reprinted in a pocket edition in 2002.

[xiv] See Nathan, Tobie. “Ethnopsychiatrie, complémentarisme, possession.” Ethnopsy: Les mondes contemporains de la guérison 5 (2003): 7-28.

[xv] This disorder is so common that it was introduced in the DSM-IV. See also Pury-Toumi, Sybil (de). “Une maladie nommée susto.”  Nouvelle revue d’ethnopsychiatrie 15 (1990): 173-207.

[xvi] Sin Chan, Ernest. “Une étiologie traditionnelle chez les Hakka de Polynésie française : le hak tao ou la théorie étiologique de la frayeur.” Ethnopsy: Les mondes contemporains de la guérison 5 (2003): 181-207.

[xvii] Barancira, Sylvestre. “Théorie et traitement traditionnel de la frayeur.” Paper presented at the Centre Culturel Français de Bujumbura, Bujumbura, Burundi, March 30, 2004.

[xviii] Large scale massacres occurred in 1959, 1962, 1965, 1972, 1988, 1992, 1993 and of course 1994. See Guichaoua, André. “Zoom sur… Les crises de la région des Grands Lacs”, Politique Africaine 68 (1997): 11-22.

[xix] See African Rights. Not So Innocent: When Women Become Killers. London: African Rights, 1995. See also Hatzfeld, Jean. Dans le nu de la vie, récits des marais rwandais. Paris: Le Seuil, 2000 and Une saison de machettes. Paris: Le Seuil, 2003.

[xx] See Hounkpatin, Lucien. “Survivre au génocide… et après ?” Revue Française de Psychosomatique 28 (2005):   99-113.

[xxi] See Zajde, Nathalie. “Le traumatisme.” Psychothérapies. Edited by Tobie Nathan. Paris: Odile Jacob, 1998, 223-279.

[xxii] On ethnopsychiatry and Holocaust survivors and their offspring, see Zajde, Nathalie. Guérir de la Shoah. Paris: Odile Jacob, 2005. See also Zajde, Nathalie. Enfants de survivants. Paris: Odile Jacob, 1993 (reprinted in 2005); Zajde, Nathalie, and Grandsard, Catherine. “Kaddish. Rituel de deuil dans un groupe de parole d’enfants de survivants de la Shoah.” Nouvelle revue d’ethnopsychiatrie 31 (1996): 119-138 ; Zajde, Nathalie, and Grandsard, Catherine. “Le groupe de parole d’enfants de victimes de la Shoah: un dipositif de recherche en psychologie clinique.” Psychologie française, 47 (2002): 73-83.

[xxiii] In French : déporté

[xxiv] Bialot, Joseph. C’est en hiver que les jours rallongent. Paris: Le Seuil, 2002, 67-68. Quote translated from the French by Catherine Grandsard.

[xxv] Deshayes, Patrick. “Frayeurs et visions chamaniques : le malentendu thérapeutique.” Psychologie française 47-4 (2002): 5-14.

[xxvi] Deshayes, Patrick. “L’Ayawaska n’est pas un hallucinogène.” Psychotropes 8 (2002): 65-78.