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Recent studies have called into question the fifth and latest version of psychiatry’s Diagnostic and Statistical Manual’s creation of new diagnostic entities and categories that are scientifically unsubstantiated and that over-pathologize vulnerable populations such as young children and the elderly.
Here, I seek to expose and challenge the philosophical presuppositions that underwrite the entire DSM enterprise. These presuppositions descend directly from the metaphysical dualism of Rene Descartes.
Descartes’s metaphysics divided the finite world into two distinct basic substances: res cogitans and res extensa, thinking substances (minds) with no extension in space and extended substances (bodies and other material things) that do not think. This dualism concretized the idea of a complete separation between mind and world, between subject and object. Descartes’s vision can be characterized as a decontextualization of both mind and world. Mind is isolated from the world in which it dwells, just as the world is purged of all human meaning. In this vision, the mind is pictured as an objective entity that takes its place among other objects, a “thinking thing” that, precisely because it is a thing, is ontologically decontextualized, fundamentally separated from its world.
The DSM is a pseudo-scientific manual for diagnosing sick Cartesian isolated minds. As such, it completely overlooks the exquisite context-sensitivity and radical context-dependence of human emotional life and of all forms of emotional disturbance. Against Descartes and his legacy, the DSM, I am contending that all emotional disturbances are constituted in a context of human interrelatedness. One such traumatizing context is characterized by the relentless invalidation of emotional experience, coupled with the objectification of the child as being intrinsically defective. No wonder receiving a DSM diagnosis can so often be retraumatizing!
Pathologizing Grief
The DSM5 makes it possible to classify traumatic bereavement—that is, grieving that endures beyond a rather brief span of time—as a mental illness. This pathologizing of grief has ancient roots extending back at least as far as the Stoics, whose stern ascetic morality preached a perfect indifference that eschewed all passionate attachments. The ideal of selfless asceticism was carried forth in early Christianity, showing up dramatically, for example, in the Confessions of the prominent 12th-century monk, Saint Bernard, who was wracked with guilt over his grief for his beloved dead brother. His brother, after all, was enjoying eternal happiness in heaven, so Bernard could only feel his grieving his loss as a manifestation of wicked selfishness on his own part.
The pathologizing of grief was continued by Descartes. In letters to Princess Elizabeth of Bohemia and Constantijn Huygens, he warned that sadness and grief could cause serious physical illnesses, and he recommended a form of mental discipline—reminiscent of both the Stoics and contemporary cognitive-behavior therapies—in which the imagination was to be directed away from the sources of emotional pain and toward objects that could furnish contentment and joy. In the current psychiatric and medical climate pathologizing grief, psychiatrists (and even general practitioners!) are conflating painful feelings with clinical syndromes and prescribing anti-depressant medication for naturally occurring intense or prolonged sadness and grief.
"Pain is not pathology," I wrote in my book, Trauma and Human Existence. The enormity and everlastingness of the grief following the loss of a loved one are not manifestations of psychopathology; they are a measure of the depth of love for the lost beloved. Traumatic states of sadness and grief can devolve into clinical depression when they fail to find a context of emotional understanding—what I call a relational home—in which they can be held, borne, and integrated. In a psychiatric climate that pathologizes grief and that advocates treatments aiming at emotional riddance, such a relational home for emotional pain is becoming ever more difficult to find. Such a circumstance is actually likely to increase the incidence of clinical depression.
The Context-Embeddedness and Existential Significance of Emotional Trauma
Emotional trauma is an experience of unendurable emotional pain. I have claimed (Stolorow, 2007) that the unbearability of emotional suffering cannot be explained solely, or even primarily, on the basis of the intensity of the painful feelings evoked by an injurious event. As I alluded to in the previous paragraph, painful emotional states become unbearable when they cannot find a relational home in which they can be shared and held. Severe emotional pain that has to be experienced alone becomes lastingly traumatic and usually succumbs to some form of emotional numbing. In contrast, painful feelings that are held in a context of human understanding can gradually become more bearable.
I have also contended that the existential meaning of emotional trauma lies in the shattering of what I call the absolutisms of everyday life—the system of illusory beliefs that allow us to function in the world, experienced as stable, predictable, and safe. Such shattering is a massive loss of innocence exposing the inescapable dependence of our existence on a universe that is unstable and unpredictable and in which no safety or continuity of being can be assured. Emotional trauma brings us face-to-face with our existential vulnerability, our vulnerability to suffering, injury, illness, death, and loss, possibilities that define our existence and that loom as constant threats. Because we are limited, finite, mortal beings, trauma is a necessary and universal feature of our all-too-human condition.
Therapeutic Implications: Emotional Dwelling
How can a therapeutic relationship be constituted wherein the therapist can serve as a relational home for unbearable emotional pain and existential vulnerability? Recently, I have been moving toward a more active, relationally engaged form of therapeutic comportment that I call emotional dwelling. In dwelling, one does not merely seek empathically to understand the other’s emotional pain from the other’s perspective. One does that, but much more. In dwelling, one leans into the other’s emotional pain and participates in it, perhaps with aid of one’s own analogous experiences of pain.
I have found that this active, engaged, participatory comportment is especially important in the therapeutic approach to emotional trauma. The language that one uses to address another’s experience of emotional trauma meets the trauma head-on, articulating the unbearable and the unendurable, saying the unsayable, unmitigated by any efforts to soothe, comfort, encourage, or reassure—such efforts invariably being experienced by the other as a shunning or turning away from his or her traumatized state. Let me give an example of emotional dwelling and the sort of language it employs from my own personal life.
My father suffered a terrible trauma when he was 10 years old. He was sitting in class, the kid sitting in front of him was horsing around, the teacher threw a book at the kid, the kid ducked, and the book took my dad’s eye out on the spot. For the rest of his life, he lived in terror of blindness—a terror that I remember pervaded our household when I was growing up.
Sixty years after that terrible trauma, he was to have cataract surgery on his remaining eye, and his optic nerve was vulnerable to being knocked out in virtue of the glaucoma medication he had been using for decades. When I went to see him just prior to the surgery, I found him in a massively (re)traumatized state—terrified, fragmented, disorganized, and deeply ashamed of the state he was in. Family members tried to offer him reassurance: “I’m sure it will be fine.” Really? Such platitudes only demonstrated to him that no one wanted to be close to him in his traumatized state.
Having gone through my own experience of devastating trauma, I knew what he needed instead. I said, “Dad, you have been terrified of blindness for nearly your entire life, and there’s a good chance that this surgery will blind you! You are going to be a fucking maniac until you find out whether the surgery blinds you! You’re going to be psychotic; you’re going to be climbing the walls!” In response to my dwelling with his terror, my dad came together right before my eyes, and, as was our custom, we had a couple of martinis together. The surgery was successful and did not blind him.
If we are to be an understanding relational home for a traumatized person, we must tolerate, even draw upon, our own existential vulnerabilities so that we can dwell unflinchingly with his or her unbearable and recurring emotional pain. When we dwell with others’ unendurable pain, their shattered emotional worlds are enabled to shine with a kind of sacredness that calls forth an understanding and caring engagement within which traumatized states can be gradually transformed into bearable painful feelings. Emotional pain and existential vulnerability that find a hospitable relational home can be seamlessly and constitutively integrated into whom one experiences oneself as being.
Integrating Emotional Trauma: “Trauma Recovery”
In concluding, however, I wish to add an existential qualifier to the claim I have just made. Like its analogue, “secure attachment,” "trauma recovery” is an oxymoron—human finitude with its traumatizing impact is not an illness from which one can or should recover. A felt requirement to recover from, or become immune to, the circling back to emotional trauma can be a source of intense shame and self-loathing when, as is inevitably the case, it cannot be achieved.
As I spelled out in my book, World, Affectivity, Trauma: Heidegger and Post-Cartesian Psychoanalysis, “recovery” is a misnomer for the constitution of an expanded emotional world that coexists alongside the absence of the one that has been shattered by trauma. The expanded world and the absent shattered world may be more or less integrated or dissociated, depending on the degree to which the unbearable emotional pain evoked by the traumatic shattering has become integrated or remains dissociated defensively, which depends in turn on the extent to which such pain found a relational home in which it could be held. This is the essential fracturing at the heart of traumatic temporality and the dark foreboding that is its signature emotion.
Copyright Robert Stolorow
References
Stolorow, R.D. (2007). Trauma and human existence: Autobiographical, psychoanalytic, and philosophical reflections. New York: Routledge.
Stolorow, R.D. (2011). World, affectivity, trauma: Heidegger and post-Cartesian psychoanalysis. New York: Routledge.
