Direct, intense psychological trauma - perhaps even adult trauma in general - is a kind of stepchild in psychiatry. An exploration of the psychology of the survivor is crucial to understanding such trauma. The study of adult trauma and survival has direct bearing on issues around death and death imagery in ways that shed a great deal of light on both psychiatric disturbance and on our contemporary historical condition.
We have learned to find models in early childhood experience for later adult behavior. But there is a beginning sense in psychiatry that a reverse process may be just as useful. Intense adult trauma can provide a model, at least in terms of understanding, for the more obscure and less articulated traumas of early childhood. This reversal was not unknown to Freud. And it is the basis for the image-model of the human being as a perpetual survivor - first of birth itself, and then of "holocausts" large and small, personal and collective, that define much of existence - a survivor capable of growth and change, especially when able to confront and transcend those "holocausts" or their imprints.1
Kardiner, who has distilled much of psychiatric thought on the traumatic syndrome emerging from World War II, began with Freud's explorations of trauma. But by emphasizing his own and Rado's view of "neurosis as a form of adaptation,"' he was able to stress the need "to unravel the sense behind the symptomatology" as well as issues around feeling and numbing. Concerning the latter, he spoke of a "shrinking" of the ego, of the organism's "shrunken inner resources," and above all of "ego contraction" that interferes with virtually all areas of behavior. Kardiner combined this stress on "ego contraction" with the equally important emphasis on "disorganization rather than regression." Contraction and disorganization - what we would call numbing and disintegration - lead readily to the symptom complex, acute or chronic, that just about everyone has observed: fatigue and listlessness, depression, startle reactions, recurrent nightmares, phobias and fears involving situations associated with the trauma (what Rado calls "traumatophobia"), mixtures of impulsive behavior and unsteadiness in human relationships and projects of all kind (including work or study) that may take the form of distrust, suspiciousness, and outbursts of violence. A convergence of observations suggests that severe threats to the organism produce patterns of stricture that have relevance for a wide variety of psychiatric impairment.
What Kardiner neglected, however, is the place of death and death anxiety in the traumatic syndrome. His advances depended upon bypassing instinctualism. But as in the case of much revisionist work, rejecting the death instinct became associated with neglect of death. The neglect is striking in traumatic neuroses, where death is so close. An evolving view puts the death back into traumatic neurosis. As early as 1953, Joseph D. Teicher entitled a paper on the subject "Combat Fatigue" or "Death Anxiety Neurosis."'1 Advocating the latter, Teicher associates his advocacy of "death anxiety neurosis" with classical emphasis upon the importance of guilt toward the dead, as intensified by prior guilt from "fantasied murder" (feelings toward one's father, for instance, in association with the Oedipus complex). But when he goes on to say that "in the neurotic form of fear of death, the sufferers are afraid to die and afraid to kill; in their illness they avoid death and murder," we find ourselves at first nodding in agreement, but quickly sensing that there is something wrong in the way he is putting things. What is right about the approach is its direct stress on dying and killing, its relationship, that is, to death. What is dubious about the statement is its equation of fear of dying and killing as a neurotic state. What Teicher means, of course, is that these fears become incapacitating, and therefore associated with "death anxiety neurosis," But the reader's impulse is to say, "Well, if that is the case, the world could use a good bit more of such a neurosis, ora modicum of its symptoms: if not fear, at least reluctance, to die or kill in military combat." The problem here is the reference point of disturbance or neurosis, a matter that turns out to have considerable importance. Both Kardiner and Teicher wrote from the vantage point of World War II, sometimes referred to as "America's last good war." It was, of course, a dreadful war: its "goodness" lay in the American combination of decisive success and equally decisive moral clarity. So evil was the enemy - at least the Nazi enemy - that to annihilate him could only be perceived as virtuous. Consequently, those soldiers who broke down, who were "afraid to die and afraid to kill" on behalf of this crusade, could be quite comfortably viewed as neurotic.
This was not so in the case of the Vietnam War two or three decades later. That war, for American participants, was ambiguous in the extreme. Its combination of doubtful justification, absence of structure (as a counterinsurgency action in which the enemy was nowhere and everywhere), and consequent frequency of killing or even massacre of civilians all contributed to various forms of confusion and reluctance to fight. Under those conditions moral revulsion and psychological conflict became virtually inseparable, sometimes in the form of delayed reactions.
Months or even years after their return to this country, many Vietnam veterans combined features of the traumatic syndrome with preoccupation with questions of meaning - concerning the war and, ultimately, all other areas of living.* Most of these men were not incapacitated by their symptoms and could not be called "neurotic." Indeed, their anxiety, guilt, and anger could serve animating functions in terms of both introspective and "extrospective" (outward-looking or social) exploration. They seemed to need those emotions for their assimilation of the pain and confusion they had experienced. The traumatic experience, or at least elements of it, had a constructive function for them. And in many of these cases, both the syndrome (or some of its components) and the doubts about the war began with a confrontation which broke through existing patterns of numbing and evoked images of dying or killing in Vietnam.
An approach to traumatic syndrome should focus on death and related questions of meaning, rather than requiring us to invoke the idea of "neurosis." This deathcentered approach suggests a moral dimension in all conflict and neurosis.
The psychology of the survivor helps greatly here. The survivor is one who has come into contact with death in some bodily or psychic fashion and has remained alive. There are five characteristic themes in the survivor: the death imprint, death guilt, psychic numbing, conflicts around nurturing and contagion, and struggles with meaning or formulation."1 Each of these has special relevance for traumatic syndrome, and in combination they affect survivors at both proximate and ultimate levels of experience.
The death imprint consists of the radical intrusion of an image-feeling of threat or end to life. That intrusion may be sudden, as in war experience and various forms of accidents, or it may take shape more gradually over time. Of great importance is the degree of unacceptability of death contained in the image - of prematurity, grot esq ueness, and absurdity. To be experienced, the death imprint must call forth prior imagery either of actual death or of death equivalents. In that sense every death encounter is itself a reactivation of earlier "survivals." The degree of anxiety associated with the death imprint has to do with the impossibility of assimilating the death imprint - because of its suddenness, its extreme or protracted nature, or its association with the terror of premature, unacceptable dying. Also of considerable importance is one's vulnerability to death imagery - not only to direct life threat but also to separation, stasis, and disintegration - on the basis of prior conflictual experience. But predisposition is only a matter of degree: if the threat or trauma is sufficiently great, it can produce a traumatic syndrome in everyone, as was largely the case in the manmade flood disaster at Buffalo Creek, West Virginia, in 1 972.*
The survivor retains an indelible image, a tendency to cling to the death imprint - not because of release of narcissistic libido as Freud claimed, but because of continuing struggles to master and assimilate the threat (as Freud also observed), and around larger questions of personal meaning. The death encounter reopens questions about prior experiences of separation, breakdown, and stasis as well as countervailing struggles toward vitality; reopens questions, in fact, around all of life's beginning and endings. So bound to the image can the survivor be that one can speak of a thralldom to death or a "death spell."
The death imprint is likely to be associated not only with pain but also with value - with a special form of knowledge and potential inner growth associated with the sense of having "been there and returned." The death encounter undermines our magical sense of invulnerability by means of its terrible inner lesson that death is real, that one will oneself die - and this vies with our relief at no longer having to maintain that illusion. The result can be something resembling illumination.
Affecting the outcome and the degree of anxiety is the extent of the sense of grief and loss. What we may say here is that, in severe traumatic experience, grief and loss tend to be too overwhelming in their suddenness and relationship to unacceptable death and death equivalents for them to be resolved. Many of the symptoms in the traumatic syndrome have to do precisely with impaired mourning, or what Mitscherlich has called "the inability to mourn." What is involved in our terms is the inability to reconstruct shattered personal forms in ways that reassert vitality and integrity.
Thus the death imprint in traumatic syndrome simultaneously includes actual death anxiety (the fear of dying) and anxiety associated with death equivalents (especially having to do with disintegration of the self). This powerful coming together of these two levels of threat may well be the most characteristic feature of image-response in the traumatic syndrome.
The extraordinary power of this imagery - its indelible quality - has to do not only with death but with guilt. What is extremely important, in addition to ultimate threat, is the limited capacity to respond to the threat and the self-blame for that inadequate response.
We have stressed the importance of the image for motivation, its anticipatory quality in the sense of providing a "plan" or "schema" for enactment. But in the face of severe trauma, precisely that process is radically interrupted. The soldier whose buddy is suddenly killed or blown up right next to him, for instance, experiences an image that contains feelings not only of horror and pity but an immediate inner plan for action - for helping his comrade, keeping him alive, relieving his pain, perhaps getting back at the enemy - or at least a psychic equivalent of any of those forms of action. But under the circumstances - and all the more so in a massive immersion in death (as in Hiroshima and the Nazi death camps) - both physical and psychic action are virtually eliminated. One can neither physically help victims nor resist victimizers; one cannot even psychically afford experiencing equivalent feelings of compassion or rage. Freud raised this kind of issue in trauma when he drew an example from children's play in which he emphasized that "children repeat unpleasurable experiences. . .(so) that they can master a powerful impression far more thoroughly by being active than they could by merely experiencing it passively." And Erikson has similarly stressed the severe psychic consequences of inactivation as opposed to the capacity for activity in any threatening situation. The inactivation of which we speak is within the image itself, and therefore a violation of the kind of psychic flow one can ordinarily depend upon. One feels responsible for what one has not done, for what one has not felt, and above all for the gap between that physical and psychic inactivation and what one felt called upon (by the beginning image-formation) to do and feel.
The image keeps recurring, in dreams and waking life, precisely because it has never been adequately enacted. And there is likely to be, in that repetition, an attempt to replay the situation, to rewrite the scenario retrospectively in a way that permits more acceptable enactment of the image - whether by preventing others from dying, taking bolder action of any kind, experiencing strong compassion and pity, or perhaps suffering or dying in place of the other or others. In that way the hope is to be relieved of the burden of self-blame. But whatever actual recovery and relief from guilt one achieves depends much more on the capacity to grasp and accept the nature of one's inactivation under such circumstances.
From this standpoint we can take another look at survivor or death guÜt. We have mentioned the survivor's fundamental inner question: "Why did I survive while he, she, or they died?" The image-centered version of that question is: "Why did I survive while letting him, her, or them die?" It is a relatively simple step to feel that by having so failed in one's image-actions at the time, "I killed him." Or that "if I had died instead, he, she, or they would have lived." This last feeling may in part reflect the psychic death one did actually undergo - the extreme stasis or numbing accompanying one's inactivation in the face of death and threat - and the related sense that subsequent resumption of vitality in the absence of true enactment (mostly in the form of preventing the dead from dying) is wrong. Death guilt ultimately stems from a sense that until some such enactment is achieved, one has no right to be alive.
One could define the traumatic syndrome as the state of being haunted by images that can neither be enacted nor cast aside. Suffering is associated with being "stuck." Hence the indelible image is always associated with guilt, and in its most intense form takes the shape of an image of ultimate horror: a single image (often containing brutalized children or dying people whom the survivor loved) that condenses the totality of the destruction and trauma and evokes particularly intense feelings of pity and self-condemnation in the survivor. To the extent that one remains stuck in such images, guilt is static, there is a degree of continuing psychological incapacity, and traumatic syndrome can turn into traumatic neurosis. But there is also the possibility of finding something like alternative enactment for the image that haunts one, of undergoing personal transformation around that image. In that sense the very association of guilt with the traumatic syndrome makes possible a transforming relationship to its indelible imagery. And here are the beginnings of a psychological explanation for religious visions of realization and moral growth through suffering.
Only part of oneself feels discomfort at having survived - the experience is also associated with relief, even joy or exhilaration. These feelings can, in turn, contribute to additional guilt. The joy at having survived remains tainted by its relationship to that gap between image and enactment, between the excruciating, demanding picture one had constructed and the muted, devitalized, limited actions and feelings one could muster.
In all this, self-condemnation strikes us as quite unfair. The traumatized person seems to have to endure the additional internal trauma of self-blame. This is why there is a "paradoxical guilt" experienced by victimized survivors. This guilt seems to subsume the individual victim-survivor rather harshly to the evolutionary function of guilt in rendering us accountable for our relationship to others' physical and psychological existence. This experience of guilt around one's own trauma suggests the moral dimension inherent in all conflict and suffering. We have no choice but to make judgments about trauma and our relationship to it. Just as there is an inseparability between psychological and moral dimensions of guilt, we may say the same about all psychological disturbance. Psychological pain always includes a moral judgment; moral judgments express psychological conflict and realization.
In that sense there is no such thing as a value-free mechanism in either traumatic syndrome or any form of neurosis or psychosis. If we can speak of evolutionary purpose, we may say that the capacity for guilt was given us so that we might imbue all behavior, perhaps especially pain, with an ethical dimension. There is no denying the enormity of the cost, of the secondary pain via the guilt itself. That cost is starkly visible in the "paradoxical guilt" of the traumatic syndrome, which in turn has bearing on equally "unfair" forms of guilt in many different neurotic and psychotic conditions. In such states we observe the destructive manifestations of an emotion necessary to humanity, of the emotion concerned with critical selfjudgment. And we come to suspect that beyond guilt itself, neurotic and psychotic versions of it are also integral to the human condition.
At the heart of the traumatic syndrome - and of the overall human struggle with pain - is the diminished capacity to feel, or psychic numbing. There is a close relationship between psychic numbing (including its acute form, "psychic closing-off") and death-linked images of denial ("If I feel nothing, then death is not taking place") and interruption of identification ("I see you dying, but I am not related to you or to your death"). The survivor undergoes a radical but temporary diminution in his sense of actuality in order to avoid losing this sense completely and permanently; he undergoes a reversible form of symbolic death in order to avoid a permanent physical or psychic death. From the standpoint of formative process those patterns can be understood as expressions of an internal decision of the organism concerning investment and, therefore, experience of feeling. When made under conditions of acute trauma, that "decision" is neither voluntary nor conscious.
There is a close relationship between the phrase used by a Hiroshima survivor, "A feeling of paralysis of my mind," and a Buffalo Creek survivor's sense, in explaining his isolation from people around him, "Now... it's like everything is destroyed." Those two comments refer respectively to patterns of stasis and disintegration, and suggest important elements of separation as well. For all three death equivalents are important in the dissociative disintegration of the traumatic syndrome. As a consequence, psychic action, the essence of the formativesymbolizing process, is virtually suspended, and the organism is in a state of severe desymbolization. In that sense psychic numbing undermines the most fundamental psychic processes. That is why we can speak of it as the essential mechanism of mental disorder.
These manifestations of psychic numbing are directly responsible for the two additional survivor struggles we have not yet discussed, those around suspicion of the counterfeit and quest for meaning. The survivor struggles toward - and in a way, against - re-experiencing himself as a vital human being. Conflicts over nurturing and contagion have to do with the human relationships he requires for that revitalization, and with their impaired state. The survivor experiences feelings of weakness and special need, along with resentment of help offered as a reminder of weakness. Any such help is likely to be perceived as counterfeit. This is so not only because of its association with weakness, but because prior forms of dependency in human relationships have proven themselves unreliable; one's human web has been all too readily shattered, and in rearranging one's image-feelings, one is on guard against false promises of protection, vitality, or even modest assistance. One fends off not only new threats of annihilation but gestures of love or help. Part of this resistance to human relationships has to do with a sense of being tainted by death, of carrying what might be called the psychic stigma of the annihilated. This stigma, which victims have always experienced, is usually explained around the idea of s elf-concept: if one is treated so cruelly, one tends to internalize that sense of being worthless. To modify and add to that principle, we could say: having been annihilated and "killed," one feels oneself to have become part of the entire constellation of annihilation and destruction, to be identified with - live in the realm of - death and breakdown. The whole process, of course, is intensified by others' fear of the survivor's death taint. He becomes associated in their minds with a constellation of killing and dying which, should one let him get too close, endanger "ordinary healthy people." That is, associations to his experience can activate latent anxieties in others concerning death and death equivalents.
In the case of severe trauma we can say that there has been an important break in the lifeline that can leave one permanently engaged in either repair or the acquisition of new twine. And here we come to the survivor's overall task, that of formulation, evolving new inner forms that include the traumatic event, which in turn requires that one find meaning or significance in it so that the rest of one's life need not be devoid of meaning and significance. Formulation means establishing the lifeline on a new basis. That basis includes proximate and ultimate involvements. The survivor seeks vitality both in immediate relationships and ultimate meaning, the one impossible without the other. Some Hiroshima survivors, for instance, could reanimate their lives around peacemovement activities, which offered a sense of immediate activity in like-minded groups and ultimate significance within which their otherwise unassimilable experience could be understood. If the world could receive a valuable message from Hiroshima, that is, and they could be the agents and disseminators of that message, then what happened to them could be said to have a larger purpose. The same principle applied to Nazi death-camp survivors in their struggle to establish and participate in the State of Israel. More typical is the quest for vitality around direct biological continuity - the tendency of many survivors to reassert family ties and reproduce, and thereby assert biological and biosocial modes of symbolic immortality. In any case, the ultimate dimension, the struggle for resurgent modes of symbolic immortality, is crucial to the survivor, though rarely recognized as such.
Without this kind of formulation the survivor remains plagued by unresolved conflicts in the other areas mentioned - by death anxiety, death guilt, psychic numbing, and immobilizing anger and suspicion of the counterfeit. Numbing in particular, the desymbolizing center of the traumatic syndrome, is likely to persist. For to overcome that numbing, new psychic formations that assert vitality and one's right to it must evolve.
There is a three-stage process available to the survivor of actual or symbolic death encounter, consisting of confrontation, reordering, and renewal. The second of these stages, reordering, is likely to be dominated by struggles with guilt, and especially with converting static to animating forms of guilt. Confrontation, in the sense of recognizing the threat to existing forms and allowing for a certain amount of necessary dissolution of them, must precede those struggles. And for them to bear fruit they must be followed by renewal at both proximate and ultimate levels, and, equally important, in centering arrangements that integrate these levels. But without guilt-associated struggles around fidelity to the dead and the experience of deadness, and to oneself as a witness, no such renewal or formulation is feasible.
A major difficulty here is the literalism the survivor imposes upon himself in viewing his death encounter. So terrifying and awesome does he find it, so demanding are his requirements of fidelity to it, that he may bind himself to what he takes to be its absolutely unaltered reality and permit himself no psychic movement from that perceived reality. But where that is the case the "reality" he locks himself into is a false one, since perception of any experience is achieved only by inner recreation of it. And the literalism he imposes upon himself turns out to be a form of numbing in the area of image-formation, a suppression of psychic action. To be literally bound to a traumatic experience is to permit oneself no psychic vitality in relationship to the experience itself, and to limit vitality in other areas of life as well. This nearsanctification of the literal details of the death immersion was a considerable barrier to writers and artists attempting to give form to Hiroshima. The same issue affects every survivor within the confines of his own psyche. Here we may speak of a vicious circle in which death guilt and death anxiety reinforce numbing, which, in turn, holds one to suspicion of the counterfeit and to a relationship to the death immersion that is literalized and unformulated, which, again in turn, leaves one naked to death anxiety and death guilt.
To break out of this vicious circle in the direction of formulation, the survivor must find a balance between appropriate blaming (which may indeed include considerable anger toward those who bear some responsibility for the traumatic events) and scapegoating (total concentration on the target for anger in a way that continues to literalize and inhibits assimilation of the experience). He must look backward as well as forward in time. His tendency to claim a personal "golden age" prior to the death encounter can, it is true, distort, but may also serve as a source of life-sustaining imagery now so desperately required. To be forward-looking, to be receptive to experience that propels one toward the future, one must assemble those image-feelings available to one that can assert, however tenuously, the continuity of life.
1. Litton RJ: The Life of the Self. New York. Simon & Schuster Inc. 1976.
2. Wadder R: Trauma and the variety of extraordinary challenges, in FursiSS (ed): Psychic Trauma. New York. Basic Books Inc. 1967.
3. Teicher JD: "Combat Fatigue' or "Death Anxiety Neurosis." J Nerv Men Dis 1953; 117:232-242.
4. Littori RJ; Death in Life. New York. Touchstone Books. 1976.
5. Lifton RJ: Home From the War. New York. Simon & Schuster Inc. 1973.