Abstract
Professor McFarlane [1] observed: ‘Psychiatry is a slow-moving juggernaut which is driven as much by politics and convention as it is by the application of knowledge and the conversion of knowledge into effective interventions. The role of prejudice and enthusiasms in psychiatry is, perhaps, most apparent in psychiatry's ambivalent relationship with the field of traumatic stress. The last two decades have been a period of dramatic growth in the study of traumatic stress’. In this context, Paul Valent's book forces that juggernaut to switch gears and pick up speed from the outdated 19th century paradigm into the 21st century. No simple task.
The politics of trauma dictated that governments, democratic or totalitarian, must consider the legal and financial consequences of state-sanctioned trauma. To uncover the profound impact of trauma meant confronting three barriers that served to distort reality. First, government and political self-interest. Professor Yehuda Bauer [2], eminent Holocaust scholar and Chair of the International Institute for Holocaust Research at Yad Vashem in Jerusalem, observed that while 34 million soldiers died in the 20th century, 169 million civilians were murdered by governments and politicians.
Second, since government legislation mandates the professional activity of medicine, state-sanctioned medical abuse and trauma is generally covered up, as occurred under both Nazi and Communist regimes.
Third, health professionals are resistant to openmindedness in the face of trauma. Paradoxically, it was Freud [3] who observed that in cases of extremetrauma ‘of a galley-slave in antiquity, of a peasant during the Thirty Years War, of a victim of the Holy Inquisition, of a Jew awaiting a pogrom… it is… impossible for us to feel our way into such people… [due to]… the gradual stupefying process, the cessation of expectations …’ and concluded that ‘It seems to me unprofitable to pursue this aspect of the problem any further’. Sixty years later mental health professionals, many post-Freudians in the vanguard, dare to explore: to listen to testimonies; to feel their way into survivor experiences; to extend conceptual horizons to transmission of trauma across generations.
In order to do justice to both the public face of trauma and the subjective experience, we must remove these barriers. For every school of thought there is a counterreaction. Against the school of denial stands Valent's book. He observes that forces that disrupt and fulfil our lives are the dialectic of: ‘chaos and order, light and dark, good and evil, life and death’ detailed in the precursor to the present volume [4]. He offers, as the book's title suggests, a new dialectic of ‘trauma and fulfilment therapy’.
Valent confronts the current culture that tends to reduce, fragment, trivialize or deny trauma and to restrict psychological diagnosis to straitjacketed labels. Instead he offers innovations grounded in 44 case illustrations (separately indexed). It's a daring effort. In an overarching personal philosophical statement Valentdefines ‘trauma’ as a ‘threat to purposeful survival and fulfilment according to the life cycle of self and others’ (p.3), ‘… beyond stress, a state in which a previously lifeenhancing equilibrium is irretrievably lost’ (p.32). Cases include a range of traumatic settings (bushfire, physical illness, Holocaust) to illustrate how trauma leads to the layers of stress responses, the clusters of symptoms forming posttraumatic stress disorder (PTSD), and the varied treatments that need to be extended toaccommodate ‘meaning’, ‘morality’ and ‘purpose’ – hence ‘fulfilment therapy’.
Dr Valent sketches Freudian and Janetian ideas, to a range of 20th century treatments from military psychiatry, work with Holocaust survivors, victims of natural disasters and torture and abuse victims. Their needs and current treatments set the stage for the central principles of his conceptual design: first, the triaxial framework which comprises ‘process’, ‘parameter’ and ‘depth’ axes (chapter 3) to provide axis coordinates to locate trauma and life fulfilment; second, the survival strategies (chapter 4) that go beyond thetraditional ‘fight-flight-freeze’ to encompass rescue; attachment; assertiveness; adaptation; fight; flight; competition; and cooperation.
Taken together this framework and the survival strategies support a new approach to trauma, which, Dr Valent argues, integrates otherwise fragmented symptoms and clusters forming illness. In part 3, the wholist view is applied to four treatment principles distilled earlier.
So, what is the ‘wholist approach’? It deals with what is most meaningful to patients and is clinically comprehensive (p.71). The power of the approach is evident when planning treatment (cases 13–44) as detailed in part four. Confronted by a series of traumatic conditions, Valent's compassion is noteworthy. I was deeply moved by the plight of a Vietnamese woman's grief upon her mother's death. A worrying aspect of her anguish was the perdition of her mother's soul. It emerged that the daughter had converted to Catholicism, but she had not urged her mother to speed up her conversion. The daughter felt that ‘because of her, her mother's soul was lost for ever (traumatic rescue at sacred spiritual depth).’ (case 24, p.119). I found the account of the intervention elegant.
It is one thing to conceptualize, hypothesize and introduce new language and to apply non-linear logic to clinical situations. It is another to articulate the process with illustrations as Dr Valent has achieved. Building on insights from decades of clinical work and research reveals deeper and more complex truths about trauma. In his cases he illuminates its darker side and confronts his patients' unspeakable and unknowable truths. He avoids collusion with the conspiracy of silence while challenging the conventional wisdom and doctrines in traumatology. One small quibble, I found the excessive use of subheadings rather disruptive.
Whether his contribution will add a new chapter to the history of traumatology only time will tell. In the meantime, his framework ensures that professionals and politicians alike will find it harder to ignore the reality of trauma and its legacy. A careful reading will leave lasting impressions on the reader.