Book Reviews: A Psychoanalytic Understanding of Trauma: Post-Traumatic Mental Functioning,the Zero Process,and the Construction of Reality

Dr. Fernando treats us to a precise description of what trauma is and what it is not. In a professional climate where classic Freudians look toward metapsychology, but aficionados of the Diagnostic and Statistical Manual of Mental Disorders (DSM) exclude pathology and etiology, his contribution is a welcome clarification that should aid all therapists, school systems, workers’ compensation referees, lawyers, and judges. He also proposes a sophisticated theoretical viewpoint on trauma that will make the most experienced psychoanalysts pleasurably and comfortably rethink what they had thought previously about the issue.

Dr. Fernando explains that trauma comprises what he aptly terms “zero process,” which includes the following three elements:

Etiology

An external event occurs to any person—adult or child.

The external event causes a severe, overwhelming affective response, including painful depressive affect, rage, and fear. In those over age 6, of course, guilt may be generated as well. ¹

Pathology

The overwhelming affects generated by the external event melt down normal mental (ego) functions, such as the organizational function of the mind (integration), abstraction ability, reality testing, the relationship to reality (Frosch 1989), different types of memory, sometimes self-preservation, and sometimes critical judgment about danger. ² In other words, analogous to the theoretical standstill of molecules at 0 degrees Kelvin, in a trauma, mentation freezes.

There may be concomitant object relations disturbance because of the overwhelming affect: regression in self and object constancy, the institution of splitting operations, and sometimes, a specific type of thought-slivering, “disassociation” (connected to “unrepresented states”), which Dr. Fernando redefines later with needed exactitude.

Because the intensity of the affects generated by the event has at least temporarily destroyed certain mental functions, including different aspects of memory, the recollection of what happened and the person’s reactions to it are not stored in an organized form.

Rather, what Dr. Fernando calls “shards” of memory are stored. The peculiarity of these partial memory formations is that they cannot be retrieved from repression through the usual techniques of free association and defense/resistance interpretation.

What happens next is that the shards of memory are relived in symbolic form (in the traumatized person’s life), somewhat truncated and separated from one another. These memory traces (Freud 1900) are therefore very difficult to identify as deriving from the same event. The reliving can involve a plethora of constellations of defensive operations, including but not limited to pathological altruism, counterphobic activity, somatization, phobic avoidance, and symptomatic behavior. ³

Treatment

The fractured elements of the memories and perceptions of the event, the overwhelming affects, as well as the experience of breakdown of object relations due to those affects, cannot, as mentioned, be directly recalled. All of these elements, however, can be reconstructed and reintegrated as they reappear, somewhat concretely, toward the analyst during dynamic or analytic therapy.

Because thoughts were disengaged (the ego functions of abstraction, integration, reality testing, perception, memory, intellect, and/or orientation to time, person, place, and situation got ruptured) during the event (i.e., the factors that lend the name “trauma” to the process), and because the perceptions cannot be remembered in an organized way, Dr. Fernando suggests the term zero process. By this, he means to indicate that the mind, during the event, has stopped operating either with secondary or primary process mechanisms. With a subtle nod to complexity theory (Morin 2008; Papiasvili in press), Dr. Fernando reminds the reader that, in real life, primary and secondary process still run; their relation to the ego damage takes somewhat unusual forms, which he goes into later in the book.

As a reminder, secondary process, according to Freud (1900), is logical, time-oriented thought. Today, we know that although secondary process is often conscious, it is also unconsciously involved in repetitive acts (Piaget 1973). Primary process refers to symbolic, condensed thinking which is seen in recalled dreams, psychiatric symptoms (like phobias and obsessions—and delusions), parapraxes, jokes, and enactments. Primary process is no doubt constant (Reiser 1999), often unconscious or preconscious (Kubie 1966), and it is often unconsciously influential even when secondary process is being used consciously. However, ironically, both Brenner (2006) and Kohut (1971) point out that primary and secondary process can be conscious or unconscious, they operate simultaneously, and very often some aspect of each of those types of thinking is used as a defense in managing conflict and compromise formation (Arlow & Brenner 1964).

The elements of zero process are enhanced and enlarged throughout the book. The smoothness of the weaved elaborations, because I am prone to musical associations, caused me to think of flow akin to the 18th variation from Rachmaninoff’s Rhapsody on a Theme of Paganini (Rubinstein 2011). Dr. Fernando gives many clinical examples, including people who were sexually abused as children by either a mother or a father, and describes one case of a female rape victim.

In his thoughtful analytic work with patients who have endured these types of horrible experiences, Dr. Fernando deftly illustrates how, through the patient’s reactions to the analyst, sometimes of a transferential nature, sometimes not, the analyst is able to divine the shards of memories that had been broken apart by the trauma originally. The analyst actively verbalizes the reconstructions so that the patient can reexperience the affect associated with the trauma, grieve, and reorganize defenses (Brenner 1975). Thus, whole object relations and more adaptive compromise formations arise in the healing process.

An Outline Of The Book And Some Of My Impressions

Editorializing on the Theme

We all sort of know about trauma. Today, the term trauma has entered vernacular English usage and has almost become a cliché. People who see themselves—or others—as victimized claim to have become traumatized by microaggressions. It has become common in the United States for people to list their gender-preferred pronouns after their signatures to avoid the trauma of being mislabeled. Certain words in the English language have taken on a heretofore hidden significance that may traumatize others if used in speech or writing. ⁴

Beyond these social considerations, however, there seems to be a more pressing clinical and theoretical debate about the concept of trauma. The DSM has wrestled with this term since at least 1980, when DSM-III proposed certain criteria for posttraumatic stress disorder while simultaneously purposely removing all concepts of etiology and pathology (American Psychiatric Association 1980). The DSM-III phenomenological criteria were not horrible, and in fact Dr. Fernando includes one of those older criteria in his definition: the event had to be “beyond the regular expectations of the person” (p. 10). Seems reasonable, but this criterion was deleted from later editions of the DSM. The rest of the DSM-III criteria were extraordinarily limited, barely covering the spectrum of what was understood by psychoanalysts at the time (cf. Kernberg 1975; Kris 1956). By the advent of DSM-5-TR (American Psychiatric Association 2022), the definition—by committee—of the concept “trauma” became, to use legal language, “overbroad”—in other words, it became putatively useless. ⁵

Of course, psychoanalysts have been concerned with trauma since the late 1800s, when Breuer and Freud postulated that sexual abuse during childhood seemed to be the etiology of many psychological disorders in adulthood. Freud made so many inroads into conceptualizing trauma throughout his career, including the concept of a “stimulus barrier” (Freud 1920) that is abrogated in trauma, that even a brief list would overwhelm this review. Of course, Dr. Fernando (p. 13) credits Freud’s seminal definition that trauma involves a state of “helplessness” sometimes leading to physical immobilization (Van der Kolk 2014).

Good (2006) collected an erudite group of updates on the early “seduction theory.” Those chapters debate the definition of trauma, the mental pathology of trauma, and the etiology in certain people who experience what, since Vietnam, been known as posttraumatic stress disorder (Camp 2015).

Meanwhile, beginning in the 1970s, the enormous problem of sexually violent predators (along with laws and Supreme Court decisions governing their management) emerged into public awareness. The legal problems about what to do with such people and the etiology and treatability of their problems have come under recent scrutiny (Blackman and Dring 2016). Furthermore, the whole question about the treatment of both traumatized people and those who do the traumatizing has become a national issue in the United States, ⁶ where “bullying” in schools has resulted in zero-tolerance policies that attempt to stop the persecution of certain children by other children. The traumata caused by Internet bullying, well known by now, have resulted in several suicides (Murez 2022).

In this matrix of social and personal angst, there have been several attempts to define, explicate, and treat traumatized individuals (Levine 1990). However, the whole subject had remained somewhat murky, and the theories about the different aspects of posttraumatic states were disorganized. Renik (1981) astutely described posttraumatic dreams and separated them from traumatic dreams, persuasively arguing that such dreams’ etiology was eerily similar to that of examination dreams—that is, unconscious self-assurance that the dreaded deed was no longer occurring or did not occur. Lansky (2000) highlighted the importance of destruction of the self-image as a part of definition of trauma, and how the shame about this temporary self-deterioration (similar to zero process) caused multiple defensive operations after the fact (including ruminative focus on the actual event and counterphobic mechanisms), contributing to posttraumatic stress disorder.

Getting Into the Weeds of Theory and Technique

Some of the topics Dr. Fernando covers in this virtual textbook on trauma include discussion of different types of traumata, such as sudden events, chronic ongoing upheaval, shock trauma type II (Terr 1995) and strain trauma (Kris 1956).

He also addresses diagnostic problems associated with diagnosis of posttraumatic stress disorder in borderline personality disorder (where splitting, psychic instability, and unprocessed memories are present (as per Janet) (p. 12). In patients with premorbid borderline personality organization, therapeutic work must deal with preexisting ego weaknesses (presumably using techniques known variously as containing [Bion 1959], empathic listening [Bird 1955], or witnessing [Mucci 2019]; see E. Papiasvili, Global Editor (in press) for distinctions and similarities).

In opposition, he mentions bland trauma (p. 21), which heals without treatment, due to “tincture of time” (Burch 1971).

In addition to the fracturing of memories during a trauma, compromise formations may later arise. Such include repression of drives and conflicts in response to triggers, leading to repetitions and conversion symptoms (p. 14). Unconscious guilt typically arises over oedipal victory when there is a loss of a parent during the first genital phase. All this may recur symbolically in the transference to the analyst.^7,8

Counterforce defense, an original concept of Dr. Fernando’s, denotes the liberation of anger in a patient after a successful defense interpretation, because anger/aggression was used to fuel the repressing force to begin with. Dissociation, when it occurs, can be concomitant with repression (see below).

Dr. Fernando describes how primary process interacts with zero process fragmentation, emphasizing that zero process can occur during “established pathological mourning” (Volkan 1981). When this occurs, the object can be frozen in time, or there can be a contemporaneous persistent misery.

Transgenerational transmission of traumatic memories (Cao, Blackman, & Xu 2018; Tummala-Nara 2020; Volkan 2014) can simultaneously occur through the “depositing” mechanism used by the original traumatees, abetted by a form of introjection used by their targets. The shards of memory act “like a memory that has not yet happened” because of the failure of integration, similar to the “if only” fantasies described by Akhtar (1994).

Another section describes how Freud’s economic theory (augmented by Hartmann, Kris, & Lowenstein 1949) may be of use—considering that primary process utilizes mobile cathexes, whereas secondary process utilizes bound cathexes. Dr. Fernando posits that zero process is governed by frozen cathexes. Dr. Fernando elaborates on drive theory, suggesting that “functional drives” exert a pressure to complete what is sensed as unfinished (p. 43) (also see Blackman 2020, Epilogue).

He discusses the different types of memory which can be affected: short term, long term, episodic (explicit), emotional (or conditioned), procedural (fantasies) (cerebellar mechanisms), knowledge (or semantic), implicit (nonverbal) (temporal lobe mechanisms), autobiographical, and verbal (later). He goes over the role of the hippocampus and amygdala.

Further, Dr. Fernando covers superego facets of trauma, zero process objects (p. 47), and zero process introjects, which “have a motivation independent of drives and of . . . ego interests” (p. 47) and thus push to become a present, real experience.

Regarding treatment, Dr. Fernando introduces techniques for reconstruction during the “fogginess” of treatment (p. 55). He covers false memory syndrome and its vicissitudes, the distinction between flashbacks and true “traumatic memories,” and how chronic trauma causes a “reliving in the future” (p. 69).

Regarding zero process drives and zero process defenses (chapter 3), “ego breakdown [managed by defenses] during trauma means that the regular sequence of construction of present experience and its memorialization is stopped short, and there is a . . . push to complete this sequence” (p. 73).

In his astute dissertation on dissociation, Dr. Fernando explains, “trauma behaves like a current experience (not exactly repressed).” In fact, Dr. Fernando now clarifies that dissociation “involves the partial or total inaction of the ego functions of integration and differentiation” (p. 87). Dissociation keeps things separate “because of the lack of normal integrative functions . . . consciousness loses its normal synthesis and unity . . . [there is also loss of] . . . memory and perception.” However, dissociation is different from splitting in borderline patients; the splitting mechanism manages “love vs. hate, invaded by primary process,” whereas zero process (dissociation) indicates “lack of integration of various aspects of experience” (p. 88). Finally, in dissociative identity disorder, “there is almost always either serious and early sexual abuse and/or serious threats to the life of the person witnessing mutilation . . . and murders” (p. 106).

More complexity is to be found in his discussion of zero process and “temporal shifting.” These phenomena include that the trauma does not seem real to the patient and that the trauma is experienced as happening in the future.

Dr. Fernando’s argues against

a trend in psychoanalysis in which various aspects of trauma are traced to early infancy and mother-child interactions. I would argue that this tendency [by analytic theoreticians] represents a defense of the temporal shifting of the breakdown [from the time it occurred] . . . to the past. (p. 98)

He also introduces his concept of a “contrast defense,” where “the person avoids things that are too great a contrast with the trauma or other environmental problems, such as deprivation” (p. 103). In addition, “[the process] . . . does not allow . . . some love and attention. . . . If [traumatized people] let in . . . love and caring, then they are overcome by the sadness and pain of their past deprivation” (p. 103).

An entire chapter is devoted to the treatment of borderline personality disorder, referencing King Lear, deficits and defenses, dealing with both repression and internalizations (chapter 4). He spends considerable time in explicating treatment of the central posttraumatic complex (chapter 5).

Finally, the book includes a glossary of Dr. Fernando’s creative and novel synthetic terms characterizing trauma (pp. 216–218).

Conclusion

If you will pardon another musical association of mine to this fortress of a book, “I Cover the Waterfront” ⁹ seems apt. The enormous amount of useful information in this book is conveyed in a style that peaks intellectual curiosity without traumatizing the reader with unnecessary intellectualizations.

We owe a large debt of gratitude to Dr. Fernando, who put to work his own prodigious synthetic abilities and knowledge to furnish us with this treasure of a book—which, among other things, demonstrates and synthesizes, without simplification, the complexity of the multiple aspects of mental functioning that can be affected by external events. He utilizes a liminal porridge of the best of psychoanalytic theories to delineate the mental mechanisms involved when events are not just “upsetting,” but “traumatic.” Finally, he describes treatment techniques designed to aid us in better helping individuals who have suffered due to trauma.