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A symposium on trauma organized by the Association for Child Psychoanalysis and held in London in 1984, bore witness to the continuing interest in the subject. Prepared papers by Jules Glenn (1984) and by Edgecumbe and Gavshon (1985) stimulated lively debate; but it was clear from the very active discussions that a number of issues remained unresolved. Twenty years earlier a symposium on the same subject led to an extensive collection of papers edited by Sidney Furst (1967) and did a great deal to map out the ground and clarify some important points. The contributions to this symposium led Anna Freud (1967) to point out that a number of technical terms in psychoanalysis had, in the course of time, suffered a widening use which had blurred meaning to a point at which valuable concepts were lost. She continued:
We are in the position of witnessing this typical process with regard to the definition of trauma which extends at present from the original notion of the break through the stimulus barrier at one extreme to the notions of the accumulative, the strain, the retrospective, the screen trauma, until it becomes difficult at the other extreme to differentiate between adverse pathogenic influences in general and trauma in particular [p. 235f.].
She added that, like everyone else, she too had tended to use the term trauma rather loosely until then, but that she would find it easier to avoid this in the future.
Careful consideration of these papers, including Anna Freud's own contributions, together with subsequent writings on the subject, suggest that this is more easily said than done. There is a repeated difficulty in restricting the definition of trauma to a serviceable theoretical concept that meets clinical needs and experience. This paper makes no such attempt, but argues that, if full benefit is to be derived from the many important contributions made to the subject, it is necessary to draw clear distinctions between three different conditions. Two of these were repeatedly discussed by Freud, namely, traumatic neurosis and traumatic (automatic) anxiety. The third, which may be called the post-traumatic neuroticlike state, requires separate discussion and illustration.
Freud's view of the nature of the traumatic neurosis was particularly clearly set out in Beyond the Pleasure Principle (1920) in the course of discussion of the significance of the compulsion to repeat. The disturbance arises when the ego is totally unprepared for a "traumatizing" event of an external kind. A contemporary example would be that of a car crash coming totally out of the blue, of which the driver had no anticipation and no opportunity for psychic preparation. Freud's view was that, in such conditions, the stimulus barrier broke down and the ego was overwhelmed with a degree of anxiety that it was totally unable to master at the time. The ego was "knocked out" and was temporarily unable to function. This period of loss of functioning follows immediately on impact and continues for a short and slightly variable period. In the current example an observer would see the victim as dazed, and would no doubt refer to him as suffering from "shock." The inference that ego functioning is lost is supported by the fact that the subject retains a clear recollection of the circumstances of the crash, but has no memory for the period immediately following the collision.
The subsequent clinical picture is well known. It is characterized by restlessness and variable but diffuse anxiety. A striking feature is the recurring dream in which the circumstances of the crash are vividly relived. These frightening dreams were, in Freud's view, not really "dreams" at all in the sense in which these are understood psychoanalytically. They are a vivid reexperience of the disturbing event during sleep, in the course of which the excess excitation, bounded by the ego in its attempted restoration of functioning, is fractionally and repeatedly discharged. The traumatic event may be relived in the form of daydreams or preoccupations during the day.
In the present context, two clinical points
must be made about this condition. The first is that even the
fully blown picture tends to resolve itself, without
treatment, is somewhere around 8 months, although there are
exceptions. Even a minor degree of anticipation may allow
sufficient preparation for the "shock" to be less pronounced
and for recovery to take place within a comparatively short
time. The factors which occasionally lead to an extremely
protracted result are not always easy to understand. The
second and related point is that, if the victim can be
invited by the therapist to recollect the trauma over and
over again, with appropriate affective discharge, the period
during which the condition persists can be effectively
reduced. In World War II, psychiatrists dealing with
traumatic neuroses (as opposed to battle exhaustion) arising
in the front line found that chemical abreactions using ether
or pentothal restored the victim to normal functioning within
something like three weeks. We now know that the abreaction
can be carried out without chemical assistance. The traumatic
neurosis can therefore be conceptualized in terms of Brueur
and Freud's notion of "strangulated affect" (1895) and,
indeed this was explicitly foreshadowed by Freud (1893) and
was considered in relation to the abreactive process.
The second condition with which we are concerned is traumatic (automatic) anxiety. It is well known that Freud reformulated the theory of anxiety in 1926. Anxiety was no longer initiated by repression; repression was initiated by anxiety. Anxiety functioned as a danger signal seated in the ego that warned of an impending situation of danger. The danger itself was such that, if the ego were unable to mobilize its defenses, it would be overwhelmed and rendered helpless by automatic anxiety in the face of a "traumatic anxiety- situation" (p. 148). The prototype of these danger situations was considered by Freud to be trauma of birth. Although studies by Spitz (1947) cast considerable doubt on whether birth per se is trauma at all and emphasized the role of the nurse, midwife, or doctor in initiating the child's "negatively tinged excitation" (1965, p. 38.), Freud had been quite clear that these responses were essentially vegetative and preceded the child's capacity to experience psychic anxiety. With the acquisition of this capacity, the child is subject to that form of pervasive psychic excitation which Freud had in mind in speaking of automatic anxiety.
It is this pervasive anxiety which floods the ego when a traumatic anxiety situation is encountered and overwhelms the ego. The sequence of these basic danger situations is familiar. When the very young child is threatened by a degree of pervasive anxiety with which he is unable to deal, and which can only be assuaged by the ministrations of a mother who detects the source of that anxiety, we have the prototype for later fears of annihilation. This is followed by fear of the loss of the object, fear of the loss of the object's love, castration anxiety, and fear of loss of the superego's love (Freud, 1926). once ego development is sufficiently advanced to take an affective sample of one of these basic danger situations, to experience them in miniature, it can try to bring to bear its resources to ward off the threat and avoid the onset of pervasive (traumatic) anxiety.
Further comment is called for on traumatic anxiety and traumatic neurosis. First, traumatic anxiety is experienced by every child at all stages of development, is very often rapidly reversible, and is, to that extent, not a traumatizing experience in the sense of Edgcumbe and Gavshon (1985). Every infant, when his needs are not met, experiences "traumatic" anxiety. Indeed, if this is balanced by a reasonable amount of gratification, so that the balance between pleasure and pain is not seriously disturbed, the frustration is a motivating factor in development. The Garden of Eden offers little incentive for its inhabitants to set out on further explorations.
The situation is quite different in the traumatic neuroses. At first sight, it may appear that this condition shares with traumatic anxiety the state of reduction to helplessness. There are, nevertheless, important differences. When the ego is overwhelmed in the traumatic neurosis, it is not simply flooded with pervasive anxiety. It is totally knocked out in a flood of excitation. What is experienced is not psychic anxiety but somatic vegetative excitation. A fuller account of the developmental factors involved in this process has been given elsewhere (Yorke and Wiseberg, 1977; Yorke et al., 1980), and its relevance for the concept of trauma has been discussed by Furman (1984).
A breach of the stimulus barrier initiates the traumatic neurosis. The question of whether one can reasonably postulate a protective shield against excessive stimuli from within as well as without. Anna Freud (1967) explicitly said that one could. She took as her starting point Freud's statement that "the essence of a traumatic situation is is experience of helplessness on the part of the ego in the face of an accumulation of excitation whether of external or internal origin." Since then she considered that this quotation designated the ego as "the central victim in the traumatic event," she argued that "it implies that there exists not one stimulus barrier (against environmental stimuli) but two protective shields against two types of dangers threatening from the inner as well as from the outer world. These include, of course, those occasions where otherwise harmless external happenings are given threatening meaning on the basis of existing internal constellations" (p. 236).
It is important to observe that, in the statement quoted by Anna Freud, Freud was referring to traumatic situations - that is, those of basic danger. He was not referring to events that precipitate a traumatic neurosis. The one threatens or leads to pervasive anxiety; the other to vegetative excitation and involves a breach of the stimulus barrier. It is unfortunate that "reduction to helplessness" is so often held to characterize the two without the necessary psychoanalytic qualifications which show how different they are.
The fact that this difference is repeatedly overlooked may well spring from Freud's varied use of the word "trauma" in different contexts and in different circumstances. The problem is in part a historical one and is compounded by the persistence, with fluctuating emphasis, of the preanalytic, traumatic theory of neurosis in later formulations. In this connection, Greenacre's account (1967) of the different meanings of the word "trauma" in succeeding stages of Freud's writings is indispensable. She reminds us, for example, that in reviewing his work with Breuer, he referred to "traumas" following the most trivial experiences of childhood (Freud, 1906), while in the Introductory Lectures many years later, he compared the traumatic neuroses with the symptom neuroses, and said that, although the two could not be closely compared, even in the latter there was no need to abandon the "traumatic line of approach as being erroneous: it must be possible to fit it in and subsume it somewhere else" (1916-17, p 276).
It seems possible that considerations of this kind underlie the notion of a second barrier against internal stimuli. To avoid further perpetuation of ambiguities, a breakthrough of such a stimulus barrier would have to be distinguished from an untimely penetration of the repression barrier. Only two conditions come to mind where the concept of an internal stimulus barrier might appear, at first sight, useful: namely the stage IV nightmare in adults and pavor nocturnus in children. Studies of these conditions, which seem identical in all essentials, indicate that they occur during NREM sleep and are related, not to dream materials of the usual kind but to frightening thoughts which follow the secondary process (Fisher et al., 1970) The well known result - that the child sits upright in a state of absolute terror and total confusion - may suggest that something analogous to the initial state of traumatic neurosis has occurred by virtue of an invasion of the barrier from within. Ego functioning is again knocked out. It is during the resulting state of confusion that the individual may be endangered - a patient of my acquaintance who suffered repeatedly from stage IV nightmares once walked, in her disorientation, through a second story window and seriously injured herself.
Nevertheless, pavor nocturnus and the stage IV nightmare differ in at least two major particulars from the condition resulting from the breach of the external stimulus barrier. First, they occur in a state of altered consciousness, when the ego is already vulnerable. Secondly, the result is not a persisting disorder. Even though the substantial impairment of ego functioning may last for many minutes of even longer, once it is over, the child or adult returns to normal health. And while these nocturnal states require further study, the need for a concept a second stimulus barrier appears, even in this restricted clinical context, an open question.
If the part played by the economic factor in all these conditions is taken more fully into account, the strength of the stimulus barrier or, in the case of traumatic anxiety, of other opposing agents, is as important as the strength of the force arranged against them (A. Freud, 1967). Vulnerability is not evenly distributed among people; it is well known, for example, that the level of the pain threshold varies from person to person. One can certainly encounter cases of psychic shock that stop short of traumatic neurosis and suggest that any breach of the barrier has been less than total. It would indeed make nonsense of the concept of a developmental line of anxiety, and signal anxiety were held not to exist. While this consideration should certainly be kept in mind in what has been said, it does not invalidate the usefulness of the distinctions which have been emphasized. On any developmental line, way stations are still way stations and cannot be telescoped together.
The third condition to be discussed is what I have called the posttraumatic neuroticlike state. It may best be considered with the help of an extended illustration. The patient, a Scotsman in early middle age, was a businessman with pharmaceutical training. In the course of analysis, he relived in transference a fantasy that his head was inside his mothers bottom and was being constricted by it. The context in which it occurred is of special interest.
He did not seek help on account of any somatic symptoms. His initial complaints were of intermittent free-floating anxiety, episodes of mild depressive affect without any specific conscious content, and difficulties in establishing friendly relations with others. He had a girl friend of whom he was somewhat possessive, but his relationships were otherwise formal and restricted to essential contact.
A few weeks after the start of treatment he expressed a number of fantasies in which I was attacked about the head - first by unknown persons, then by himself. In these attacks the brain and skull were seriously damaged. I commented on the growing intensity and frequency of these fantasies. He then told me that, around the age of 4 or 4 1/2, he had been admitted to a hospital for a mastoidectomy, after a good deal of pain. He remembered the stay there as something horrific. Visiting was not allowed, and he had no access to his family. His happiest memory was of greeting his father who came to collect him on discharge.
These concerns dominated the treatment for a considerable time. Fantasies of sadistic violence, in which he viciously attacked my head, appeared again and again in limitless variations. To begin with, these fantasies were not reported with appropriate affect, and although the sadism itself was expressed in the most direct manner, it was accompanied by only the most muted of feeling states.
A sadomaschistic transference expressed the reexperience of the frightening operation in which he was either the victim or the vengeful attacker. I was repeatedly equated with the surgeon who drove knives into his body and mutilated his victim's skull, or who put damaging or dangerous words into his ears. The fantasy was he was the victim of a violent homosexual intercourse, experienced in terms of the chisel and the skull, soon came into awareness and became the subject of protracted working through.
Before long, it became clear that the reexperience of the operation was in no way limited to content of this kind. It had become the overdetermined center of all manner of conflict and anxiety. Almost everything that concerned or disturbed him appeared to have some reference to this one dramatic episode. The anesthesia under which the operation was conducted (in fantasy or reality) played a central role. Episodes of drowsiness occurred in the analytic session; feelings of suffocation appeared with unfailing regularity; fantasies of being overwhelmed by smells, of being smothered and reduced to oblivion, brought repeated distress as the associated affect became more available.
If, as a result of the continuing analytic work, material centered on the operation, the anesthesia and all the circumstances that went with it slowly yielded to a better understanding of the patients intense conflict at almost every stage of development, they did so reluctantly and only intermittently. When, for example, positive oedipal material became a central feature of our work, the wish to enter the body of the analyst and mother slowly achieved direct expression. The childhood nature of the fantasy was graphically illustrated by the "recollection" with which this vignette began. He was standing like a 3-year-old behind his mother's legs with his arms clasped firmly around her thighs. This was immediately followed by the fantasy that, in this position, he would have his head right up his mother's skirts, and in no time at all was pushing it into her bottom. At his point in the session he complained of a headache; and when I relieved him of this with an interpretation of the oppressive force around him, the pain gave way to a pleasant and welcome anesthesia as the warmth and the smell overcame him.
It is striking how completely the phallic and anal material came together in the patient's childhood fantasies and their current reexperience. The orality, too, was conspicuous. At one time or another, every part instinct or its derivatives achieved some form of expression in the context of the trauma as he remembered it or, perhaps more correctly, fantasized it. Thus, the thoughts of being peacefully put to sleep were linked with the notion of satiation at the breast and resulting contented oblivion; but even this brought to mind fantasies of anesthetic intubation.
Exhibitionism and scopophilia played a considerable part in this man's material. It was repeatedly presented in terms of the hospital experience. Getting undressed was linked in his mind with a fantasy of being stripped naked by the nurse, and getting dressed in terms of being wrapped in hospital gear or in bandages. The nurse repeatedly came to represent the woman who humiliated him, mocked him, and exposed his tiny genital to view. And, inasmuch as there was always another side to the conflict, she could also represent the protector who clothed him and at times hid him comfortingly from view. The intense ambivalence was manifest in these myriad ways at nearly every stage of treatment. Impulses to urinate and fears of wetting the couch were almost inextricably linked with fears of a scolding for failing to ask for a bedpan. Skin erotism, likewise, was manifest in terms of the many things that were done to his body in preparation for the surgical assault. (In later phases of the analysis all manifestations were shown to have far more varied determinants as these were brought into awareness.)
The way in which the analysis repeatedly brought to consciousness apparent manifestations of the surgical trauma may best be conveyed by some sessional material. I have chosen an illustration from the fourth year of treatment to give some indication of the persistence of this content and to demonstrate how, even at this stage in the analysis, it could still play a conspicuous part in the treatment.
Part of my consulting room had been freshly painted. When the patient lay on the couch, he expressed his pleasure at the smell of new paint. He had experienced some feelings of dizziness the previous day, as if his brain were being damaged. He had a fantasy that he was suffering from a brain disorder, perhaps of an infective kind. It made him very sensitive to what he called "levels of consciousness."
At his club the previous day, he had found himself feeling angry with a fellow committee member. This colleague who, incidentally was a doctor, always spoke with authority, as if he knew everything and had a right to be in charge. The conversation was becoming somewhat acrimonious, though he himself had not expressed his feelings. He looked around the room and reflected that the building was falling down. They would have to move. This seemed to add to the general air of acrimony and discontent." The hostility seemed too much for him, and he was somewhat alarmed when the man who assumed so much authority began attacking one of the women members. He realized that his own feeling was unmistakably a childhood one that brought back to life quarrels between his parents, in which he was always the mediator. He wanted to attack his doctor colleague.
We had already in previous sessions, had occasion to look at his fantasies of a violent primal scene, in which he intervened and rescued his mother from the hostile father. No doubt it was the work we had already done that helped him to say, suddenly and decisively, "I realize it can't really be about the doctor on the committee. I have no real quarrel with him. I suppose you're the one I really want to attack, but that makes me feel guilty and bad." He then observed that he had experienced the unsteadiness, the dizziness of which he had spoken, on leaving the committee meeting.
After acknowledging his comments on the primal scene and his reexperience in terms of myself and my wife, I suggested to him that he must be struck by the way in which so many of his thoughts still took us back to the operation in childhood. The fantasy of neurological or brain damage still returned, and the unsteadiness, presumably was still linked to the anesthetic experiences. Could it be that, in his fantasy, the attack on his own head and the concomitant anesthesia followed the attack on myself in the form of the committee doctor? Did he perhaps experience this as a retaliation for his own aggression? "Well," He responded, I do have a sense of being unjustifiably hostile to older men. I get angry when I'm not treated as an equal. I suggested that, when he experienced the childhood feeling to which he had referred, he was not treating himself as an equal. He was silent for a time.
After some reflection, he said he must annoy his girl friend by repeatedly drifting off in his thoughts whenever she talked to him. He thought this must make her quite angry. He recalled that his mother used to "drift off" whenever he wanted to talk to her, so perhaps he was retaliating for his mother's behavior by doing the same to his girl friend. Some comments about the forthcoming weekend as well as a future holiday brought thoughts of my "drifting away" from him and physically absenting myself in the same way that his mother had done when she had forcibly sent him to the hospital.
For some time, almost any session picked at random would contain some reference, however slight or disguised, to the hospital experience although as the analytic work proceeded, there were longer stretches when any such reference was marginal. And although physical experiences played no part in the discomforts that drove this man to seek treatment, they repeatedly played a part in the analysis. They appeared in bodily sensations, in feelings of impaired consciousness, of unsteadiness, and of transient pain. Although their appearance was not exclusive to the consulting room and affected him elsewhere, and even imposed themselves upon his patterns of sleep, they almost always had transference manifestations. But perhaps the most striking feature of all was that, with rare exceptions, they could be traced to fantasies and reexperiences of the hospital trauma, especially the operation itself.
Thus I believe, this hospital experience can properly be regarded as a trauma, it appears to have attracted to itself, almost like a magnet, nearly all the major conflicts, expectable or otherwise, which preceded it as well as so many conflicts that must have followed it. The hospital experience therefore functions as an organizer. (Kennedy, 1986) which structures the patients disturbances and anxieties and lends them the shape they they assume when they reemerge in analysis. The analytic task in a case such as this consists of the slow isolation of the trauma from all that goes before and all that follows after. Whether this can ever be completely accomplished is another matter. However this may be, it seems justified to call cases of this kind posttraumatic neuroticlike states.
Some of these points may be made with greater force in the light of a treatment session from a comparatively late stage in the analysis. The patient reported that he was awakened during the night by his girl friend who was now pregnant. She said she couldn't sleep on account of a rash that was itching. He looked at it, could not identify it, gave her some calamine lotion, and went to sleep. He had a dream in which his feet were sinking into mud. When he finally extricated himself, the mud was clinging to his body.
In his associations he recalled that, the day before, he had been trying to fix a leak in the water tank and, in doing so, had become very dirty. For some time he felt very smelly and dirty for reasons which puzzled him. He reminded me of the several occasions on which he had already referred to this experience. There was a note of reproof in his voice. He said there was a bit in the dream which suggested that he had managed to find a way of dealing with the mud and getting rid of it.
This reminded him that he had been somewhat intrigued by his girl friend's rash and was determined to find a way to help her. He was a keen reader of medical literature and always regretted he had not become a doctor. He got hold of some textbooks on dermatology and decided it must be an allergic response. With more detective work and further questioning of his girl friend he traced the cause of the allergy and decided it must be an allergic response. With more detective work and further questioning of his girl friend he traced the cause of the allergy and dealt with it successfully. He was proud of his accurate diagnosis and treatment. The cause for the reproachful tone soon became clear. He had got his girl friend "out of the mud": why hadn't I solved his problem with the dirty skin in the same effective way he had solved hers?
He turned again to his fascination with rashes. When he examined his girl friend, he had put his ear to her tummy to see if he could feel the baby kicking or hear the heart beat. He couldn't. He had a fleeting fantasy that the child would be brain damaged. But he couldn't understand why the rash should make him listen for the child. He also noticed that, right now, he felt very hot as well as sticky.
I said that I wondered if he was recalling some childhood illness of his own in which he was hot because he had a fever, and felt dirty and sticky because he had a rash. Perhaps it was an illness which sometimes led to brain damage. He said, "That's funny. As you were talking I thought of measles. I did have German measles - I think at 6 or 7, but I had forgotten about it until now. I was frightened because my mother left me to go out. I heard later she'd knocked down a child who had to be taken to the hospital with a broken arm." I said, "So this was another illness linked with brain damage and an absent mother who injured a child." This reminded him that he, too, had once broken his leg and had a greenstick fracture of the fibia. He remembered being taken to the hospital lying in the back of the car. He paused, and then went on, "I know I'd also suffered from chicken pox, though I'm not sure when. I had a small cousin whose brain was already damaged and who died from the measles about the same time."
He again thought about the water tank. (Earlier, we had traced part of his interest in water to a childhood fascination with urination, especially in little girls.) Whenever he was hot, he longed for something cool on his skin. He remembered that as a child his favorite book was The Water Babies and it was the chimney sweep with the filthy skin who was at the center of the story. He went back to the greenstick fracture. He remembered begging his mother to relieve him of the pain. When he got to the hospital, the anesthetic did just that and it was marvelous.
In the analysis he had already discovered that he liked the smell of new paint; and the pleasant effects of a little alcohol before he went to bed gave him a sense of freedom from disease. But he only acquired his bedtime habit during analysis, and it was necessary to understand his pleasure in terms of its significance in the transference. It had for some time been progressively easier to link his recurrent experiences with both pleasure and pain and with conflicts of a varied nature deriving from different developmental phases. They were no longer to be understood in the light of an inevitable link with the "traumatic event." The separation of my patient's trauma from other historical aspects of his development allowed him to welcome a whole range of positive experiences and pleasurable activities as well as understand the many miseries which had occurred independently of the operation in a new light.
The material from the foregoing session is not, however primarily reported to emphasize his point. It is the striking illustration of the way in which later significant events, conflicts, and experiences were drawn into the trauma that has to be underlined. Glover (1929), in reporting a patient who remembered how he burned his hand when he was about 3 1/2 but had no recollection of a circumcision occurring at the same time, suggested that traumatic memories might have a screening function. Furst (1967) discussed this postulate in underlining the fact that a "screen trauma," like a screen memory, can serve either to cover another more significant trauma or else can stand for a group or series of traumatic events. A point of this kind has indeed been repeatedly made in the analytic literature and is described, for example by Anna Freud (1951) and by Kris (1956) in his discussion of strain trauma. What we are dealing with in my adult patient, however is something more; future events are drawn back and absorbed into the single trauma long after it occurred.
Hansi Kennedy (1986) described the treatment of an adolescent whose phimosis in early life was the subject of his mother's intrusive ministrations and led at the age of 2 years 8 months to operative treatment. [circumcision] The boy felt deeply that he had never been loved, and the attention given to his penis represented his principle tie to the mother. A leading feature of this analysis was the repetition, in thinly disguised enactments, of the manipulation of his genitals and the painful excitement this engendered in the transference. This dominated the early stages of the treatment, and its sadomasochistic character could be traced long afterward. The author took the view that the boy's protracted experience of the mother's genital attentions and the subsequent operation had a decisive effect on all later development, as well as serving to incorporate all the antecedent conflicts. For this reason, Kennedy refers to the boy's collective experiences as an "organizer" in a sense comparable to my use of the term in connection with my adult patient.
It may rightly be asked what is meant by the term organizer. I have the impression that Kennedy's use of the term is, like mine, descriptive. That does not mean that our uses are identical, although, in each instance, we try to convey and identify a pathological process in terms which may be both clinically and theoretically useful. It is true that the presenting clinical pictures are very different, but the events which in each case became such a powerful determinant in shaping the nature and quality of the treatment experience can surely be called traumatic.
Discussion of psychic trauma has been handicapped by colloquial use of the term which broadens its application to a point where it undermines its psychoanalytic usefulness. The problem is compounded by a blurring of distinctions between what can properly be called the traumatic neurosis and what is often called traumatic anxiety. This sometimes results in hybrid concepts in which earlier and important precisions are lost. Furthermore, it seems possible that our understanding of the trauma concept has not been made easier by the hypothesis of a breakthrough of the barrier against internal stimuli - a notion that risks confusion with an untimely breakthrough of the repression barrier. That is not to say that the notion should be abandoned without further consideration.
Further thought needs to be given to the posttraumatic neurotic- like states. Although these have been understood in terms of trauma as "organizer," this term is used by both Kennedy and myself in a descriptive sense. This does not obviate the necessity for greater metapsychological clarity in the further study of these conditions. That task still lies ahead.
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