Trauma, Ethics and the Political beyond PTSD: The Dislocations of the Real

Gregory Bistoen

The inclusion of Post-Traumatic Stress Disorder (PTSD) as an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980 triggered a resurgence of interest in trauma research, stimulating the production of a huge amount of empirical data and a range of theoretical innovations over the past three decades. Interestingly, these intensive research efforts stem from a variety of scientific disciplines, which, according to Vincenzo Di Nicola (2012a), can be roughly divided into two large traditions. On the one hand, psychological trauma has, of course, been extensively studied from an explicitly clinical perspective. This research pole encompasses disciplines such as the neurosciences, cognitive and behavioral psychology, clinical psychiatry, psychoanalysis and so on. On the other hand, and rather atypically for a psychiatric disorder, trauma has increasingly become a topic of interest for cultural fields of enquiry such as literature research, holocaust studies, women’s studies, and postcolonial research. Needless to say, these various disciplines and, on a larger scale, the clinical and cultural poles of trauma research, are characterized by radically divergent values, epistemological assumptions, methodologies, beliefs and aims – to a degree that it would be justified to speak of two separate ‘trauma communities’, each with a distinctive and irreducible understanding of trauma, despite their commonalities and interrelations (Di Nicola, 2012b). Whereas the clinical research pole is largely associated with a positivist and empiricist approach to trauma rooted in a biomedical model, the cultural pole is more influenced by social constructionist and postmodern scientific paradigms.

The combined research efforts of the last three decades can therefore be said to have given birth to a body of knowledge that, with a wink to Jacques Lacan’s (1949) mirror stage theory, is best described as a corps morcelé: an amorphous, split or divided corpus that cannot be identified as a whole when viewed from the vantage point of whichever of its constituent parts. In other words, the sprawling knowledge of trauma that is produced in these various fields of inquiry cannot be integrated into a single, unified discourse, due to the lack of a point of reference from where such an operation could occur. As Dominick LaCapra (2001) observed: ‘no genre or discipline “owns” trauma as a problem or can provide definitive boundaries for it’ (p.96).

My own research starts from the observed tension between cultural and clinical accounts of trauma. Because of the distinct perspectives on the same phenomenon, their juxtaposition offers somewhat of a ‘parallax view’; the shift between both vantage points apparently puts the scrutinized object in motion. When we consider the points at which these traditions diverge in their understanding of trauma, then the underlying presuppositions of both, which often remain implicit, suddenly light up with great clarity. Moreover, it has been argued that the gap that separates both approaches discloses something about the studied phenomenon itself: from this point of view, the observed lack of integration in the corpus of trauma knowledge is not merely the result of the different perspectives from which trauma is studied, but rather indicative of a split or gap in the concept of trauma itself (Di Nicola, 2012a). Every attempt to describe and localize this gap, for instance by means of the introduction of a dichotomy (for example, cultural versus clinical; moral versus theoretical (Fassin & Rechtman, 2009); mimetic versus antimetic (Leys, 2000)) brings a degree of order to the confusing multitude of trauma studies and theories, without however exhausting the tensions internal to trauma. As Di Nicola shows, each posited dichotomy is ‘shifting, porous and unstable’ (2012a, p. 103): it will always give rise to cases that cannot be allocated to either of the proposed poles of the dichotomy. Psychoanalytic theory is a good case in point: although it is first and foremost a clinical theory, its insights are often adopted in cultural work on trauma.

It follows that in the confrontation with this gap, my goal is not to attempt an impossible Hegelian-style Aufhebung of the tension between the thesis and its antithesis. Nor is it even to aid in the construction of a ‘common ground’ or bridge between them. The idea is rather that the inter-implication of both traditions disrupts their respective independent flows; it lays bare a number of aporias that are otherwise easily missed. The goal is ultimately to subvert a number of distinctions and divergences that separate both traditions, for example the purported discrepancy between clinical-therapeutic and sociopolitical goals in clinical and cultural accounts of trauma respectively. In line with the general rationale of this project, I believe that the disruption caused by juxtaposing both outlooks is a motor force for theoretical innovation.

This book focuses on trauma in its relation to politics and ethics. It is my contention that recent philosophical analyses of the dynamics of rupture in sociopolitical change can be put to use to incorporate the political dimension in our understanding of trauma. Whereas trauma is ordinarily understood as a rupture on a psychological, intra-individual level, these philosophical theories make use of Lacanian psychoanalytic theory to comprehend how rupture appears on a trans-individual, collective or societal level – and how this constitutes a possibility and a prerequisite for the creative invention of new political or economical structures. Whereas current psychological trauma approaches have been criticized for obscuring and neglecting the sociopolitical aspects of trauma recovery, philosophical theories of rupture are at risk of downplaying the suffering of those caught up in movements of radical social change – in favor of an emphasis on the creative possibilities of such disruptive moments. I believe the choice between an psychological and a sociological level of analysis and intervention to be a false one. Through a discussion of Lacanian psychoanalysis, I hope to show where this dichotomy becomes unstable, and how this can broaden our understanding of trauma recovery as an ethical endeavor with political consequences, beyond a medico-technical framework.

The concept of trauma has become ubiquitous in contemporary society. Whenever a sudden, unexpected and horrific event disrupts the normal run of things, the language of trauma is deployed by professionals and lay-persons alike in an attempt to make sense of the unthinkable. More generally, it has been argued that in our postmodern times, the scientific disciplines of medicine and psychology have increasingly taken over religion’s primary role of providing meaning and coherence for a world continuously shaken up by the unforeseeable. This is evidenced, for instance, by the observation that ‘therapeutic forms rather than religious ceremonies are becoming the predominant cultural rites that accompany public and private events’ (Pupavac, 2004, p. 495).

The old, biblical proverb that ‘God works in mysterious ways’ still echoes the ways in which religion used to assure people that the senseless would be revealed to be meaningful after all, once our human restraints were transcended in the hereafter. If God is dead, then he can no longer perform this pivotal task of holding the world together, of being the universal hypokeimenon or subjectum of everything that is – or at least of providing the semblance of possibility of such a harmonious unity in which everything has purpose and makes sense, by grace of the bestowment of some sort of divine Order that allocates everything its rightful place. In the vacuum left behind in the West by God’s demise, then, science can be said to be the prime candidate to take upon itself this abandoned function of providing meaning and guaranteeing order. Understand that this is not necessarily science per se, as it is practiced by scientists themselves, but rather the way in which this form of human activity is recuperated and put to work in popular discourse (that is, scientism). The chorus of pre-modern religiosity with its returning theme of a unifying One continues to stir up deep-rooted desires for a universe that closes in upon itself, one that, in the final analysis, will be shown to make a whole. Deep down we still believe that everything happens for a reason, and science has now become the instrument on which we rely to unearth the obscured links in a supposedly complete causal chain. God’s proclaimed death, then, did not prevent the suffusion of theological images and sensibilities in the sciences of modernity, as can be seen for instance in the fantasy of Nature as a cosmic One-All ruled by unbreakable, timeless laws (Johnston, 2013). It is no longer God but Nature itself that is believed to guarantee the rationality and ultimate cohesion of reality. Science, then, is identified as our means to access these securing eternal laws of nature. We put our faith in it to guide us through our existential predicaments. As we will see, the psy-sciences occupy a central position in this dynamic, with trauma as the central concept to think the effects of a confrontation with a point of radical incomprehensibility.

The word trauma is, confusingly, often used in two distinct ways. In lay terminology, it often denotes a type of event that is considered both out of the ordinary and inherently destructive. Originally, however, psychological trauma referred to a type of pathological reaction towards such a devastating event. Trauma is what happens to a person’s psychological functioning when he or she is confronted with something that defies his or her ability to grasp. In cognitive psychology this is seen as a failure to ‘process’ a certain type of data related to the traumatic event. Subsequently, this unprocessed material is thought to incessantly haunt the psychic system, disrupting its normal functioning and inciting a cascade of maladaptive sequelae, in a repeatedly thwarted attempt to finally conclude this obstructed mental processing. In other words: the psyche is understood as, ideally, an integrated or unified system that smoothly combines external data with internal objectives to guide behavior. Trauma describes what happens when an incommensurable element enters and disturbs the psychic space. When we are confronted with the boundaries of our capacity to process something, simply because it literally concerns the impossible that nevertheless took place, trauma describes the potential psychic consequences of this encounter: the shattering experience of a profound sense of meaninglessness and dislocation. Ideas of integrative unity and its disruption are thus central to these phenomena.

When today disaster strikes and cracks suddenly appear on the purportedly smooth surface of life, it astonishes no-one that the representatives of the disciplines of (trauma) psychiatry and psychology are called upon to enter the field. Today, no-one is surprised to find that thousands of psychosocial workers are dispatched to far-away, non-Western countries in the aftermath of natural disasters or violent conflicts, in an attempt to attend to the local population’s psychological needs (Fassin & Rechtman, 2009). As Derek Summerfield (1998, p. 1580) duly noted, the rise of trauma work in humanitarian operations is rooted in the aforementioned way that ‘medicine and psychology have displaced religion in Western culture as the source of descriptions and explanations of human experiences’. The disciplines of psychiatry and clinical psychology have come to proffer the culturally sanctioned answers to the impossible questions of life’s contingencies. Science takes the place of religion in the precise sense that it is called upon to provide sensible answers at times when there are none. But more importantly, the scientific apparatus serves as a guarantee for the validity of these answers: it offers us authoritative answers in which we can trust.

As part of the shared belief system of Western societies, the idea of trauma is experienced as both self-evident and natural. This means that we expect the human response to adversity to be universal across times and cultures. Consequently, the inclusion of trauma psychiatry in humanitarian aid campaigns, which started only at the end of the 1980s, appears to be both logically and morally justifiable. This innovation was premised on the assumption of a distinct ‘psychological fallout’ of war and catastrophes for whole populations (Summerfield, 1997). Moreover, what was known about trauma suggested that this type of wound does not heal simply with the passing of chronological time, but needs to be addressed in its own right.

It came as a great surprise when researchers found that the application of interventions based upon this supposedly universally valid trauma framework resulted in paradoxical (that is, harmful) effects when applied in both Western and non-Western settings (for example, Bisson, Jenkins, Alexander, & Bannister, 1997; Bracken, 2002; Herbert, et al., 2001; McNally, 2009; McNally, Bryant, & Ehlers, 2003; Raphael & Wilson, 2000; Rose, Bisson, Churchill, & Wessely, 2002; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). Such findings, among others, prompted a series of critical analyses of the assumptions behind the contemporary dominant conceptualization of traumatic pathology, the diagnosis of Post-Traumatic Stress Syndrome or PTSD. As a result, a great number of conceptual and practical deficiencies that haunt this biomedical trauma model have been identified by trauma scholars from a variety of academic backgrounds. The current project is built around a selection of a number of interrelated core problems associated with the PTSD approach to trauma.

First, the construct of PTSD effectuates a problematic decontextualization that determines the manners in which we understand and react to these phenomena. There are many factors involved in this operation. At the level of the definition of PTSD itself, for instance, there is the conceptual annulment of the peculiarities of any given etiological stressor, in favor of an emphasis on  the commonalities between traumatic responses at the level of pathological mechanism and symptom manifestation. The idea that different types of events can cause the same symptoms through a similar etiological pathway – one of the core ideas defining the PTSD construct, which ties back to the historical background against which it was conceived – can lead to negligence of the manners in which the specificities of the social, cultural, political or economical context of the stressor play a part in both the origin and outcome of trauma, as well as in processes of recovery.

Second, the emphasis on the individual as the locus of scrutiny and intervention in Western psychotherapeutic approaches seems particularly unfit to address the problems that surface in the wake of a collectively suffered event, as is the case with political violence, large-scale disasters, and so on. Furthermore, it is antithetical to responses that aim to alter the social conditions associated with various forms of distress. An increasing number of trauma scholars have argued that traumatic pathology does not occur in a vacuum, and that successful recovery from trauma requires the recognition of the importance of an individual’s relations to the Other (a Lacanian concept that refers to other people as well as to the socio-symbolic order in which we are immersed).

Third, these decontextualizing and individualizing operations have been argued to have a political effect in themselves, as they produce a focus on immaterial recovery (that is, a change in someone’s individual psychological functioning) over material recovery (the modification of a trauma-generating context). Trauma psychiatry therefore risks becoming a depoliticizing instrument in service of the status quo.

Taken together, these points of criticism suggest the need to acknowledge the influence of culture and context in trauma definitions and interventions, and to depart from a limited focus on the individual. Furthermore, although the political dimension is very present whenever we deal with psychological trauma, it proves difficult to recognize and engage it within the confines of the PTSD model. What is needed, then, is conceptual work on trauma that takes into account context and culture, and that helps to envision how sociopolitical change on a collective level is related to processes of recovery. It is my contention that the Lacanian psychoanalytic framework proves very powerful to deal with these issues, primarily because of its unique conception of both the subject and the Other as the locus of the symbolic order in which the subject is constituted.

I start off in Chapter 1 by unearthing the factors that contribute to the decontextualizing and depoliticizing effects of the PTSD diagnosis. To this end, I critically discuss some of its underlying presuppositions and their relation to the biopsychomedical discourse from which this diagnosis stems. I describe how these presuppositions, which remain largely implicit, lead to types of interventions that neglect and obscure the political dimensions involved in both the genesis of and recovery from trauma. This analysis aims to show that far from being neutral and value-free, PTSD-informed interventions have very real political consequences, as they (unintentionally) reinforce the political and economical status quo and foreclose alternative modes of responding to these situations. It is precisely because PTSD purportedly describes a reality that transcends particular contexts and cultural determinations, that is, because of its avowed universality and neutrality, that it is able to serve as a disempowering political instrument – in the sense that to claim ‘that one is beyond ideology’ is itself the ultimate ideological gesture. It follows that the application of the knowledge associated with PTSD, for instance in humanitarian aid campaigns, must be handled with great care. The discussion in Chapter 1 renders the link between trauma and its often neglected political dimension more palpable, suggesting the need for a conceptualization of trauma that includes it.

In Chapter 2, French philosopher Alain Badiou’s (2001) work allows me to tie the discussed problems of PTSD’s decontextualization and depoliticization to a more general crisis of ethics in the West. I thereby agree with Fassin and Rechtman’s (2009) compelling thesis that evolutions in trauma theory should always be read against the background of an equally developing societal moral climate. I offer a reading of the current success and omnipresence of trauma discourse as reflective of the prevalence of the ethics of human rights as the dominant moral compass for our times. Although this ethical doctrine seems self-evident to a contemporary eye, considering its emphasis on the prevention of suffering and death, Badiou’s controversial analysis suggests that it ultimately amounts to a nihilistic resignation that must be resisted. The success of this doctrine is tied to the catastrophic consequences of the utopian projects of the 20th century. Badiou laments that the resultant fear of collective action in the name of a shared cause has left us with a type of ethics that is essentially negative, defensive and conservative. This ethical doctrine, then, is founded on a number of basic assumptions and related to a series of undesirable consequences that bear a striking resemblance to those discussed with regards to PTSD. It turns out that a well-defined ethical position is at the heart of several problems affecting PTSD, which presents us with the injunction to think anew the interrelatedness between the fields of trauma, ethics and politics – a project to be carried out in Part II of this volume.

The objective of the second, psychoanalytically inspired part of this book is not so much to develop a ‘better’ alternative to existent practices, but to provide a conceptual framework that clarifies the manners in which these three fields are related. This will require an elaboration of how the psychiatric level (of the particular, the individual) can be articulated with the sociological level (the universal, the collective). The main hypothesis driving this work is that Lacan’s concept of the real is at the intersection of trauma, ethics and politics. The analysis of this concept will throw new light on the issues touched upon in the first part of this book.

In Chapter 3, I discuss Lacan’s evolving views of the real, while introducing a number of other key Lacanian concepts that will be of use in what follows. I discuss the two major conceptions of the real: ‘presymbolic’ and ‘postsymbolic’. It becomes clear that the real should not be taken as the ultimate referent of external reality, but rather as a productive negativity that dislocates the representation of external (symbolic-imaginary) reality. Subsequently, I go on to show how this notion of the real generates an interesting take on trauma that diverges from the more familiar, biomedical trauma discourse. As will become clear, the Lacanian approach to trauma breaks with the familiar inside/outside, self/other and individual/collective dichotomies. Furthermore, it introduces a non-linear conception of time to make sense of the counterintuitive dynamics of trauma.

In Chapter 4, I scrutinize the paradoxical notion of an ‘ethics of the real’, which refers to Alenka Zupančič’s (2000) denomination of the particular form of ethics that derives from Lacan’s elaboration of the subject. Already here, we see an intriguing connection appear: the real is defined simultaneously as traumatic on the one hand, and as the condition of possibility for the subject, and thus of ethics as such, on the other. This chapter aims to elucidate this estranging logic, which leads to the identification of the Lacanian real as characterized by the dual function of ‘productive destruction’.

In Chapter 5, I aim to show the centrality of this same concept in the movements of politics. According to Yannis Stavrakakis (1999; 2007), it is a disruptive encounter with the real that initiates time and again a process of symbolization – along with the ensuing hegemonic struggle between alternative symbolizations of this real. Rupture, in this way, is connected with sociopolitical innovation. However, the traumatic impact of such large-scale, societal ruptures has not been explicitly addressed within these socio-political theories. The juxtaposition of Lacanian trauma theory and philosophical contributions on rupture-predicated societal change allows us to think the ‘moment of the political’ in its relation to trauma recovery.

The category of the real, then, is at the centre of the interconnections that proved so difficult to account for in the PTSD-model of trauma. In Chapter 6, I describe some of the consequences of this interrelatedness centered around the real. First, I argue that many psychological theories of trauma commit a logical fallacy in their description of the process of trauma recovery, claiming that the psychological buildup needs to be remodeled so that it can accommodate the ‘new trauma information’. In this move, they take as a given that which must first be constituted by the subject: the content or ‘meaning’ of the traumatic episode. Second, I argue that Lacan’s notion of the act can be put to work to conceptualize this neglected but primordial aspect of trauma recovery. Furthermore, I demonstrate that it is this moment of the act that opens up the path towards collective action and social change. The incorporation of the dimension in the act in trauma recovery, moreover, requires us to take up an alternative ethical position.