Yasmin Nilofer Farooqi
In recent years, there have been major advances in our understanding of the neurobiology of the stress process and trauma-related diseases. Certainly, the complexity of the brain and the protean nature of behavior remain the most elusive areas of science but also the most important to understanding the spectrum of trauma and human resiliency.
Over the past decade, the biomedical approach to psychopathology has swept away and effectively eradicated the psychological approach. It dehumanizes and compartmentalizes the individual by emphasizing the symptoms rather than the whole person. Furthermore, our thrilling search for the complete human genome has led behavioral scientists to attribute the majority of human behavior and illnesses to our genetic change. Conversely, psychologists such as Freud (as cited in Strachey, 1962), Firestone (1987), and Firestone, Firestone, and Catlett (2003) have attributed human behavior and psychopathology to the sum of early life experiences, imprinted as patterns on the brain. Firestone et al. (2003) argued that the medical model conceptualizes the patient as ill or as possibly suffering from a disease or biochemical imbalance. Luhrmann (2000) deplored the potential consequences of the increasing medicalization of psychiatry and psychology. “We are so tempted to see ourselves as fixable, perfectible brains. But the loss of our souls is a high price to pay” (p. 293). Sluzki (2001) warned that in our society “we endure an era of ‘mindless mental health,’ in which everything is referred back to brain functioning, and psychiatric and human miseries of all kinds are dealt with by the, after all, not-so-magic bullet of this or that designer medication” (p. 149).
With advancement in science and technology (e.g., MRI scans of the human brain), the extreme positions of nature versus nurture seem to give us a myopic viewpoint of human personality and behavior. Consequently, this divide has triggered a paradigm shift toward the biopsychosocial model (systemic multidimensional approach) in psychology to understand the whole person rather than the sum of the parts of personality.
With this paradigm shift, we have moved from conceiving trauma as a purely physical phenomenon to seeing trauma as a complex set of physiological and psychological experiences. Yet, even in this millennium, the clinical psychologists, psychiatrists, neurobiologists, and medical professionals continue to define trauma in terms of horrific extremes of human experiences while underestimating the cumulative effect of “little traumas” (p. 2) of everyday life. It may be argued that such a myopic viewpoint of trauma is reinforced by the way the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev; American Psychiatric Association, 2000) defines posttraumatic stress disorder:
Extreme traumatic stressor involving direct personal experiences of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury or threat to the physical integrity of another person or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. (Criterion A1, p. 463)
Indeed, these drastic traumas, such as disastrous airplane crashes; earthquakes; hurricanes; the September 11, 2001, terrorist attacks; bomb blasts; the Vietnam War; the Afghan War; the Gulf War; and the Iraq War have forced the professionals to once again consider these unfortunate victims empathetically and attempt to develop more efficient methods of treatment. “Over the past 150 years, the evolution of what defines a traumatic event and its medical-psychological consequences has been tortuous” (p. 1). I agree with Scaer that the traditional Cartesian concept of mind-body dualism in the medical sciences has in fact hindered our understanding of the human brain and its functions. Furthermore, it has relegated the stress-related diseases, such as shell shock in World War I and whiplash syndrome in motor vehicle accidents (MVAs), to a separate and less important class of psychological ailments. As a result, the effectiveness of trauma treatment and the quality of life of the millions of survivors of little to horrific traumas have suffered for more than a century across the globe.
In this age of information technology, our lives are full of little traumas, mostly hidden and long forgotten, such as early childhood abuse and neglect; territorial disputes; influx of information; poverty; car accidents; risky biomedical and surgical interventions; and social, racial, religious, cultural, ethnic, and gender discrimination and persecutions. Unfortunately, the professionals and the society often overlook these apparently less dramatic but very real and complex hidden traumas. Firestone (2000) stated, “People are torn between feelings and experiencing their lives and leading a self-protective lifestyle, cut off from feelings and emotional involvement” (p. 41). Scaer notes, “Unfortunately, the time and the aging of the traumatized population usually resulted in their abandonment and a loss of interest in pursuing the study of ‘little traumas of every day life'” (p. 1).
Behavioral studies of animals, such as those conducted on dogs by Pavlov in the 1800s and by Seyle in the 1900s (as cited in Sarason & Sarason, 1987, p. 67), have demonstrated how the mechanisms of the brain function to deal with the potential trauma of life-threatening events and how these traumatic events in turn shape the brain. Thus, it may be argued that our experience of life's little traumas (as mentioned above) might have shaped every single aspect of our existence, especially our response to trauma and survival skills. I think Scaer's major accomplishment is that he convinces the reader that the cumulative experiences of our life's “little traumas” (p. 2) may not be less powerful than horrific traumatic events, such as the September 11 terrorist attacks or Hurricane Katrina.
The Trauma Spectrum: Hidden Wounds and Human Resiliency was written to promote our current understanding of the deeper and complex mechanisms of trauma. Scaer has skillfully illuminated the wide-ranging and often hidden, though pervasive, effects of trauma on our brain and body. He proposes that some of the stress-related diseases, such as whiplash syndrome, tics, irritable bowel syndrome, migraine, chronic fatigue syndrome, and myofascial pain, are related to effects of prolonged stress and the process of traumatization. He further argues that viewing these trauma-related disorders as simply the products of the mind would seriously confine our understanding of the spectrum of trauma and severely limit our ability to treat them. However, if we considered the brain and the body in conjunction with the mind, this would pave the path for a more holistic and successful treatment of trauma-related disorders.
The Trauma Spectrum is a well-structured and well-organized book divided into three parts: Brain Mechanisms and Trauma, The Trauma Spectrum, and Trauma in Health and Disease. These parts are further divided into nine chapters: “The Brain/Mind/Body Continuum,” “How the Brain Helps Us to Survive,” “Trauma as Imprisonment of the Mind,” and “Genes, Experience, and Behavior” (Part 1); “Preverbal Trauma,” “The Spectrum of Societal Trauma: From Neglect to Violence,” and “The Trauma of Illness and Its Treatment” (Part 2); and “Somatic Dissociation: Conversion Hysteria, Stigmata and Reflex Sympathetic Trauma” and “Diseases of Stress and Trauma” (Part 3). These chapters are logically well connected and followed by an insightful conclusion (“Healing Trauma and the Power of the Human Spirit”) and an optimistic epilogue (“Understanding Your Life”).
In my opinion, the book will be of great interest not only to the practitioners and students of psychotherapy, medicine, psychiatry, and neurology but to anyone interested in understanding the mind-brain-body continuum and its interaction in trauma- and stress-related diseases. The author skillfully convinces the readers of the magnificent, innate capacity of the human organism for emotional and physical health and resiliency. His rationale is that people can restore themselves in the aftermath of the terror and helplessness of traumatic events, as supported by interesting medical anecdotes and his own painful but inspiring autobiography. In fact, The Trauma Spectrum presents a very positive vision by demonstrating that human beings have a profound ability to heal from trauma, given guidance and appropriate somatic-based, multidimensional therapeutic interventions.
Scaer, a neurologist with more than 30 years of rich experience working with victims of MVAs, has courageously redefined trauma as a continuum of variably negative events cumulated over the life span, ranging from little traumas (childhood abuse and neglect) to horrific events, such as wars and natural disasters. He has skillfully integrated the Darwinian theory of evolution and the adaptive value of emotions with other theories of perception, cognition, and affect. On the basis of his professional training and clinical experience treating trauma-related diseases, he has proposed a unique but somewhat complex and elusive model of brain pathways for trauma and the brain-mind-body continuum. Nevertheless, he offers a new understanding of the undercurrents (little, long-forgotten, hidden wounds) that unconsciously dominate many of our feelings, life preferences, and responses to trauma, which is of immense value to medical and mental health professionals. In fact, The Trauma Spectrum is a unique and valuable book in the field of traumatology because it helps both clinicians and their patients to identify and sort through the many and varied forms that trauma-related symptoms can take. Furthermore, the author brings our attention to the innate capacity of the human organism to restore itself in the aftermath of the terror and helplessness of trauma.
Scaer has skillfully combined some of the basic concepts from psychoanalytical, Darwinian, and existential-humanistic paradigms with cognitive-behavioral and biomedical models of personality development, adaptation, and psychopathology. He extensively depends on an overview of current literature and on the classical animal studies and experiments of Pavlov and Seyle to support his theoretical framework rather than referring to three-dimensional images of MRI brain scans of his MVA cases. However, his in-depth and insightful analyses of real-life anecdotes from his own professional and personal experiences of life traumas support his radical theory of trauma and the concept of the brain-mind-body continuum.
Scaer courageously talks about the intergenerational abuse and neglect of children while highlighting his own painful experiences with traumatic healing:
I was a voracious thumb sucker—so bad that my parents fashioned tiny wire cages to fit over my thumbs to keep them out of my mouth…. I was a little boy with a host of nervous tics. (p. xiv)
Within such touching anecdotes lie many of the challenges that are so eloquently and competently addressed in this book: (a) the complex and wide-ranging spectrum of trauma, from little traumas to horrific traumas; (b) the institutionalized sources of trauma in a culture; (c) the traumatic medical-surgical care delivery system, which considers our bodies as malfunctioning machines that need to be fixed; (d) the abuse and neglect of children and the accumulative impact of such long-forgotten little traumas on mental and physical health; (e) the importance of understanding of the myriad effects of trauma (prior negative life events) on the brain and body; (f) the complex and intricately interrelated functions of brain-mind-body; (g) the immense need for an integrated view of trauma-related diseases; (h) the power of human resiliency; and (i) the efficacy of a holistic therapeutic approach in medicine.
In the first part of the book, Scaer proposes the brain-mind-body continuum and his simple model of brain pathways for trauma. Though he has skillfully integrated Darwinian theory of evolution and the adaptive value of emotions with other contemporary theories of perception, cognition, and affect, I found this model somewhat elusive in description without any research-based findings. To me it is a very confusing assumption that the “unconscious brainstem” (p. 31) could cause involuntary physical response and other reflexes. The author fails to differentiate between the “unconscious process of repetition compulsion” (p. 94) and “conditioned reflex responses” (p. 258). He seems to have replaced the Freudian concepts of unconscious repetition compulsion and fixation with reenactment of trauma, somatic dissociation, and involuntary physical response to stress and trauma. To me it looks like old wine in a new bottle.
Scaer extensively uses the Darwinian theory of evolution, Seyle's theory of stress, and Pavlovian principles of classical conditioning to explain our survival behaviors: the flight-fight-freeze response to threat or trauma or stress. “The brain pathways and behaviors in this response [the flight-fight-freeze response] are common to all animals, from reptiles to primates” (p. 28). Being a neurologist, Scaer could have given evidence from functional MRIs of his MVA cases rather than depending on assumptions and inferences drawn from thought-provoking anecdotes and clinical observations. I think evidence-based anecdotes would have been more valuable and an objective source of information in support of his rationale.
In the second part of the book, Scaer explores the pervasive effects of trauma on the brain-mind-body and on all facets of one's daily life and inner experiences. He argues that all traumas are fundamentally nonverbal; therefore, people are unable to talk about their traumas. Thus, somatic experiencing may facilitate cognitive awareness of the hidden traumas and insight into brain-mind-body functions. Certainly, this assumption departs from the conventional psychological understanding and treatment of trauma cases, which often benefit from “talking sessions.” However, no clinical case studies or evidence-based research findings are given to support the author's radical viewpoint.
In the third part of this book, Scaer discusses innovative, multidimensional therapeutic interventions that make use of the innate human capacity for self-regulation and resilience to promote healing. The book concludes on an optimistic note, asserting that, by understanding ourselves and others, we can heal our life wounds and deal with many poorly understood stress- and trauma-related diseases.
The epilogue would be most valuable and enlightening for those who are striving to understand the little traumas of life and survive through the painful journey of healing from long-forgotten traumas. “Perhaps the ability to laugh at ourselves and without regret is the ultimate gift of healing from trauma” (p. 289).
Certainly, the author has done a masterful job of letting the individual voices of the traumatized individuals resonate in his honest communication, acceptance of painful feelings, and understanding of what it means to live with the accumulated “little traumas” (p. 2) of life and to heal from trauma-related diseases. This book gives an optimistic viewpoint of human personality and adaptation. Scaer demonstrates through his autobiographical study of trauma and real-life trauma cases (which he treated as a neurologist) that we are the victims of neither our genes nor our past. The author forces the reader to seriously examine institutionalized and intergenerational sources of trauma, such as neglect and subtle abandonment of the child, gender and job discrimination, use of horrific images and violence in news and entertainment media, and medical-surgical procedures. “Are we so traumatized as a society that we are drawn to images of violence as part of traumatic recapitulation” (p. 144)?
The graphic and repetitive coverage of the September 11 World Trade Center attacks led to a host of emotional and physical symptoms, not only in people who witnessed the scene but also in the larger TV audience across the globe. “This fact alone may explain why man is the primary source of traumatic stress for his own kind” (p. 43). At times, the author uses sexist language, as noted in this quotation. Moreover, most of his assumptions lack rigorous scientific scrutiny and research-based empirical evidence, probably because he heavily depends on literature review and past behavioral experiments and psychoanalytical studies. Nevertheless, I fully advocate the author's proposal for medical and cultural changes to promote emotional and mental health and unfold human resiliency.
Unlike the brilliant and revolutionary work of Firestone (2000), Scaer fails to describe the process through which parents can uncover and work through ambivalent feelings toward their children to gain a more compassionate view of themselves and of their children. Although Scaer proposes a systemic, multidimensional approach to trauma therapy, he heavily depends on Freudian, Darwinian, and Pavlovian concepts and principles. He argues that healing from trauma entails not only extinguishing cues and memories that perpetuate the process but also providing meaning to the messages provided by the body—the barometers of one's state of stress and emotional well-being.
I fully agree with the author that the little traumas over the life span and the meaning that one attributes to them in the context of prior negative life events, especially those experiences in the vulnerable early childhood, mold one's personality, choices of mates, profession, appetite and eating habits, social behavior, posture, physical and mental health and diseases, and overall response style to dramatic and horrific traumas. Thus, understanding these deeper and complex mechanisms of trauma can provide us a cogent rationale for holistic treatment for trauma-related diseases.
The author eloquently examines the significant role of cognitive awareness, insight into the meaning of trauma-related symptoms, and wisdom of self for transformation from trauma. Indeed, healing from the hidden wounds of trauma is a painful but resilient journey throughout life that is unknown to the medical specialists and scientists of this millennium. Virtually all fields of science and technology are marked by progressively increasing levels of specialization. However, as researchers and scientists involve themselves in the complexities of specific areas, they tend to lose sight of the relation of their topic to other issues. In contrast, Scaer has illustrated the immense need for an integrated view of trauma by emphasizing intimately interrelated brain-body functions rather than two distinct parts of the whole person. He argues that the human organism behaves as an integrated unit with magnificent capacity for resilience and power to overcome the debilitating symptoms of trauma.
Despite some limitations, this is a highly engaging and informative book of immense value for those interested in understanding, treating, and preventing trauma-related diseases. I strongly recommend this book as essential reading material for professionals and students in all related areas of mental health and medicine. The author's skill in writing, clarity of thought, rich clinical observations, systematic conceptualizations of real-life trauma cases, therapeutic expertise, encyclopedic knowledge, and professional integrity shine through all 308 pages of this appealing book.