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Publications: Book Reviews
Review of Wounded by Reality: Understanding and Treating Adult Onset Trauma

Title: Wounded by Reality: Understanding and Treating Adult Onset Trauma
Author: Boulanger, Ghislaine
Publisher: The Analytic Press
Reviewed By: Elizabeth Hegeman, Vl. XXVII, No. 4, pp. 54-56

Wounded by Reality starts by asking a simple question—'whether psychoanalysis can effectively treat those who have suffered massive psychic trauma in adulthood' (p.3). Ghislaine Boulanger replies that 'we have the tools but not the theory'—because developmental theory, and ambivalence toward real trauma, have so pervaded psychoanalytic epistemology that it is almost an automatic assumption that trauma must be understood in terms of childhood experience, and in terms of explanatory schema that are anchored in childhood within the self. She points out that this assumption is contradicted by research findings that show the profound and enduring impact of adult onset trauma, whatever the developmental history, and misleads us into looking for a history of psychopathology when we treat adult survivors of serious trauma. The book that follows 'considers the uneasy relationship that has existed between psychoanalysis and catastrophic trauma' (p.4), showing through gripping clinical examples and masterful explication of psychoanalytic theory, just how uneasy that relationship is, and what clinicians and theorists can do about it.
In the second chapter, Boulanger distinguishes the impact of adult onset catastrophic dissociation from the impact of childhood trauma: while dissociated self-states in childhood can serve to protect the development of the self allowing a form of development to continue, the adult survivor in contrast must live 'between two deaths' (p. 38). The first death occurs as annihilation terror leads to the collapse of the self leaving the survivor feeling as if she is living outside the human community. The second death is biological death that may come many years later. Chapter three establishes the factors behind the inadequacy of psychoanalytic epistemology that stem from our history. Chapters 4-7 reexamine the actual process by which the adult self is destroyed. Drawing on what Boulanger considers the greater flexibility of relational theory, and on recent findings in cognitive, neurological, and developmental psychology she brings alive the actual experience, or failure of experience, brought about by specific forms of annihilation anxiety. Relying on the concept of the core self, the self that recognizes itself and integrates symbolic and subsymbolic biological aspects, Boulanger addresses the loss and the process of recovery of the experience of self-cohesion. Heeding Stern's (2000) call, Boulanger has brought into relational theory 'the more arbitrary, random, traumatic and unintelligible parts of life' (2000, p. 768). This development opens up the relationship to enactments of unformulated experience within the analytic relationship, and thus to the healing and integration, of the unreal, the unthinkable, parts of the self and of reality that have never before been imagined.

Valuable and comprehensive as the theoretical richness of this book is, the most precious and spiritually moving part is Boulanger's ability to share her clinical self. In chapter 8, 'The Ancient Mariner's Dilemma: Constructing a Trauma Narrative' she describes in simple detail her painstaking journey with a survivor of the World Trade Center. The movement from a frozen narrative to a living one can only happen in the relationship with an analyst who can give up the need to protect the patient and herself, and 'encourage the patient to cast her verbal and associational net more and more widely' (p. 150) and who “must give up any pretense of innocence” (p. 168) so that she can form a personal understanding of the fragments of self that have become symptoms and keep the survivor from being able to rejoin her life.
The final two chapters address the individual and collective resistance of survivors, professionals and society to doing what is needed. Resistance to treatment here is reformulated in this context as all the rationalizations we employ in order not to know about the subjective experience of terrifying and uncontrollable events: among them, the fear of professional censure, the narrator’s fear of spreading contamination and toxicity, the problem of vicarious traumatization, and the analyst’s fear of retraumatizing the survivor in the telling of the story. And finally, in a new and more political sense, she points out that the institutional forces of government, the military, insurance companies, and organizations all have a stake in minimizing and undermining the expression of painful affects, even negating and denying the existence of the wounding circumstances that bring them about. Perhaps the bias in psychoanalysis that maintains the focus on trauma as a childhood experience is itself an example of these forces.

For the purposes of teaching about trauma to psychology students, Wounded by Reality is a perfect example of the theoretical masterwork that does not lose its touch with clinical reality. In addition to correcting the course of development of the theoretical understanding of trauma in every chapter, it fleshes out the voices of the subjects, both the patient and the author/analyst who discover meaning together. The clear, strong writing make it suitable for all: advanced undergraduates, graduate students, psychoanalytic candidates and practicing clinicians. In teaching and learning about trauma, there is always the danger of retraumatization; the narrator fears the unwitting inflicting of pain, and/or his or her own sadism in passing on the toxic knowledge. Boulanger manages this problem by letting the reader feel her passionate and compassionate voice; she suggests that it might be necessary to push past and normalize the clinician’s “initial incoherence”, to recover her own thinking self, so that the survivor can begin to inhabit her own narrative again. When she says in the very beginning of the book 'we have the tools', it might be more accurate to say that now that she has pushed forward to a new place in clinical stance, we have the tools.
Boulanger has herself followed closely the path of current understanding of adult onset trauma, beginning in 1976 when she began to study of Vietnam Veterans. In recent time she has given the time and energy too few of us have devoted to acting on our principles – she has been one of the leaders of the movement to expose and oppose the American Psychological Association's collusion with military psychology to permit psychologists to continue participating in illegal interrogations. This ongoing struggle is described and documented at websites and She has written a book that poses the explicit and implicit question to us as clinicians—where can we find the courage to enter into the world of the shattered adult? And how can we live with ourselves if we don’t oppose the forces that make it happen? Boulanger shows the way, for she has been there.

Stern, D.B. (2000) The Limits of Social Construction. Psychoanalytic Dialogues, 10: 757-769.

© Division of Psychoanalysis, 1999-2005
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