Journal of Traumatic Stress, Vol. 2, No. 4, 1989

The Collapse of a Structure: A Structural Approach to Trauma M o r d e c h a i B e n y a k a r 1, Ilan Kutz 2, H a i m Dasberg 3 and M a x J. Stern 4 Accepted March 12, 1989

Applying an analytic approach to the concept o f trauma, the authors differentiate trauma from other stress disorders and define trauma as the collapse o f the structure o f self along all its referential planes, resulting from the encounter o f a catastrophic threat and a chaotic response, producing the unique traumatic experience. The post-traumatic state is conceptualized as a reorganizing transitional state, aimed at restoring autonomy, which can proceed by encapsulation only. The post-traumatic stress disorder is regarded as the manifest cfinical syndrome o f the post-traumatic state. By providing a systematic conceptual framework, the analytic structural approach to trauma allows clearer guidelines f o r the diagnosis and treatment o f traumatized patients. KEY WORDS: structuralapproach; trauma; collapse of structure; PTSD; stress disorder.

INTRODUCTION Psychic trauma, or trauma in brief, is a time honored concept that is currently facing extinction. What started as a central explanatory theme ~Brull Community Mental Health Center, Sackler School of Medicine, Tel-Aviv University, Director of The Analytic Institute of Group Psychotherapy (Israel), President, The International Cardiac Rehabilitation Research Foundation. 2Director Consultation Liaison Service, Meir General Hospital, Shalvatah Psychiatric Center, Hod Hasharon; Sackler School of Medicine, Tel-Aviv University. 3Medical Director, Ezrat Nashim Jerusalem Mental Health Center, Associate Professor of Psychiatry, Hebrew University, Hadassah Medical School. 4Director of Psychiatric Head-Injury Unit, Loewenstein, Rehabilitation Hospital, Raanana, Sackler School of Medicine, Tel-Aviv University. 431 0894-9867/89/1000-0431506.00/0© 1989PlenumPublishingCorporation

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dominating early modern psychiatry appears now, in the most central nosology, the DSM-III-R, as only a part-title of the Post-traumatic Stress Disorder (PTSD) without independent existence or explanation of its own (APA, DMS-III-R, 1987). In that nosology the word "traumatic" has no definition or conceptual context and is used interchangeably with a "traumatic event" which is undifferentiated from the concept of "stressor." Trauma has become devoid of any of its original connotations of disruption and discontinuity, and has become meaningless, used in the vernacular to imply any terrible situation. We are now experts on what happens after trauma, but still have but a vague idea as to what this thing called trauma is. It seems that unless trauma is seriously justified as a theoretical and clinical concept, it may come to be equated with, and diagnosed by its symptomatology alone. It is worthwhile to trace the evolution of the concept of trauma. Originally derived from the Greek verbs that mean to pierce, to exhaust, to wear out, it stands for "wound" or "injury" (Winnik, 1969). It was also used in Greek to signify object damage, or loss or defeat. Freud, at the turn of the century, borrowed and extended its meaning to imply psychological damage. For him trauma, particularly in the developmental phases, was the core of all subsequent psychopathology such as hysteria (Freud, 1888), melancholy [Freud, 1917 (1915)], and obsessive-compulsive neurosis [Freud, 1895c (1894)]. Though he never actually defined trauma in a precise manner, he regarded trauma "as a consequence of an extensive breach being made in the protective shield against stimuli" (Freud, 1920). Inherent in this concept were the original notions of disruption and discontinuity. Freud himself, in his later writing, reexamined trauma, this time shifting the accent from the "external event" to the intrapsychic realm [Freud, 1926d (1925); Freud, 1939a (1937-39)]. Over the past several decades clinical and theoretical reformulations were generated, all stressing various aspects of what their authors considered to be the core of trauma. Among the issues discussed were the role of the external event (Kardiner and Spiegel, 1947), against the background of internal reality, early predisposition (Greenacre, 1952; Moses, 1978), and early "Nuclear cumulative traumas" (Kahn, 1963). Other explorations included the notion of death anxiety and the destroyed sense of invulnerability (Lifton, 1979), the role of meaninglessness in the context of existential experience (Brull, 1969; Frankel, 1962), the role of biology in the etiology and symptomatology of trauma (Kardiner and Spiegel, 1947; Kolb and Multalipassi, 1982; Dobbs and Wilson, 1960), the importance of social support, and the centrality of cognition and imagery (Horowitz, 1970, 1976; Brett and Ostroff, 1985). Far from being a complete one, this list of themes demonstrates that the notion of trauma is as central to human existence as it is complex, and as yet, has not attained conceptual consensus (Freud, 1969; Winnik, 1969).

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As Israeli psychiatrists, who continue to confront victims of a past Holocaust and present wars, we believe that "trauma" is an indispensible concept that should be revived and redefined to include the original notion of breakdown and disruption (Dasberg, 1976). The intensity and number of symptoms and the allusion to a severe external event simply do not suffice (Kutz et al., 1988). If trauma is to be used, not just as a vague historical rudiment, but as a viable, meaningful clinical concept, it must convey its original metaphorical essence; the notion of injury and discontinuity, which, in its psychological context should capture the sense of irreparable tear of self and reality.

THE STRUCTURALAPPROACH By virtue of its inherent global nature, a structural approach enables the inclusion of a wide range of explanatory models and theories of trauma within one complementary framework. Structural analysis may be deployed as an epistemological tool for the clinical examination of the stressors and threatening events and their relationship to psychological disruption and discontinuity. A structural approach, in a variety of forms, has risen from and has been applied to all fields of knowledge that involve organized complexity. Physical systems (Bohm, 1980) and biological systems (Goldstein, 1939; von Bertalanffy, 1968) have been examined structurally, as have been political thought (Ward, 1975), and anthropological (Levi-Strauss, 1963) and sociological structures (Parsons, 1960) and systems that reflect the products of the mind, such as language (Chomsky, 1957; deSaussure, 1959) and cognition (Piaget, 1959; Rapaport, 1957). Recently, attempts have been made to apply structural theory to developmental theories of mind and personality (Kegan, 1982; Kohlberg, 1976). A structure is not easy to define (Piaget, 1970): "As a first approximation we may say that structure is a system of transformations. Inasmusch as it is a system and not a mere collection of elements and their properties, these transformations involve laws: the structure is preserved or enriched by the interplay of its transformation laws, which never yield results external to the system nor employ elements that are external to it. In short, the notion of structure is comprised of three key ideas: the idea of wholeness, the idea of transformation, the idea of self-regulation." In the terminology of General Systems Theory the three principles of wholeness, transformation, and self-regulation are essential for defining

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autonomy (Durkin, 1981), and are true for a simple biological system such as a bodily cell, as much as they apply to social or psychological structures. A structural approach presupposes that realities, as well as their internal representations in humans, are not arbitrary aggregates of physical bodies and events, but an arrangement of components forming simultaneous or continuous relationships between them, with enough stability to enable prediction (Lewis, 1965; Matte Blanco, 1975). Each structure is a substructure of a wider ecological system and is a superstructure to its own composing subsystems. Thus, a structural approach proposes a continuous exchange of action between the structure and its environment, so that a state of dynamic equilibrium is maintained and a continuous process of shaping and being shaped is constantly in motion (Piaget, 1970). To maintain wholeness in human systems is reflected in the capacity to have a sense of identity, continuity, and internal consistency in the face of a relentless external and internal pressure. This is an operational definition of autonomy in humans and it implies that the self, like all other structures, must be adaptable. Adaptability is related to the principle of transformation and implies rearrangement of equilibrium according to homeostatic mechanisms, and goal directed development. These mechanisms perform by means of continuous accomodation to internal and external forces, or by assimilation of incorporated material. These transformative mechanisms require the capacity for boundary-forming, and the ability to shift from "closed" to "open" states (Durkin, 1981). Open states involve temporary, partial abolition of boundary functions, and some degree of "merging" with the outside. By their very nature, open states are transitional states. Closed states involve a period of shut-down and disconnection from the external environment while the structure is undergoing internal processes of assimilation, that is, recreating its internal relationship to include all the newly exchanged information so that wholeness can be maintained. Like its open-phase counterpart, the closed state is also transitory, since a permanent closed state is incompatible with the continuation of life. Thus, there is always some shift from one state to the other. The capacity for forming flexible configurations while maintaining wholeness must be, at least to some degree, self-regulated. The structure is endowed with the capacity for self-reference and "self-knowledge," that allows recognition of information regarding external and internal change, and can, within its limits, initiate or terminate adaptational operations, switching from open to closed states, and so on. In this manner, the structure is moving along one of its optional developmental courses, while continuously shaping and being shaped along the course of its life.

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REFERENTIAL PLANES AND DIMENSIONS

AS ANALYTICAL TOOLS Regardless of the developmental stage an individual has reached, the human psychological system, at any stage, maintains its balance and coherence (Kegan, 1982). This it does by relating its representational schemes of self and of reality to several planes of reference and to dimensions of time and space. These planes of reference and dimensions lend continuity (existence) and location (identity), and may be conscious or unconscious, rational or irrational, comprised of cognitive and emotional elements (Grotstein, 1978). Traditionally, different schools tend to attribute deterministic causality to certain parts of the system such as the unconscious, emotional, or cognitive spheres. The alternative offered by the structural approach is to examine the complexity of the interrelationship of schemes and elements without assigning apriori causality to any of them. For such a task, it may be helpful to utilize certain planes of reference and dimensions as descriptive analytical tools so that events and processes within the structure can be studied. The Structural Planes

To the referential planes that defines relationships between elements in the psychological structure, we refer to as strueturalplanes. Those planes that define the relationship of elements within the psychic structure will be named psychostructural. The planes that define the relationship between the representations of the self and that of its social surrounding, that is its human environmental superstructure, will be named the soeiostructural. The Functional Planes

By the same token the referential planes that define the action that occurs between the elements of the structure will be refered to as the functional planes. The plane that defines the activity of elements within the psychic structure is the psychofunctional planes, while the plane that defines the activity between the representations of the self and that of its social environment will be named the sociofunctional plane. It is important to realize that these referential planes and dimensions are analytical tools which enable the observation and analysis of any human system along certain axii. Each referential plane artificially isolates and highlights a particular dimension, thus providing a magnified focus on one aspect of the human structure at a given moment, while minimizing or ignoring others.

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That, of course, does not imply inaction along other planes. On the contrary, any event, in any given time, occurs simultaneously along all four planes.

E X A M P L E S OF USE OF R E F E R E N T I A L P L A N E S 1. The Psychostructural Plane This relates to various intrapsychic forces, whether conscious or unconscious, defense mechanisms, and postulated intrapsychic elements like id, ego or superego. For example, the psychoanalytically conceptualized claim that the "ego strength could not withstand a specific assault," is a statement describing an event along the psychostructural plane. Likewise, the notion of a superego threat dictating a given response, such as avoidant behavior, is another psychostructural claim.

2. The Psychofunctional Plane This refers to the products of actions of specific psychic mechanisms like anxiety, anger, or apathy. Examples are the anger that arises as a result of an inadequate military command, or the fear that appears as a result of being in a battlefield. The appearance of a forbidden feeling, or the eruption of emotions with unrecognized intensity, such as the overwhelming affects described by Krystal (Krystal, 1968; Krystal, 1978) in relation to trauma, may be examples of threats along the psychofunctional plane.

3. The Sociostructural Plane The sociostructural plane describes the relationships between members of a given social unit; a couple, an extended family, a therapeutic group, a military unit, etc. For example, the dominance of the father in a family, or the commanding position o f the officer in relationship to his soldiers are descriptions along the sociostructural plane. The loss of a leadership due to the death of a commander at the eye of the battle, or the dispersion o f a highly cohesive military unit at a time of a crucial situation, are illustrations of a threat along this plane. Likewise, the uprooting of a whole community due to persecution, or the severing of links with its support group, illustrate the same threat along this plane.

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4. The Sociofunctional Plane

This plane encompasses those types of prevailing moods or behaviors that express the interactions within a given social frame such as; power struggle in a group, angry silence in a family, morale in a military unit, etc. For example, the inability to speak freely within a fighting field unit, is an example of a threat or a problem along this plane and the result along that plane would be despondent or forbidden unit attitudes that are a threat to the healthy cohesiveness of the group. It is important to note that every phenomenon in human life occurs simultaneously on all four planes, but every change need not be manifested overtly on all levels at any given moment. Sometimes, in order to achieve a change, it is necessary to keep at least one plane steady, or at least a part of it, while others are being restructured. For example, newly arrived immigrants are threatened on the sociostructural and sociofunctional planes. If their psychostructural and psychofunctional planes are stable they are able to withstand the abrupt change. The more threatened they feel on the "psycho" planes, the more they tend to hold on to old habits and customs preserving some elements of sociostructural and sociofunctional planes until enough stability is maintained on the psychostructural and psychofunctional planes to enable gradual inevitable changes along the "socio" planes. Another example relates to the psychoanalytic setting in individual therapy. The sociostructural framework, that is the therapist-patient roles, is clearly defined and must remain fixed. That leads to a specific interaction along the sociofunctional plane where the stable attitude of the therapist allows a wide range of responses on the part of the patient. The relative stability of these two planes promotes changes on the psychofunctional plane (e.g., anxiety), and eventually the psychostructural plane (e.g., defenses).

S T R U C T U R A L C O N C E P T OF T R A U M A We define adult psychic trauma as the collapse o f the structure o f self along all four referential planes resulting from an encounter o f a catastrophic threat and a chaotic response. This occurs at a discrete point in time and results in the experience of loss of autonomy. This experience of loss of autonomy is incompatible with former recognized relationship that define the sense o f self. A u t o n o m y in humans, as previously mentioned is the capacity to have a sense of identity, continuity and internal consistency in the face of relentless external and internal pressure. The traumatic experience, once occurring, cannot be integrated into the structure of self and meaning, and hinders the continuation of autonomous functions of the structure.

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THE THREAT: "STRESSOGENIC" A N D "CATASTROPHIC" THREATS

In modern nosologies (i.e., DSM-III), the word "stressor" is used to signify the external event. The word stressor is taken from the language of mechanical physics and indicates pressure. We prefer to apply the word "threat" since it assumes pressure and disruption, but it also indicates the existence of a subjective assessment of imminent pain, harm, or danger. Stressogenic Threat is the one which proves to disrupt reorganization along one or more referential planes of a structure, but never all planes at once. The structure can accommodate to this threat by adjustments and changes on other planes. This kind of threat is in contrast to the Catastrophic Threat which overwhelms the organizational capacities along all planes at once. The structure is unable to accomodate to this kind of disruptive threat. None of the above-mentioned threats can be defined solely by the inherent nature of the event, but only retrospectively by the event/response relationship. The fact that certain threats are commonly agreed upon to produce a traumatic experience, while other events are not, relates to the "traumatogenic potential" of the threat, or its "traumatogenicity." The potential of inducing a traumatic experience is not directly correlated with the nature of the threat. The existence of traumatogenic potential within the threat, does not necessarily imply that it may ever materialize into a catastrophic threat, which, by definition, demands a specific disruptive encounter with the responder. When applied to human systems, one central question to be clarified is against what or whom is the threat pointed? Is it against one's physical integrity or against one's belief systems? Experience teaches us that certain people will choose to give up their lives rather than go on living at the price of surrendering their world of ideas and beliefs, which, for them, is incompatible with existence. In other words, physical and mental integrity are but instances of the self-structure and its various representational schemes. The traumatogenicity of a threat is its potential to become a threat to the wholeness of the self-structure, which includes its transformational operations and its capacity to self-regulate its integrative processes. When the attempts at performing these integrative processes fail on all referential planes, the threatening potential materializes into an actual catastrophic threat. The other central question regarding threat is related to its mode of operation. How does the threat endanger the self-structure? By what mechanisms does it threaten the integrity of relations and functions that define and maintain the structure as a functional whole? What makes one threat more traumatogenic than others? Certain criteria are required to specify traumatogenicity. These include: (1) Loss, (2) Unpredictability, (3) Proximity (to the self-structure), and (4) Suddenness. These criteria, in various combinations of intensities, act synergistically and endow the threat with its traumatogenic valency.

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Loss is a mandatory criterion, because it always threatens the integrity of the structure by virtue of annihilating dements or functions, without which the structure cannot retain its functional wholeness. Since the self-structure and its various representations are physical as well as symbolic, loss may be related to either. Loss of a person, or loss of significant environmental obejcts illustrates the physical aspects. Psychological loss may be exemplified by the loss of integrity of an idea, or loss of one's honour, or loss of a way of life. Unpredi'ctability forms a threat to structural integrity by challenging and threatening the efficacy of the structure's transformative capacity and self-regulatory operations. When events lose their lawfulness, faith in one's self-regulating capacity is diminished or lost completely, hoplessness and helplessness prevail, and one resigns, not only to the events but also to the loss o f one's former capacity and identity. Saddenness is related to unpredictability, but not synonymous with it. It is a temporal limitation upon the operational modes and, when combined with other criteria, severely disrupts the adaptational capacities which require time in order to take place. Threats can also be characterized by the different kinds of Proximity to the self-structure and its various representations. Thus, the degree of involvement could include a collective (i.e., community) or a personal threat, direct or indirect threat, physical threat to life, or psychological threat (i.e., narcissistic injury), and by no means is this list exhaustive. The degree of proximity to the self-structure is idiosyncratic and contextual and cannot be graded by any ready-made list of events. The difference between a stressogenic and a catastrophic threat can be explained by applying the rule-law distinction. Rules are conceived arbitrary, structure-dependent, and local sets of guidelines that help mitigate laws, which are immutable, universal and incorporeal forces (i.e., laws of nature). Rules can be altered, avoided or bargained with. Laws of nature are inexorable. When there is a qualitative shift from one set or rules to another (rules of victory to rules of defeat during battle) or from rule control to law control (loss of control during earthquake, flood, etc.), a shift from a stressogenic to a catastrophic threat occurs. According to Thorn (1975), sudden discontinuous shifts from one set of rules to another, or from rule control to law control, are "disasters."

T H E RESPONSE: R E O R G A N I Z I N G AND CHAOTIC RESPONSES

By response, we refer to the specific adaptational activities performed by the system as a result of the impingement of the threat. In the encounter which defines a trauma or the absence of it, there are two responses matching the two kinds of threats.

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A reorganizing response is one in which the structure makes compensatory changes in its internal order and relationships within and between its planes and dimensions, while retaining its overall wholeness. In accordance with the rules of adaptation mentioned above, the human system continues to maintain its structural integrity by accommodating its boundaries and by assimilating the threat. When assimilated, the threat is transformed into an integral addition to the human meaning-system, in the context of growth and development. A chaotic response is characterized by a breakdown of the relationship of the elements composing the structure. This destructuralization results, by definition, in the lack of relationship among the different components of the structure. The process that eventually culminates in destructuralization is characterized by unsuccessful attempts at reorganization, or even by total inability to reorganize the inter-relationships into the former structural (meaningful) whole. Observed analytically, the structure does not succeed in its attempts to secure even one referential plane, which would support its former, familiar, identifying relationships. The structural planes have lost their internal order and hierarchy, while the functional planes are now threatening and stormy and reflect the intense fears of the chaotic state. Stressogenic threats and reorganizing responses, on the one hand, and catastrophic threats and chaotic responses on the other, are diametrically opposed kinds of encounters. The first one constitutes the pair of stress and adaptation, an obligatory condition for growth and development. The other constitutes a threat so disruptive (the catastrophe) that the adaptation apparatus and its mechanisms, which are part of the very structure itself, collapse, leaving a disorganized state lacking the relationship that defined it as a structure.

THE TRAUMATIC EXPERIENCE So far, we have defined trauma as an encounter of a catastrophic threat and a chaotic response. However, what we actually study, from an examiner's point of view along four analytical, referential planes, is what the patient presents us with; the traumatic experience. It is through experience that structuralization of meaning and reality proceeds. Likewise, it is though this inner experience that the human structure is informed of its collapse and of its inability to continue as an autonomous system. This inner experience is neither a threat nor a response, but the very substance of subjectivity. As Huxley said "Experience is not what happened to you, it's what you do with what happens to you" (Huxley, 1972). Through the expression of this highly subjective inner world clinicians can learn of the loss of relationship defined

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as the chaotic response, and may approximate the nature of the catastrophic threat. The traumatic experience has been described and expressed by various metaphors. Together, they all draw a picture of what we refer to as a structural collapse. Freud mentioned "an experience which within a short period of time presents the mind with an increase of stimulus too powerful to be dealt with or worked off in a normal way, and this must result in permanent disturbances of the manner in which the energy operates" (Freud, 1917), and "excitations which are powerful enough to break through the protective shield" (Freud, 1920). Lifton and others talk of the individual's envelope of invulnerability being destroyed by intense fear. Krystal (1968) and others use terms like "flooding" or "overwhelming" of the defenses of the ego. Some existentialists (Brull, 1969; Frankel, 1962) underline the "loss of meaning" and others (Janof-Bulman, 1985) describe the "shattered assumptions" of the victims regarding their reality and their self image. These invaluable metaphors and explanations of traumatic experience provide a sense of an assault too great to withstand, a breach in continuity, a wound or a "trauma," thus confirming the original metaphor that was created to describe the experience of collapse. However, "meaning" and "shattered assumptions," according to Piaget and Kegan, are constructed along, and abide with, all structural obligatory laws. Applying structural theory enables one to fit all these metaphors and explanations into a more basic coherent explanatory structure, which, in turn, can add further insights into the nature of the "the protective shield" and its breakdown, and help explain other unresolved enigmas related to the seemingly inexplicable, sometimes irreversible, change in the system's function. Some core questions that have thus far not been addressed in a satisfying manner can now be reexamined. For instance; why is it that the individual does not re-erect the "shield" or the "Ego defenses," once the threat has passed, and resume former normal function? Can a trauma victim ever recover completely? All these are related to the traumatic experience and its relation to the self-structure. The initial stage of the traumatic experience, that of "flooding" and piercing of the "protective shield," directs attention to what is described by General Systems Theory as boundarying operations. "The boundarying operation may be defined as the dialectical process whereby living structure opens/closes itself" (Durkin, 1981), and is an essential function of the living system's autonomous mechanisms. We propose to regard the initial stage of the traumatic experience as that when a structure enters a f o r c e d open state. An open state is a temporary, partial, and usually self-regulated semipermeability or full abolition of the boundaries, for a brief amount of time. By definition, it is an unstable state. Similar to the process of merging that occurs in situations of intense intimacy, the open state caused by realization

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of the catastrophic threat is an event causing a state of fluctuations. Usually this state cannot last long and is followed by closing of the boundaries. The closed state is necessary for the process of assimilation where the disorganized emotional-cognitive information acquired during the open state is adapted or metabolized within the structure so that a sense of coherent wholeness prevails. It is the ability to shift back and forth "at will" from relatively closed to open states that is one of the self-regulatory functions that define autonomy. In a psychological context it is manifested as the inner experience of free will and choice. Likewise, it is the capacity for assimilating the new information, incorporating it within the schemes of self and reality while maintaining internal consistency, that provides a sense of growth through experience, while preserving wholeness. However, unlike other open states, the forced opening of the structure's boundaries in the traumatic state and its inability to terminate this unstable state by closing, despite maneuvers along all referential planes, is esentially different. This forced open state, and the inability to terminate it, is accompanied, in human systems, by intense emotions such as immense fears; not just death fears, but the horror that the self and the world will never be the same again. This situation cannot be dealt with as long as the open state continues and the unacceptable emotions keep mounting. The instability of formerly recognized relationships, that defined the structure as such, intensifies. The support that can, at times, be recruited from the system's evironment (the sociostructural and sociofunctional planes), may be unavailable because of insufficient time, or because the social and geographic environment may be drastically destructured (as in massive threats such as wars, disasters or Holocaust) (Davidson, 1985; Steiner and Neumann, 1978). Once the process of destructuralization is in motion, environmental support, even when clearly available to the onlooker, may not be made use of by the trauma victim, because of the compromised functional capacity that manifests itself in the inability to identify or recruit the surrounding socioenvironment. What cause the traumatic experience is not merely the presence of amounting unacceptable emotions, but the perception of the diminishing ability, or even loss of ability, to perform the essential autonomous functions that define the human system. The central feature of the traumatic experience is the final horrible "realization" that the rules that define the individual's identity and reality are not operational any more. In structural terms, this means that wholeness, transformation, and self-regulation are no longer feasible, and hence, the very existence of the structure itself is questionable, incomprehensible, or nonexistent. At its very core, the traumatic experience is the sudden perturbation of relationship that produces helplessness, manifested in the sense of loss of mastery, identity, and existence. Traumatic experience is an unstructured experience. However its chaotic state

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(response), that of loss of relationships and functions between the structure's elements, cannot last long, and is always followed by a reorganizatory attempt, the one that we define as the post-traumatic state. THE POST-TRAUMATIC STATE The post traumatic state is a reorganizatory attempt aimed at restoring autonomy after destructuralization has occurred. It is essentially different from the regular adaptive "reorganizatory response" to a "stressogenic threat," described earlier, which is a response that does not culminate in trauma and collapse. Since the unstructured traumatic experience cannot, by definition, be structured, the post-traumatic state reflects a temporary coexistence of two incompatible organizational configurations; chaos vs structure. This unique coexistence of life force and its predictable rules, and the disintegrative forces of desolation and destruction has been summed up by Gabriel Dagan, a psychotherapist and a survivor of Auschwitz concentration camp in the following manner: I think that in Auschwitz we have been hit in the core of the denial of death. Something has been damaged, s m a s h e d in this mechanism, and through this irreparable crack, death keeps dripping into life. Just as I have found myself then, in Auschwitz, alive within death, so, now, death penetrates into my current life, as if returning the stream of life into the shadow and darkness of that e x p e r i e n c e . . . W e are labeled as 'the survivors' and not as 'the released' or '~he freed' from the concentration camps. Maybe the label is accurate. I have survived hell but I have not been released from it. It is still inside me, day and night. (personal communication, 1987)

This experience, mentioned by Lifton as "death imprint" (1979), and described by Brull as "living with the impossible" (1969), expresses the bane of the traumatized person; the inability to assimilate the traumatic experience. Reorganization occurs by isolating and representing this unstructured experience, without ever having the experience become an integral part of the rest of the system. The combined effect of isolation and repression is what we refer to as "encapsulation" of the traumatic experience. The reorganizatory process that eventually culminates in the encapsulation, can appear as a full-blown clinical disorder with a host of dramatic symptoms, or may proceed unrecognized, manifested by subtle, attenuated, or hidden symptoms. Thus, presence or absence or the nature and severity of symptoms cannot be a sole indicator of the past occurrence of a trauma. Furthermore, similar symptoms may appear in stress disorders which are not the product of traumatic experience, such as a variety of anxiety or depressive symptoms over "noncatastrophic" threats related to stress or loss. According to the view suggested by this paper, trauma, and post-traumatic states are not only at the very end of the stress spectrum but also are qualitatively different from other

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stress situations in that they represent a state of collapse and destructuralization. By the same token, the post-traumatic states, though reorganizatory in essence, differ from other stress-induced reorganizatory states, since they reflect the repeated attempts at overcoming inner experiences that can be encapsulated but never assimilated. When the post-traumatic state is manifested clinically, we refer to it as the Post-Traumatic Stress Disorder.

POST-TRAUMATIC STRESS DISORDER

As defined, the post-traumatic stress disorder is a reorganizatory state with a full-blown clinical manifestation. The appearance of symptoms is an indication that reorganizatory attempts are taking place. It is at the point of an overt clinical disorder, and only at this point, that we may diagnose the immediate, acute, and chronic types of the disorder. While increasing attention is being paid to the Post-Traumatic Stress Disorder, clinical experiences shows that the patients suffering from this overt disorder probably represent the minority of those who survived traumatic experience. The delayed type of Post-Traumatic Stress disorder can serve as a case in point. The covert nature of the post-traumatic process becomes apparent when we remember that it may take years, and even decades (van Dyke et al., 1985) before the clinical symptoms eventually erupt. By definition, the post-traumatic state must have been already present in the delayed type, but not expressed as a clinical disorder. Many traumatized people do not express the full clinical picture and do not attain patient status. The reflection of their pain and difficulty is played out in the wider arena of daily life without involving the clinic the way Post-Traumatic Stress Disordered patients do. These people may adopt specific life-styles that betray the existence of the hidden traumatic experience in an indirect or disguised manner. Thus, they may display exaggerated, idiosyncratic sensitivities, and vulnerabilities when confronted with additional "regular" stresses, or they may develop substitutional attachments and certain behaviors, ranging from extreme dedicated altruism on one side of the spectrum, to defiant or destructive styles on the other. The problematic position of symptoms in relation to trauma, their indeterminate nature and overlapping of other diagnostic categories, and their unpredictable temporal appearance, raises the question of their relationship to the DSM-III categorization. The DSM-III-R, in its laudable attempts at objectivity, assigns semiquantitative rules which include one vague criterion regarding the nature of the stressor and three criteria comprised of symptom groupings. Such a semiquantitative approach is useful for research methodologies and unified diagnostic labeling, but does not truly convey the

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essence of the post-traumatic states. Counting the number of symptoms and assessing their severity is insufficient for making the diagnosis of trauma, even when a precompiled list of "recognizable stressors that would evoke significant symptoms of distress in almost everyone" (APA, DSM-III, 1980) is available. Instead of the simplistic additive mode for arriving at a diagnosis, a structural approach would dictate that symptoms should serve only as partial guidelines and clues for determining the important question for the diagnosis of trauma. This is whether or not destucturalization and collapse have indeed occurred. This question can be answered by the reconstruction of the person's various dimensions and planes. This reconstructive quest, with the question of collapse in mind, would allow the clinician to suspect a few, or even an absence of, bona fide symptoms as concealing a cataclysm and help the clinician understand the efforts of the traumatized patient at restructuring his world of meaning. Similarly, it would enable the clinician to avoid assuming the occurrence of trauma from the visibility of symptoms alone. A structural approach may thus heighten clinical sensitivity and intuition, which underlie any diagnostic process.

SOME IMPLICATIONS

FOR THERAPY

The principles of structural analytic approach have influenced military and civilian settings for the treatment of trauma victims in Israel. Since the 1973 Yom-Kippur war, continuous effort has been placed on planning the optimal military approach for the treatment of Combat Stress Reaction (CSR) casualties within the combat arena (Benyakar et al., 1978; Neumann and Levi, 1984). Our proposed analytic structural approach has been shaped by the experience accumulated during the recent decade, and has been instrumental in reshaping special installations, utilizing the theory and practice propounded in this article. The underlying principle upon which these installations are constructed is the creation of therapeutic spaces, which are aimed at providing stability of space and time (Ogden, 1985), as well as stability of the sociostructural and sociofunctional planes, thereby enabling more "open states" on the psychostructural and psychofunctional planes. This analytic structural approach to trauma is obviously not confined to combat casualties, but to all victims of traumatic experience. In all these traumatized patients there is a tendency to report and threatening details, and many therapists, led astray by the horrible content, tend to equate the terrible situation described with the origin of the collapse. This erroneous equation may lead to some form of"pseudo-abreaction," where a horror story is stereotypically and repetitiously retold, without any real benefit for the patient. In this case, the repeated story is but a barren reflection of the en-

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capsulated experience that is never really touched, namely, the experience of the end of the world and loss of self. A structural approach enables the detection of the chaotic response and characterization of the idiosyncratic conditions related to its appearance in each individual. This allows for the planning of the intervention and selecting the referential planes upon which a therapeutic change is desired or feasible. By understanding the effect of the threat on the various planes of reference, the therapist may find a better way for understanding the encapsulated experience. The patient is offered an opportunity for abreacting and reorganizing in the optimal timing and the appropriate fashion. It is not always easy to assess the prognosis and outcomes of the posttraumatic process of encapsulation. Clearly, in certain individuals this leads to an irreversible impoverishment and clinical deterioration. Others, while not being able to rid themselves of the encapsulated traumatic experience entirely, can still transform the inherent persisting pain into a source of creativity and inspiration.

CONCLUSION Analytic structural theory serves as a unifying language that bridges concepts of existing models of trauma. Views of trauma as external threat, internal response, traumatic situation, piercing of shields, loss of meaning, and so on, can now be viewed as facets of an all-encompassing model of the structural approach. In analytic structural thinking, trauma is envisioned in the context of the self-structure and analyzed along the planes of reference, which are cross sections of schemes of the self. Trauma is defined as: the collapse o f the structure o f self along all its referential planes, experienced as the loss o f autonomy, and resulting from a specific intrusive encounter, in a specific time, o f a catastrophic threat and a chaotic response. Trauma always involves the destructuralization of the self-structure and its reality representations. Hence, trauma cannot be used synonymously with severe stress and suffering, just as severe and suffering are not always indications of trauma. It is insistence on the primacy of destructuralization as the obligatory defining criterion which allows the determination of whether or not a trauma has occurred. Accordingly, both the threatening event and the clinical symptomatology, which have heretofore been the definitive diagnostic criteria of trauma, retain a role as mere guidelines to the diagnosis of trauma and Post-Traumatic Stress Disorder, and thereby assume a less central position as diagnostic hallmarks of trauma and its aftermath. While the structural definition of trauma proposed here is binary (trauma either has or hasn't occurred), it nevertheless pays tribute to the vast

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c o m p l e x i t y o f h u m a n v u l n e r a b i l i t y . It p r o v i d e s r o o m to e x a m i n e the m y r i a d , p o t e n t i a l , h u m a n t r a n s f o r m a t i v e m a n e u v e r s a i m e d at a v o i d i n g s t r u c t u r al collapse. S i m i l a r l y , it allows for the e x a m i n a t i o n o f the v a r i e t y o f e n c a p s u l a t i o n a t t e m p t s o f the t r a u m a t i c experience, a f t e r c o l l a p s e has o c c u r r e d . O n l y a s t r u c t u r a l a p p r o a c h c a n explain h o w such d i s p a r a t e events as a heart attack, car accidents, rape, war or c o n c e n t r a t i o n c a m p experiences, or, in fact, a n y p s y c h o s o c i a l c h a n g e m a y be t r a u m a t o g e n i c , t h o u g h t h e y d o n o t all seem " o u t s i d e t h e r a n g e o f h u m a n e x p e r i e n c e , " a n d m a y p o t e n t i a l l y , but not necessarily, culminate in t r a u m a or its post-traumatic sequelae.

ACKNOWLEDGMENTS S u p p o r t e d in p a r t b y the M i l d r e d A c k e r m a n F u n d o f the C e n t e r for I n t e r n a l M e d i c i n e . T h e a u t h o r s t h a n k D a v i d B o h m , G e o r g e Vaillant, Sue J a c o b s o n , a n d Y e h u d a F r i e d f o r their advice a n d c o n t r i b u t i o n s . T h e y also t h a n k J o n a h T a p u a h for his technical assistance.

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