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Psychiatry and Politics

Creating Sanctuary: Toward the Evolution of Sane Societies, Sandra Bloom, New York: Routledge, 1997, 306pp., $19.95.

Arthur D. Robbins
Volume 26, Number 4, Spring 1999

What are the community conditions which will be most conducive to the recovery of adults who have been abused as children? How are these conditions to be realized in the hospital setting? Can what we learn about the hospital community help us understand what is wrong with our society and what needs to be done to restore it to health? These are the questions Dr. Bloom poses. Her answer: "We came to understand that an essential part of recovery for our patients, ourselves and our communities is a reconnection with the political, a willingness to shoulder the responsibilities of citizenship that accompany healthy life in a democracy...."

By understanding what works in the hospital setting and what doesn't, Dr. Bloom gets a deeper understanding of what is wrong in the world outside and what needs to be done to fix it. She operates on these two levels at once. Circumstances necessitate such dual participation, psychiatric and political, for all of us. "There is no longer any place to hide." No longer can we "bear the silence that gives consent." It is time to speak out "against tyranny in all its forms."

The abuse of power in the home or the halls of Congress are one and the same. The one reenforces and facilitates the other. There is no difference between political corruption and sexual corruption. They entail the same lying, denial, secrecy, and ruthless exercise of power.

Dr. Bloom's book is divided into five parts. Part I is a comprehensive and cogent exposition of trauma theory with an underlying theme: For those who were abused as children, the social connections have been broken and must be repaired if recovery is to occur. Under the rubric of "attachment theory," Part II discusses social connections from a theoretical perspective, offering research and insight in support of the belief that social connection is essential to human survival. Part III applies the social viewpoint to the inpatient psychiatric setting, reminding us of the many successful experiments, going back as far as the eighteenth century, in the humane treatment of hospitalized psychiatric patients. Part IV brings into play the content of the three previous parts in a sustained discussion of the experience of the author and her colleagues in their struggle to bring humane treatment to hospitalized adults who were traumatized as children. Part V applies what was learned from the hospital community to the community at large. What is wrong with our society and what do we have to do to fix it? There is a common theme throughout the book in discussing individual pathology and social pathology. Social connections have been broken. They must be restored if the individual is to flourish, if society is to flourish.

The process of healing adults who have been abused as children entails a new way of seeing and a new way of being in the world. The personal transformation of the healer is the initial and essential first step towards healing. What is required is not so much enhanced self-understanding as a revision of one's perception of what is real and possible in the outside world. Dr. Bloom describes this process most aptly. Initially, without knowing it, she had been experiencing a certain kind of blindness, a "figure-ground problem." She could see the vase but couldn't see the old hag. She lacked the proper context. By refocusing her attention and by allowing herself to listen to her patients and hear what she didn't want to hear, there occurred a shift in her "assumptive world" that "knocked me off my pins."

Dr. Bloom underwent an epistemological crisis, "my own personal earthquake," a crisis which was to bring about a dramatic transformation in what she understood to be true about the world she lived in. She was being called upon to discard much that she thought was true and to accept and integrate much that she wished were false. Before her emerged an "entirely new intellectual landscape," a frightening vision. "I did not want to know this information."[italics in original] "How could this be true? How could there be so much child abuse?...It made us all sick - sick at heart, sick in our souls, and sick to our stomachs."

The world is never the same again. "Trauma destroys the wall of safety and invulnerability that we use to shield ourselves from harsh realities.... It is too painful to bear. Blaming the victims for their problems and thereby allying oneself with the powerful perpetrator is far easier than emotionally containing the raw pain of innocent suffering and helplessness." What happens when we apply this new understanding to human nature in general, history, philosophy and current events? Everything starts changing before our eyes. The ground shifts beneath our feet. "Trauma theory challenges, reinterprets, expands, and even demolishes many of our existing paradigmatic structures - the underlying rules and practices that give form and meaning to our lives."

Struggling to remain strong and optimistic in the face of terrifying trauma, and at times overwhelmed by the attempt, Dr. Bloom and her staff had to simultaneously wage a battle with corporate health care, which chose to deny the treatment that she knew was essential for her patients. But even this was a useful lesson "in graphically detailing the necessity of total system change and the difficulties involved in attempting to fix a part without fixing the whole." Thus the willingness to allow the patient's trauma into one's awareness requires not only the strength and commitment to be actively present for the patient, fashioning a sanctuary for recovery in the hospital setting. Simultaneously, one must be present and active in the world outside, engaged in a political battle with the powers that be to allow truth and recovery to prevail.

The social treatment of severe psychiatric illness has a long and proud history going all the way back to the end of the eighteenth century. Two hundred years ago it was understood by Pinel, in France, Chiarugi and Pisani in Italy, Langerman in Germany, Tuke in England, and Benjamin Rush in the United States, that the insane are not animals but tortured souls who will respond favorably to the right admixture of "kindness, compassion, and rational conversation." This humane and interpersonal approach to mental illness was initially referred to as Moral Treatment, then the Therapeutic Milieu. Dr. Bloom has coined her own term, "The Sanctuary." The key to treatment is in the selection of the attendants, who by virtue of their interactions with the patients are able to reconnect them to social reality. This was the approach employed by Harry Stack Sullivan with his schizophrenic patients at Shepard-Pratt Hospital in Maryland in the 1920's.

The remarkable thing about Moral Treatment is that it worked, and involved no physical coercion and very little in the way of medication, especially in the days when today's medications were not available. The movement spread rapidly in the United States. Success rates were impressive. By 1837, Eli Todd at the Hartford Retreat had cured 91.3 percent of his recent cases. All of this was gradually undone, however, as the asylums, originally set aside for the treatment of serious mental illness, became holdings tanks for social misfits in general - the senile, syphilitics, the retarded, alcoholics, opium addicts, impoverished immigrants and the like. With an increase in the population and the varieties of unrelated conditions to be treated, success rates dropped and with them the necessary funding to hire and train competent staff. All of this should not blind us to the fact that "kindness, compassion, and rational conversation" in a safe and attractive environment will cure severe mental illness.

For the therapeutic milieu to be effective, it must exclude all that is destructive in the society outside its walls - the competitiveness, hypocrisy, the hierarchy of power and authority. It must be a Utopia of sorts. The community is the container for overwhelming emotion, it is the source of control. It is an attractive, appealing and engaging environment. It is a place for learning how to consciously live out one's pain. It is a place for laughter and enjoyment. To the degree that it is feasible, no one person is in charge, even amongst the staff. As much as possible, patients themselves are involved in making decisions which affect their community. This is cure by democracy.

Although Dr. Bloom places strong emphasis on being true to one's emotions, there is even greater emphasis on the appeal to reason and intellect. The goal is to no longer act and react but to verbalize. Patients are educated on the subject of trauma and its effects. They are encouraged to see recovery as a choice which they have the freedom to make or not make. Rather than encouraging the expression of the child component of the personality, patients are encouraged to draw on their adult resources. Behavior is examined and articulated. What is automatic is to become deliberate. There is an increase in tolerance for pain. The social support makes this possible. The patient must grieve all she never had as a child. "Write, write, write" is Dr. Bloom's advice to her patients. She is against the uncontrolled reliving of the childhood trauma. Rather it is to be integrated within the context of adult intellectual strengths.

Signs and symptoms are a key to the past. Recalling forgotten trauma results in symptom reduction. Symptom reduction, in turn, is validation of the memories. There is an epistemology at work here. It is possible to know the past, with confidence, without having recourse to external sources of validation. "With sufficient experience in looking at the whole system that comprises a person, an experienced clinician develops a sense for stories that make sense and stories that do not fit together or are incomplete."

Fun and laughter are recurrent themes and an important part of the cure. "We showed movies, we put in a Ping Pong table, we clowned around ourselves, we played jokes on each other and them, we hung up funny pictures, we supported and encouraged their creativity and playfulness when we saw it." For the patient to enjoy a full recovery, what she has learned must be brought into play in the world at large. "We try to help our patients see that their traumatic experiences are part of a much larger picture of the traumatic exploitation of human beings around the globe, and that what they learn to heal themselves needs to be applied to their families, their friends, and the larger social systems within which we must all live...."

Although offered as a description of an ideal community for the treatment of hospitalized patients who have been traumatized as children, in fact every one of Dr. Bloom's prescriptions applies to individual therapy in the outpatient setting: the epistemic transformation of both therapist and patient, the absence of power, status and competitiveness in the relationship with the patient (Ferenczi was one of the first to underscore the importance of mutuality in therapy), the use of humor, the appeal to adult intellect, the verbalization, the important role assigned to writing, the role of political enlightenment.

Society in "The Sanctuary" is organized around unresolved trauma. So is society outside the hospital walls, according to Dr. Bloom. America is a disturbed adolescent hiding behind the lie. The preoccupation with sex and violence, the social decay and denial, prove it. Just as with her patients, there is in society, "disrupted attachment, unmodulated affect, unmanageable anger, abusive authority, diminished awareness, multiple addictions, automatically repeated self-destructive behavior, avoidance of feeling, memory, and guilt, and massive alienation from self and others." As a society we have lost our sense of meaning and purpose. This is the effect of childhood trauma on the adult patients cared for at "The Sanctuary." Just as it is in the abusive household, we Americans "hurt individuals, and we hurt groups of people, and we hurt entire nations, and we even sometimes hurt the whole world - and then we lie about it to ourselves." Dr. Bloom offers thirteen pages of statistics in support of her argument.

This is a most important and most unusual book. It undertakes both analysis and synthesis; it faces in an integrated and cool-headed manner what many of us devote our lives to avoiding; it offers a comprehensive understanding of what ails us as individuals and as a society. It is that rarest of documents which demonstrates, at the deepest level, the ineluctable connection between the psychological and the political. As individuals and as a society, our full recovery entails full and active participation in democratic government.

Never before in the history of civilization has the key to human salvation been understood as well as it is today. This has all happened in the past twenty years. To understand just about all there is to know about human suffering, both individual and collective, one has but to focus one's attention on the effects of physical and sexual trauma on the growing child. This insight is as revolutionary and as vital as any that has occurred in any science over the past two thousand years. And yet it is grasped by a relative handful of people, marginalized by a society unwilling to face head-on a truth that is too troubling to contemplate.

The people who abuse sexual power and lie about it, and the people who abuse political power and lie about it, are the same people. It is for this reason that we cannot secure the health of our patients without simultaneously securing the health of our society. Like it or not, psychotherapists have destiny to fulfill. Either they stand unequivocally and steadfastly for the truth against all challenges, or they will disappear into a mist of obscurity and irrelevance. This they must do not just for themselves. They have a larger role to play in the life of the polis. For by standing for the truth and challenging the lie, they have the opportunity to be leaders in the quest for honest government, peace and justice for everyone.

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