The healing witness

A human face is … spread out … beneath the glance of other human faces, and it takes gladly to these glances. It stands there broad and full so that the other face may take its time and slowly penetrate it, it even lifts out its lines more sharply as if to guide the contemplating glance and spreads out its planes as carpets for the glance to rest upon if it be tired. And thus alternately resting and moving, the observing glance penetrates the face.
—Max Picard (1931), The Human Face

It is Laub’s (1992a) contention that the “emergence of the narrative which is being listened to—and heard—is … the process and the place wherein the cognizance, the ‘knowing’ of the [traumatic] event is given birth to” (p. 57). In light of Kristeva’s theory of signification, we find that the “process and the place” is the return to the beginning, the space/spacing of the chora, or maternal function. Whether for the trauma survivor or for those afflicted by illness or the “new maladies of the soul,” the mediating presence of the healing witness makes room for “the elaboration of a time for remembrance” (Smith 1998, p. 57), where the raw, “unmetabolized images and experiences” (Neimeyer 2004) of suffering can be contained and put into words. Within this “place and process,” the subjectivities of the survivor and the healing witness expand and contract. The healing witness bears witness to the survivor’s suffering by holding herself back to move closer, allowing emotions, such as aversion, dread, confusion, and anger to arise within herself, while yet affording the survivor the space/spacing necessary to speak the unspeakable. “Testimony,” mediated by such holding, “is the narrative’s address to hearing: for only when the survivor knows he is being heard, will he stop to hear—and listen to—himself” (Laub 1992a, p. 71).

But to step forward to give testimony is fraught with danger. Laub (1992a) reflects on the worst possible outcome—outright denial—in his description of Chaim Guri’s film The 81st Blow. At the heart of this film is a scene where a man tells his story of suffering in the German concentration camps only to hear the audience say: “All this cannot be true, it could not have happened. You must have made it up.” Laub comments, “This denial by the listener inflicts, according to the film, the ultimately fateful blow, beyond the eighty blows that a man, in Jewish tradition, can sustain and survive. The absence of an empathic listener, or more radically, the absence of an addressable other, an other who can hear the anguish of one’s memories and thus affirm and recognize their realness, annihilates the story. It is this ultimate annihilation of a narrative that fundamentally cannot be heard and of a story that cannot be witnessed that constitutes the mortal eighty-first blow” (p. 68).[26] As Oliver (2001) points out, without “address and addressability from and to others” (p. 88), subjectivity cannot exist. Denial, in annihilating the story, annihilates the subject.

Blaming the victim can be equally devastating. Nearly fifty years ago, Walster (1966) observed that people confronted with negative events find it necessary to assign blame to someone rather than accept the possibility that some events are random. That bad things can happen for no apparent reason undermines a belief in personal invulnerability that leads some people to blame the victim instead. According to Lerner (1980), most people have a need to believe that the world is just and that people “get what they deserve” (p. 11). In times of adversity, this is turned around to become damning evidence that they deserve whatever it is that happens to them. Landsman (2002) explains this tendency for people to believe that victims of trauma “brought on their own misfortune” as a way of “keeping intact the belief in a just world” (p. 16). People do this by either “attributing causal responsibility to the victimized individual, and if the objective circumstances make this impossible, by denigrating the individual’s character in order to see the victim as ‘deserving’ misfortune” (p. 16). According to Landsman, the worst the trauma the more necessary it becomes for people to maintain these beliefs and make these attributions.

Commonly associated with blame is shame. Kauffman (2002b) explores the psychological meaning of the word as it is revealed in its etymological roots in a pair of antonyms: cover and exposure. He notes that although shame mostly conveys a sense of exposure, as when it is used to mean “embarrassment, humiliation, being uncovered in the gaze of another” (p. 210), the word still retains a sense of covering as when it is used to mean discretion and modesty. In reflecting on these double meanings, Kauffman observes that shame has less to with the sexual body than it does with “the most private sense of self” (p. 210). He writes, “Shame is the boundary of privacy, incubator of the self, the protective cover that establishes the safe space in which the self may experience itself” (p. 210). Traumatic violation, Kauffman goes on to note, breaches this boundary.

Kauffman (2010) has recently explored shame’s deep connection with trauma. Developmentally, he positions it in stranger anxiety, claiming that it emerges “from within the space of the toddler’s bond with mother” (p. 6). Stranger anxiety arises when the private space of the mother–child bond is threatened by a stranger and is expressed by the child in “retreating, hiding, and covering the face” (p. 6). In reading Kauffman’s reflections on shame, Janet’s account of the origin of narrative memory at the moment the child can say “I will tell this to mother” and Kristeva’s theory of signification and the maternal function immediately spring to mind. For Kauffman, shame is bound up in the gestures of telling and arises just before the child knows how to say it. “Stranger anxiety,” Kauffman writes, “is an expressive language gesture. But, it is not simply expressive. It is a communicative act of showing” (p. 6). He surmises that this “performance of shame,” this hiding and covering the face, along with the shaming in the form of teasing by adults that is often reflected back to the child in this performance, is the ground upon which “a baby becomes, in the experience of others and, most probably, itself, a person with the presence and self-awareness of personhood” (p. 7). The trauma of this public uncovering, this first entry into the public sphere, Kauffman observes, is mediated by the containing presence of the mother, into whose arms the child returns for comfort.

Thus, from the start, revealing to another what is essentially private is bound to shame. But to tell the intimate details of torture and abuse can be unbearably shaming.[27] As Laub (1992a) has observed, “the speakers about trauma on some level prefer silence so as to protect themselves from the fear of being listened to” (p. 58) and having to hear for themselves what they had to endure. Mixed in with all the memories of fear and pain are the experiences of becoming an object for another, of losing one’s subjectivity and humanity, and of the shame of not having had the strength to resist the abuse (Oliver 2001, p. 99).[28] “Traumatic shame,” in the words of Kauffman (2010), “damages the ‘protective cover of beliefs’” (p. 8). It replaces beliefs in personal integrity, invulnerability, and self worth with the certainty that the trauma is bound to happen again, and as we have already seen, it does happen again, repeatedly, in unconscious reenactments.

Exposure, denial, banishment, fear, and shame are not the only dangers in stepping forward to testify. There is also the risk of re-experiencing trauma by being the object of a cold interrogation and by exposure to the objectifying gaze of the “modest witness.” Haraway (1997) describes the modest witness, whose “subjectivity is his objectivity” as “the legitimate and authorized ventriloquist for the object world, adding nothing from his mere opinions, from his biasing embodiment [italics added]” (p. 24). The sole intent of the modest witness is to establish the facts. According to Haraway, his kin fill the courtrooms and the institutes of higher learning. They are fact finders, much like the historians that Laub (1992a) described, who had gathered with a group of artists and psychoanalysts at the Video Archive to reflect on some of the survivor testimonies. When one woman recounted an uprising at Auschwitz and reported that four chimneys blew up in flames, the historians were disconcerted: only one had been destroyed, not four. They argued that since the woman’s testimony was in error her entire account was suspect and should be discounted. What is more, they insisted that the event she described had no historical significance. The skirmish had immediately been put down.

Laub was the one who had taken this woman’s testimony. He recalled that, during the interview, there were many moments when the woman’s memory faltered. There were facts she either did not know or could not face. Her job in the camps was to sort the belongings of those who were gassed, and it was clear that she had never once “asked herself where they had come from” (p. 60). In Laub’s mind, his job was not to collect historical accounts, sorting them according to their factual value, rather his task was to respect what he heard—“not to upset, not to trespass”— and honor the stories he was given. To accomplish his job both “as interviewer and as listener,” he had to safeguard the delicate “balance between what the woman knew and what she did not, or could not, know” (p. 61). He felt it his responsibility to ask himself earnestly where her account came from—and what its value was for her as a person who had survived the camps. Had the historians been attentive to the expression in her voice and in her eyes as she recounted the story of the uprising, they would have realized that the clamor caused by this insignificant skirmish tore through the camp setting hope ablaze for her and her fellow prisoners: psychologically, it was no insignificant event.

Many traumatized individuals despair of finding an empathic companion like Laub who is willing to listen to them tell of their traumas, in their own way, on their own terms. Some, unable to speak of the events they have suffered, even to themselves, cease to believe “in the very possibility of human communication”—such a survivor “envisages no one who will be present to him and for him if he returns in his mind to the places of horror, humiliation, and grief from which he barely emerged and which continue to haunt him” (Graessner et al. 1996, p. xvi). “Testimonies are not monologues,” Laub (1992a) writes, “they cannot take place in solitude” (pp. 70–71). They need the mediating presence of someone who is able to hear them. As Laub goes on to say, whenever these survivors do finally find the courage to speak out, it is vital to realize that they “are talking to somebody: to somebody they have been waiting for for a long time …” (p. 71).

Charon (2006) tells a story about the gastroenterologist, Richard Weinberg, who one day became that “somebody” for one of his patients. Reporting insomnia and recurrent nightmares with elements suspiciously indicative of abuse, the doctor asked his patient whether she had ever been sexually assaulted, and for the first time in her life, she told of her ordeal at the hands of her sister’s boyfriend when she was fourteen years old. “There is nothing he didn’t do to me,” she told her doctor, overwhelmed by sorrow and shame. Weinberg (1995) reports his reaction:
I felt completely out of my depth. I consoled her as best I could, and when her sobbing had subsided, I gently suggested a referral to a psychiatrist or a rape counselor. I’m a gastroenterologist, I told her, this is not my area of expertise. I had neither the knowledge nor the experience to help her … But she adamantly refused to consider a referral to anyone else. She didn’t trust them. I then understood that having unearthed her dark secret, I had become responsible for her care (p. 805).

Weinberg takes this responsibility seriously. He consults with colleagues in psychiatry and reads what he can about sexual trauma while meeting with the woman once a week. She eventually comes to understand that she has been blaming herself for what took place and has been purging herself through bulimia of “the stain” she feels it has left on her. In time, she is able to let go of her need to purge. On her last visit, she thanks Weinberg by handing him a gift of six Napoleons she had baked especially for him. He recounts how he returned her thanks, and then he writes, “I had been chosen to receive a gift of trust, and of all the gifts I had ever received, none seemed as precious” (p. 805).

Whether from the point of view of psychology, psychiatry, psychotherapy, autobiography, law, film, trauma studies, or literary criticism, Charon (2006) claims that what all this massive research in trauma seems most intent on understanding is this one thing: how to bear witness. Weinberg’s story provides an eloquent account of what this takes, especially for those concerned to bear witness to others so they can heal. Weinberg was called to witness because he was willing and able to answer the call. His vigilance and sincere concern prompted his patient’s disclosure. She revealed her secret to him because she could tell that he was listening to her. Listening confers trust. His attentiveness provided her with the time, the space, and the sense of safety she needed to reveal her dark secret. Weinberg then acknowledged her by responding to her testimony as both a professional and as a fellow human being, his empathy and compassion leading him to overcome his own feelings of discomfort and take on the responsibility of her care. Finally, he honored and respected the gift of her story.

Both Charon and Weinberg recognize that pursuing their calling as physicians requires more of them than following scientifically sound protocols. For Charon (2006), the ideal physician is someone like Weinberg who heeds his patients’ suffering and is careful as they tell of it “to acknowledge it, and to hear them out” (p. 179). Charon notes that whether physicians treat “post-traumatic stress disorder or crescendo angina, we must begin our care by listening to the patient’s account of what has occurred and confirming our reception of that report” (p. 132). It is her conviction that “histories must be received” as they are given and “not taken” (p. 187). In her own practice of letting her patients speak, Charon describes how she often sits on her hands to refrain from taking notes or calling up the patient’s computerized medical record. “It was only when I was able to forgo the ordering imperative,” she writes, “that I became able to absorb what patients tell me without deranging their narratives into my own form of story [italics added]” (p. 179).

In large measure, what Charon is advocating in receiving histories rather than in taking them is a return to the more intimate doctor–patient relationship that was the hallmark of medical practice in the first half of the twentieth century. The emphasis in medical schools at that time was focused on understanding the patient as a whole person rather than on the disease (Robinson 1939), as aptly illustrated by this directive: “For every hour that the internist spends in technical examinations … he will spend from one to three in talking with his patients, in educating them, in encouraging them, in hearing from them the story of their difficulties and struggles … [italics added]” (Houston 1936, p. 73). A similar theme is the repeated injunction given in the medical manuals to let patients give their histories without undue interruption (Cathell 1922). Physicians were told that questions “misdirect the story of the patient” and “encourage indicated replies” (Thomas 1923, p. 261).[29] The high value placed on the patient’s account in history taking rested not so much on the fact it deepened the physician’s understanding of his patients’ needs, which, of course, it did, as on its therapeutic effect. As Alvarez (1943) declared, “eliciting of a good history” in many cases “will practically cure the patient” (p. 116).[30]

With the rise of science-based pharmaceuticals came an urgent need for physicians to understand the biological and chemical principles behind the new medicines (Shorter 1985). In the 1950s, medical schools began emphasizing a scientific curriculum (Whitby 1953). The result was a belief that scientific knowledge more than social skill was essential for the bedside manner (Shorter 1985). Shortly thereafter, the method of history taking underwent a radical change (Shorter 1985). The main objective was no longer to hear the patient out but to discover as efficiently as possible the chief complaint. Once this was identified, a proper diagnosis could then be made and appropriate treatment and medicines prescribed (Wolf et al. 1952). After World War II, a simplified checklist form and a series of yes–no questions began to infiltrate medical practice, and patients were reeducated to give up their expectation to talk at length with the doctor and to allow paramedics and other health care professionals to take their medical histories instead (Owens 1970, p. 163). With physicians now freed from the time-consuming task of taking the history, they could focus their attention on diagnostics, drugs, and the new technologies of medicine. Physician contact time with patients dramatically decreased so that by 1985 the average consultation time with the family doctor in the US was eleven minutes (Shorter 1985).[31] As a result of these changes, medicine’s focus shifted from the patient to the disease, and doctors lost touch with their patients’ sufferings. Ultimately, the price paid for the drug revolution and medicine’s scientific shift in focus, declared Lepore (1982), was “the trend toward depersonalization and dehumanization of the care of the patient” (p. 3).

Along with the emergence of the new scientific doctor came “an avalanche” of new patients overly sensitive to bodily sensations and concerned with minor ailments (Shorter 1985, 1991). The consequence, Shorter explains, “has been the burgeoning of doctors’ resentments at being deluged with ‘trivial’ symptoms” (p. 216).[32] Among the many reasons given for this phenomenon (fear, for instance, aggravated by incessant media reports about disease), Balint (1972), a psychiatrist, had this to say, “Nowadays, with more and more of us becoming isolated and lonely, people have hardly anyone to whom they can take their troubles. It is undeniable that fewer and fewer people take them to their priests[33] … the only person who is always available … is the doctor. In many people emotional stress is accompanied by, or possibly is tantamount to, bodily sensations. So they come to their doctor and complain” (p. 225). Overwhelmed by appointments for minor complaints, Shorter explains that physicians found they no longer had the time, nor the patience, to hear their patients’ stories.

What many of these “new” patients are suffering from is not so much a harmless cold or the flu, but something much more troubling to them, what Shorter (1985) calls the “hidden agenda” behind their visits. Weinberg’s encounter with the young woman who initially complained of stomach problems but who later revealed she was purging the stain of the sexual abuse she had suffered at the hands of her sister’s boyfriend for so many years is but one example. Charon (2006) and Shorter (1985) report many cases where symptoms eventually reveal the existence of trauma or abuse, whether current or past.[34] For Shorter, the “erosion of careful listening and the concentration upon organic symptoms” has meant the loss of opportunities for healing:
[For o]ne … patients with a hidden agenda are denied an opportunity to say what is really troubling them. Some disease-oriented doctors will shrug their shoulders at this, but for patients it is a major loss causing the doctor-patient relationship to deteriorate. Second, the patient is denied the cathartic value of telling his story, a very real therapeutic benefit to which no doctor can be indifferent (p. 255).

Similarly, for Charon (2006), the consequences are serious when time is not taken to listen to patients’ stories: “patients’ symptoms get dismissed, their nonmedical concerns get ignored, and treatable disease gets missed” (p. 67). Many health care professionals worry about taking so much time to listen to what patients have to say about their own illnesses, yet Charon believes that “time is saved shortly down the road by having developed a more robust clinical alliance from the start” (p. 67). Before people can speak out about what is actually troubling them, trust must develop. The teller must confirm that the listener is able to bear and to affirm the reality of the teller’s stories. Attentive listening establishes the ground for building this trust. As one pastor in training observed in his work with the ill, “while I heard their narrative, they heard mine—my body language, choice of words and so forth, hence determining what they in turn chose to share” (Charon 2006, p. 179). It is Charon’s experience that “mutual trust builds as a result of more careful listening and more extensive telling” (p. 189).

Accordingly, Charon opens her conversations with patients by inviting them to “tell me what you think I should know about your situation,” and then she commits to listen. Charon (2006) writes, “As the patient tells, I listen as hard as I can … I try my best to register the diction, the form, the images, the pace of speech. I pay attention—as I sit there on the edge of my seat, absorbing what is being given—to metaphors, idioms, accompanying gestures, as well as plot and characters represented for me by the patient” (pp. 187–188). She observes that oftentimes patients are unaware of what is troubling them. They come to the consultation room frightened, unclear what their bodies are telling them. “All the patient knows is that she is not feeling well,” Charon writes, “To tell her doctor or nurse or therapist about feeling unwell enables her to put her out-of-the-ordinary feelings into words and then to hear, right along with the doctor or nurse, what is said” (p. 66). Charon notes, though, that not everything told to her by her patients is said in words. She is careful to listen to what is unconsciously expressed. She gives this story of a young woman who came to her complaining of severe abdominal pain as an example:
She was fidgety, spoke in fragmented speech, seemed clearly to be suffering. Since this was my first meeting with her, I asked as a matter of routine about the health of her family members. Her father, I learned, had died of liver failure. As she spoke of his horrible suffering—his abdomen swollen with fluid, his muscles spent, his mind clouded—she put both her hands, fingertips interlocked, almost protectively, over her own upper abdomen. I told her that she used the same gestures to discuss her own symptoms as she had to describe her father’s illness … she became still. She looked down at her hands, now in her lap. We were both silent. And then she said, “I didn’t know this was about my father” (p. 66).

For healing to take place, Charon (2006) believes physicians must donate themselves to the patient as “meaning-making vessels” (p. 132). They must “act almost as ventriloquists to give voice” to what the “patient cannot always tell in logical or organized language,” but only “through words, silences, gestures, facial expressions, and bodily postures” (p. 132). Charon says that physicians must then merge these expressions with other messages they receive from “physical findings, diagnostic images, and laboratory measurements” (p. 132), becoming, in essence, ventriloquists for both the subjective and the objective, the semiotic and the symbolic.

Individuals suffering from PTSD also need someone to “act almost as ventriloquists to give voice” to their traumas. The psychoanalyst, in acknowledging and interpreting the affective, nonverbal, and semiotic laden expressions and silences of the survivor, “provides new mediation for old events and thus rescues them for present living” (Ulanov 2001, p. 153). According to Smith (1998), the relationship with the psychoanalyst “will provide a space for the representation of those disassociations and splittings—repressed memories and the defenses they generate—which punctuate the life of an individual in a painful and repeated way” (p. 57). However, such an encounter, Smith says, “interrupt[s] the smooth flow of time,” becoming “time-consuming” (p. 57). If the survivor is to connect the past with the present in a reflective fashion, then the dialogue between trauma survivor and psychoanalyst must occur in an environment where the biological and emotional interiors of each are given ample time to unfold and become available to the other.

Those helping survivors as they struggle to speak of their experiences must be vigilant and sometimes intervene to temporarily stop or moderate the pace of recollection. Premature exposure to painful material without appropriate modulation of arousal can be disastrous (Steele and van der Hart 2009; Herman 1992). When the revelation of trauma fragments accelerates and threatens “to get too intense, too tumultuous and out of hand” (Laub 1992a, p. 71), the psychoanalyst has to constrict the flow, slow the narrative, and contain the patient. In the testimony of Holocaust survivors, for example, Laub (1992a) observes that “there is so much destruction recounted, so much death, so much loss, so much hopelessness, that there has to be an abundance of holding and of emotional investment in the encounter to keep alive the witnessing narration; otherwise the whole experience of the testimony can end up in silence, in complete withholding.” When the “flow of fragments falters, the listener has to enhance them and induce their free expression” (p. 71), without, however, interrupting the silence and the desire of the survivor to be alone for a moment in the creative and arduous act of giving testimony.[35]

Just as giving testimony is fraught with dangers so listening has it hazards. “For the listener who enters the contract of the testimony, a journey fraught with dangers lies ahead,” Laub warns. “There are hazards to the listening to trauma. Trauma—and its impact on the hearer—leaves, indeed, no hiding place intact. As one comes to know the survivor, one really comes to know oneself” (Laub 1992a, p. 72). Engaged in such attentive listening to the suffering of others, the healing witness, whether physician or psychoanalyst, will inevitably come to experience within himself what is being recounted—with all its upheavals of revulsion and sorrow.[36] The healing witness will feel at times the need to flee, to fix quickly, to gloss over, to intellectualize, and to interject in horror and in outrage.[37] To make room for the survivor, these reactions must also be contained. It is imperative that the healing witness be as attentive to himself as to the survivor.[38] As Laub (1992a) observes, it is only “through [the listener’s] simultaneous awareness of the continuous flow of those inner hazards both in the trauma witness [survivor] and in himself, that he can become the enabler of the testimony—the one who triggers its initiation, as well as the guardian of its process and of its momentum” (p. 58).

Because the listener comes to experience something of the trauma within herself and is able to contain it and reflect it, the survivor can come to hear himself speak. As a result of being heard, the difficult task of owning, realizing, and symbolizing the traumatic experience begins to take place. Eventually, the survivor develops his “own personal relationship to what is mediated” (Ulanov 2001, p. 153) by the healing witness, and testimonies are told where the survivor is able to say “this is my experience.” The survivor’s act of transmitting his story “outside” to someone willing and able to listen—then “take it back again, inside” (Laub 1992a, p. 69)—serves as the foundation and the impetus for further testimonies and wider reflections, some of which become incorporated into the collective memory of broader communities. According to Kristeva, the optimum outcome would be for the survivor to recount his experiences “in a way that is stranger and truer each time … to become the narrator, the novelist, of [his] own story” (Kristeva 1996/2000, p. 29). Kai Erikson (1995), who has written extensively on the sociological impact of catastrophes, has observed that although “Trauma is normally understood as a somewhat lonely and isolated business,” the stories of survivors, their wisdom, and “revised views of the world” (p. 198) eventually make their way out to other survivors; and, perhaps, to the world at large, where they might even give rise “to new possibilities for sociality that can bear witness to trauma—that can bear the painful, radical dislocations of witnessing destruction and survival” (Edwin 2002, p. 136).

Note 26: Although in the Western world Holocaust denial has been countered by Holocaust museums and memorials (as well as laws against Holocaust denial, as in France), there are many examples of the denial of suffering in contemporary society. Denov (2004), for example, speaks of a culture of denial regarding the issue of female sex offending, and men in psychiatric units in the US and UK are rarely asked questions about past histories of sexual abuse, despite evidence supporting its prevalence in this population (Lab and More 2005). Moreover, the extent of child abuse and the validity of childhood memories (the creation of false memories, for instance) continues to generate much debate (Bjorklund 2009).
Note 27: As can telling a physician, as Charon (2006) points out, about the intimate details of one's bodily functions and personal habits.
Note 28: Fear, shame. and blame are emotions that also overwhelm those who are ill, and, according to Charon (2006), "erect the most unbreachable divides between doctors and patients" (p. 30).
Note 29: As Balint (1972) stressed decades later, "if you ask questions, you get answers—and hardly anything else" (p. 133); the job of the doctor, therefore, is to "learn to listen" (p. 121).
Note 30: Jackson (1992) has pointed out that much has been written on the therapeutic effects of talking, in both medicine and psychology. "For all the emphasis on the patient's talking, though," Jackson observes, "it is consistently clear that the physician's role was also crucial and that his listening was a critical feature of that role" (p. 1625). Jackson insists that in the "talking cure," "the healer as listener is at the heart of the matter" and that "The term ‘the listening cure' would be just as relevant" (p. 1629).
Note 31: A study conducted in 1984 in the US found that the average time from the start of the consultation before the first interruption of the patient by the physician was 18 seconds (Beckman and Frankel 1984). Currently, in the US, insurance companies require that the consultation time be a minimum of fifteen minutes. In France, the average consultation time is twenty minutes, and it is seven minutes in the UK (Hope 2011).
Note 32: These new patients described by Shorter are strikingly similar to the new patients Kristeva describes. Having lost opportunities and the ability to imaginatively express the stories of their own subjectivities, these patients find themselves disconnected from their emotions and their bodies. As Kristeva (1993/1995) was quoted in the introduction as saying," … the psychic life of modern individuals wavers between somantic symptoms (getting sick and going to the hospital) and the visual depiction of their desires (daydreaming in front of the TV)" (p. 8). Her observations on the couch are supported somewhat by research reported by Pennebaker (1993) and others (for example, Spiegel 1992). These studies show that low levels of emotional expressiveness lead to a decrease in immunization function and an increase in physical illness.
Note 33: Although religion is mentioned on several occasions in this paper, I have preferred to focus on secular opportunities of reconnecting the semiotic and symbolic. Aside from religious leaders functioning as healing witnesses, prayer to a personal God expresses, according to Fleischmann (1989), a yearning and need for "a God of listening" (p. 8).
Note 34: Shorter (1991) defines psychosomatic illness as "any illness in which physical symptoms, produced by the actions of the unconscious mind, are defined by the individual as evidence of organic disease and for which medical help is sought" (p. x). Mental illness, trauma, and the stress engendered by life events are not the only factors determining the incidence and nature of psychosomatic illness. Psychosomatic symptoms are influenced and shaped as well by culture, gender, class, race, and age (Shorter 1994). It should also be noted that I am not suggesting here that all illness is psychosomatic, but I do agree with Rudnytsky (2008) that "even a physical illness will be given unconscious meanings by the person who suffers from it, and the metaphors one fashions are likely to affect the outcome of the psyche-soma's efforts at self-healing" (p. 5).
Note 35: Ferenczi (1919/1980) describes the analyst, in this regard, as an obstetrician "who has to conduct himself as passively as possible, to content himself with the post of onlooker at a natural proceeding, but who must be at hand in the critical moment with the forceps in order to complete the act of parturation that is not progressing spontaneously" (pp. 182–183).
Note 36: Doctors and psychoanalysts are vulnerable to vicarious traumatization (McCann and Pearlman 1990). According to Pearlman and Saakvitne (1995), vicarious traumatization "refers to alterations in the therapist's identity and usual ways of understanding and experiencing herself and her world" (p. xvi) as a consequence of her work with trauma survivors.
Note 37: Laub (1992a) describes a number of listening defenses aside from outrage and fear: paralysis, withdrawal and numbness, awe, "obsession with fact finding," and hyperemotionality, where "the testifier is simply flooded, drowned and lost in the listener's defensive affectivity" (p. 73).
Note 38: Inevitably, some of these reactions will escape the vigilance of the healing witness and be observed by the teller, no matter how hard the listener attempts to constrain them. For many people, trauma and illness magnify another's demeanor, making visible the most fleeting hints of inattention, betrayal, revulsion, and abandonment. In the following passage, Pearlman and Saakvitne (1995) describe how these reactions can sometimes be used to benefit the survivor:
Picture this scenario. Your survivor client is describing a particularly horrific experience of childhood abuse. You know it is coming and brace yourself to listen, yet after a few minutes you realize you are staring out the window behind him feeling numb and inattentive … As you notice your inner departure from the relationship, you can acknowledge your feelings—perhaps dread, revulsion, anger—in response to the trauma material, and your wish not to hear or know it. This inner process will allow you to reenter your body and the room. What if your client has noticed and says that you “spaced out” at a critical moment, and he is hurt and feels abandoned? You can acknowledge that you indeed spaced out, and that you are back … The client will feel heard and acknowledged by the straightforward acknowledgment that you were not fully present, and his feelings of horror may be validated by your need to distance from the material (p. 17).