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"Bound Upon a Wheel of Fire": Reflections on Trauma

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Abstract

This column approaches trauma from three perspectives-child and family psychiatry, trauma-informed care, and social psychiatry and philosophy. The tragedy of King Lear is briefly introduced as the framework for understanding tragedy and trauma. In closing, I argue for a nuanced approach to trauma that is selective but responsive to the ruptures that create trauma and tragedy in our lives. "You do me wrong to take me out o' the grave. Thou art a soul in bliss; but I am bound Upon a wheel of fire, that mine own tears Do scald like molten lead." - King Lear, Act IV, sc 7
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Psychiatric Times
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trauma
“Bound Upon a Wheel of Fire”: Reecons on Trauma
April 17, 2024
Vincenzo Di Nicola, MPhil, MD, PhD, FCAHS, DLFAPA, DFCPA
This column approaches trauma from three perspecves – child and family psychiatry, trauma-
informed care, and social psychiatry and philosophy. The tragedy of King Lear is briey
introduced as the framework for understanding tragedy and trauma. In closing, I argue for a
nuanced approach to trauma that is selecve but responsive to the ruptures that create trauma
and tragedy in our lives.
You do me wrong to take me out o’ the grave.
Thou art a soul in bliss; but I am bound
Upon a wheel of re, that mine own tears
Do scald like molten lead.
– King Lear, Act IV, sc 7
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In this week’s column, I would like to oer three perspecves on trauma from a lifelong
involvement in trauma studies. My research for the Diploma in Psychiatry at McGill University
invesgated the traumac impact of the Holocaust on third generaon survivors in Montreal.1
Later, I trained in the Harvard Program in Refugee Trauma and taught there.2 This deep
engagement led me to invesgate trauma philosophically based on the insight that both trauma
(where things shut down) and event (where new possibilies arise) are predicated on the
rupture of a lifeworld.3,4
I will organize my reecons by taking a key word from King Lear’s famous plaint in each
domain. Lear is complaining to those “in bliss” (meaning “in heaven” in his mes and “at peace”
in our own), that he has been dragged out of his misery to face not only the predicament that
binds him to a living hell but that his own reacons – his grief over the loss of his daughters and
his kingdom expressed in his tears – are scalding him. If we know how to read Shakespeare with
a modern sensibility, we may nd that he not only describes the human condion but is
precisely the one who has given us access to registers of aect and sensibility that dene what
it means to be human, as Harold Bloom argued.5 As the Polish Shakespeare scholar Jan Ko put
it, Shakespeare is our contemporary.6
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Child and Family Psychiatry7
Children and families are bound to their predicaments the way snails are bound to their shells.
“Wherever you go, you take it with you” – good and bad. Somemes, it may feel that they are
bound by chains and shackles which may be literally true as well. Somemes those chains are
the vehicle for the intergeneraonal transmission of trauma. Our goal should be to unshackle
children and families from their chains arising from their predicaments, to open new horizons
and opons for safety, healing and growth. We can sum this up very simply for clinical work by
stang that, “You have to get into it to get out of it.
Trauma-informed Care 1,2,4,8
The intensity of trauma sears experience into bodies and minds the way re does to esh. Our
goal, like treang physical burns, is to remove the oending traumatogen (whether a causc
agent or an experience), deal with its rst noxious impact, and protect the vicms from
secondary and terary consequences. There appears to be a consensus that the “body keeps
the score” as Harvard’s Bessel van der Kolk sums it up.9 Can we change the score card? Richard
Mollica, Director of the Harvard Program in Refugee Trauma, believes we can through an
empathic witnessing of “the trauma story” – a story which must be told to another person.10
Creang the condions for listening to the trauma story is at the heart “trauma-informed care,
which involves creang a healing environment for trauma vicms along with self-care for the
healers.
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Social Psychiatry and Philosophy3,4,11
Trauma places its vicms on a kind of wheel which describes the predicament in which they nd
themselves that may repeat in reality through renewed exposures to traumatogens
(traumac agents or experiences) or repeated through mental re-experiencing. Trauma is also
on the larger wheel of social context – as documented by studies on the Social Determinants of
Health (SDH)12 and Adverse Childhood Experiences (ACE).13 Once individuals are bound on these
wheels, secondary prevenon in the shape of therapy and security to migate suering may be
our best oer, but for populaons, we can and must aim at primary prevenon to diminish and
where possible eliminate adversity, which has been brilliantly outlined by Sir Michael Marmot’s
work on SDH. The slogan for this work is “fair society, healthy lives,”14 one which the Global
Mental Health movement and social psychiatry should adopt.
Finally, as a social psychiatrist and social philosopher, a plea for careful, deliberate reecon on
the nature of trauma.15,16 Just as every death is not a tragedy, not all the vicissitudes of life are
traumas. If trauma is everywhere,17 it’s nowhere. If everyone is traumazed, it loses its salience.
We need a nuanced vocabulary for human suering and to accept realiscally that there are
extreme states and harrowing situaons. Or? Or we have to invent new terms for ever more
horric, ever more traumazing situaons. Once American psychiatry coined the term post-
traumac stress disorders (PTSD) to name a set of exceponal circumstances arising from war
and related extreme situaons, the “bracket creep” sadly typical of our eld soon started to
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include every kind of hurt and disappointment in that diagnosis. Result? Complex PTSD had to
be invoked3,4,8 for more severe cases.
Not every old man facing death and despair is a tragic gure. The aging King Lear was tragic
because his own foolishness – Aristotle’s classical invocaon of hamara, the “tragic aw” –
brought him to lose the love of his daughters and the unity of his kingdom. Does that mean that
only the wealthy and the powerful experience tragedy and trauma? No. As American playwright
Arthur Miller wrote in a celebrated essay, tragedy in our mes is the distance between the
reach and the grasp of the “common man” for a cherished image.18 Tragedy, Miller asserted
and trauma, I would add – derives from the underlying fear of being displaced, the disaster
inherent in being torn away from our chosen image of what and who we are in this world.”
Insofar as we want to aach words like tragedy and trauma to social and psychological aspects
of our existence and not merely to the brute facts of ssue damage and bodily wounds, we
need a selecve denion of trauma that is at the same me plasc and responsive to the many
kinds of human predicaments in which displacement, disaster and alienaon rend ruptures in
our lives and become unbearable wounds.
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Acknowledgements
I wish to dedicate this column to Mr. Raymond Reed, MA (1937-2022), my high school English
teacher and lifelong friend who challenged me to reach beyond the connes of that world to
aend McGill University. He inspired my love of the English language, notably through
Shakespeare and Milton, and remains a model for what it means to be a Chrisan and a
humanist. A Spanish version of this column recently appeared in the Bolen CRISOL in Mexico
City and appears with the permission of the editor, Javier Vicencio, MD.19
Resources
Here is an excellent program with a compassionate and comprehensive approach to trauma:
Harvard Program in Refugee Trauma. Accessed April 9, 2024. hps://hprt-cambridge.org/
HPRT Director, Richard Mollica, Healing Invisible Wounds10
For an enlarged view of our work through Shakespeare:
Samuel Gilchrist Hall, Shakespeare: Folly, Humanism & Crical Theory. Philosophy Now.
April-May 2024. Accessed April 9, 2024.
hps://philosophynow.org/issues/161/Shakespeare_Folly_Humanism_and_Crical_Theory
And these are some crical perspecves on the current cultural obsession with trauma:
Didier Fassin & Richard Rechtman, The Empire of Trauma15
Will Self, “A Posthumous Shock: How everything became trauma”16
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Dr Di Nicola is a child psychiatrist, family psychotherapist and philosopher in Montreal, Quebec,
Canada, where he is Professor of Psychiatry & Addicon Medicine at the University of Montreal
and President of the World Associaon of Social Psychiatry (WASP). He has been recognized with
numerous naonal and internaonal awards, honorary professorships and fellowships, and was
recently elected a Fellow of the Canadian Academy of Health Sciences and given the
Disnguished Service Award of the American Psychiatric Associaon. Dr Di Nicola’s work
straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr
Di Nicola’s wring includes: A Stranger in the Family: Culture, Families and Therapy (WW
Norton, 1997), Leers to a Young Therapist (Atropos Press, 2011, winner of the Camille Laurin
Prize of the Quebec Psychiatric Associaon), and Psychiatry in Crisis: At the Crossroads of Social
Sciences, the Humanies, and Neuroscience (with D. Stoyanov; Springer Nature, 2021); and, in
the arts, his “Slow Thought Manifesto” (Aeon Magazine, 2018) and Two Kinds of People: Poems
from Mile End (Delere Press, 2023, nominated for The Pushcart Prize).
References
1. Sigal JJ, Di Nicola VF, Buonvino M. Grandchildren of survivors: Can negave eects of
prolonged exposure to excessive stress be observed two generaons later? Canadian
Journal of Psychiatry. 1988;33(3):207-212.
2. Di Nicola V. “Changelings: Children, Culture and Trauma,” Global Mental Health: Trauma and
Recovery Cercate Program, Harvard Program in Refugee Trauma, Massachuses General
Hospital, Harvard Medical School, April 23, 2021.
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3. Di Nicola V. Trauma and Event: A Philosophical Archaeology. PhD dissertaon in philosophy,
psychiatry and psychoanalysis. European Graduate School; 2012.
4. Di Nicola V. Two trauma communies: A philosophical archaeology of cultural and clinical
trauma theories. In: Capreo PT, Boynton E, eds. Trauma and Transcendence: Limits in
Theory and Prospects in Thinking. Fordham University Press; 2018:17-52.
5. Bloom H. Shakespeare: The Invenon of the Human. New York, NY: Riverhead Books; 1998.
6. Ko J. Shakespeare Our Contemporary. W.W. Norton & Co.; 1974.
7. Di Nicola V, Song S. Family maers: The family as a resource for the mental, social, and
relaonal well-being of migrants, asylum seekers, and other displaced populaons. In:
Gogineni RR, Pumariega AJ, Kallivayalil R, Kastrup M, Rothe, EM, eds. The WASP Textbook on
Social Psychiatry: Historical, Developmental, Cultural, and Clinical Perspecves. Oxford
University Press; 2023:244-255.
8. Di Nicola V. Ethnocultural aspects of PTSD and related stress disorders among children and
adolescents. In: Marsella AJ, Friedman M, Gerrity E, Scureld R, eds. Ethnocultural Aspects
of Posraumac Stress Disorder: Issues, Research, and Clinical Applicaons. American
Psychological Associaon Press; 1996:389-414.
9. Van der Kolk BA. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma.
Viking; 2014.
10. Mollica RF. Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World.
Harcourt, Internaonal; 2006.
11. Di Nicola V, Stoyanov D. Psychiatry in Crisis: At the Crossroads of Social Science, The
Humanies, and Neuroscience. Cham, Switzerland: Springer Nature; 2021.
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12. CSDH. Closing the Gap in a Generaon: Health Equity through Acon on the Social
Determinants of Health Final Report of the Commission on Social Determinants of Health.
World Health Organizaon; 2008.
13. Feli VJ, Anda RF. The relaonship of adverse childhood experiences to adult medical
disease, psychiatric disorders and sexual behavior: implicaons for health care. In: Lanius
RA, Vermee E, Pain C, eds. The Impact of Early Trauma on Health and Disease: The Hidden
Epidemic. Cambridge University Press; 2010:77-87.
14. Marmot M, Bell R. Fair society, healthy lives. Public Health. 2012 Sep;126 Suppl 1:S4–10. doi:
10.1016/j.puhe.2012.05.014.
15. Fassin D, Rechtman R. The Empire of Trauma: An Inquiry into the Condion of Vicmhood.
Trans. Gomme R. Princeton University Press; 2009.
16. Self W. A Posthumous Shock: How everything became trauma. Harper’s Magazine,
November 22, 2021, pp. 23-34. Accessed April 9, 2024.
hps://harpers.org/archive/2021/12/a-posthumous-shock-trauma-studies-modernity-how-
everything-became-trauma/
17. Maté G, Maté D. The Myth of Normal: Trauma, Illness & Healing in a Toxic Culture. Alfred A.
Knopf Canada; 2022.
18. Miller A. Tragedy and the common man. The New York Times, February 27, 1949. Accessed
April 9, 2024.
hps://archive.nymes.com/www.nymes.com/books/00/11/12/specials/miller-
common.html
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19. Di Nicola V. “Atado a una rueda de fuego”: Reexiones sobre una vida en los estudios de
trauma. Bolen CRISOL (Centro Posgrado de Terapia Familiar, Mexico), Febrero 2024;1:3-6.
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
“Atado a una rueda de fuego”: Reflexiones sobre una vida en los estudios de trauma Abstracto Este breve ensayo aborda el trauma desde tres perspectivas: psiquiatría infantil y familiar, atención informada sobre el trauma y psiquiatría y filosofía social. Se presenta brevemente la tragedia del Rey Lear como marco para comprender la tragedia y el trauma. Para terminar, el autor aboga por un enfoque matizado del trauma que sea selectivo pero que responda a las rupturas que crean trauma y tragedia en nuestras vidas. Palabras clave: trauma, tragedia, Determinantes Sociales de la Salud (DSS), Experiencias Adversas en la Infancia (EAI), Trastornos de Estrés Postraumático (TEPT), historia de trauma
Chapter
Full-text available
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Chapter
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