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Psychiatric Times
Home page teaser: Trauma is the distance between the reach and the grasp for our chosen
image
Column: Second Thoughts
Link: hps://www.psychiatricmes.com/view/bound-upon-a-wheel-of-re-reecons-on-
trauma
“Bound Upon a Wheel of Fire”: Reecons on Trauma
April 17, 2024
Vincenzo Di Nicola, MPhil, MD, PhD, FCAHS, DLFAPA, DFCPA
This column approaches trauma from three perspecves – child and family psychiatry, trauma-
informed care, and social psychiatry and philosophy. The tragedy of King Lear is briey
introduced as the framework for understanding tragedy and trauma. In closing, I argue for a
nuanced approach to trauma that is selecve 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 oer three perspecves on trauma from a lifelong
involvement in trauma studies. My research for the Diploma in Psychiatry at McGill University
invesgated the traumac impact of the Holocaust on third generaon survivors in Montreal.1
Later, I trained in the Harvard Program in Refugee Trauma and taught there.2 This deep
engagement led me to invesgate trauma philosophically based on the insight that both trauma
(where things shut down) and event (where new possibilies arise) are predicated on the
rupture of a lifeworld.3,4
I will organize my reecons 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 reacons – 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 condion but is
precisely the one who has given us access to registers of aect and sensibility that dene 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. Somemes, it may feel that they are
bound by chains and shackles which may be literally true as well. Somemes those chains are
the vehicle for the intergeneraonal transmission of trauma. Our goal should be to unshackle
children and families from their chains arising from their predicaments, to open new horizons
and opons for safety, healing and growth. We can sum this up very simply for clinical work by
stang 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 treang physical burns, is to remove the oending traumatogen (whether a causc
agent or an experience), deal with its rst noxious impact, and protect the vicms from
secondary and terary 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
Creang the condions for listening to the trauma story is at the heart “trauma-informed care,”
which involves creang a healing environment for trauma vicms along with self-care for the
healers.
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Social Psychiatry and Philosophy3,4,11
Trauma places its vicms on a kind of wheel which describes the predicament in which they nd
themselves that may repeat in reality through renewed exposures to traumatogens
(traumac 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 prevenon in the shape of therapy and security to migate suering may be
our best oer, but for populaons, we can and must aim at primary prevenon 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 reecon 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 traumazed, it loses its salience.
We need a nuanced vocabulary for human suering and to accept realiscally that there are
extreme states and harrowing situaons. Or? Or we have to invent new terms for ever more
horric, ever more traumazing situaons. Once American psychiatry coined the term post-
traumac stress disorders (PTSD) to name a set of exceponal circumstances arising from war
and related extreme situaons, 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 invocaon of hamara, 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 aach 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 selecve denion of trauma that is at the same me plasc and responsive to the many
kinds of human predicaments in which displacement, disaster and alienaon 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 connes of that world to
aend 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 Chrisan and a
humanist. A Spanish version of this column recently appeared in the Bolen 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. hps://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 & Crical Theory. Philosophy Now.
April-May 2024. Accessed April 9, 2024.
hps://philosophynow.org/issues/161/Shakespeare_Folly_Humanism_and_Crical_Theory
And these are some crical perspecves 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 & Addicon Medicine at the University of Montreal
and President of the World Associaon of Social Psychiatry (WASP). He has been recognized with
numerous naonal and internaonal awards, honorary professorships and fellowships, and was
recently elected a Fellow of the Canadian Academy of Health Sciences and given the
Disnguished Service Award of the American Psychiatric Associaon. Dr Di Nicola’s work
straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr
Di Nicola’s wring includes: A Stranger in the Family: Culture, Families and Therapy (WW
Norton, 1997), Leers to a Young Therapist (Atropos Press, 2011, winner of the Camille Laurin
Prize of the Quebec Psychiatric Associaon), and Psychiatry in Crisis: At the Crossroads of Social
Sciences, the Humanies, 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
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prolonged exposure to excessive stress be observed two generaons 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 Cercate Program, Harvard Program in Refugee Trauma, Massachuses General
Hospital, Harvard Medical School, April 23, 2021.
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3. Di Nicola V. Trauma and Event: A Philosophical Archaeology. PhD dissertaon in philosophy,
psychiatry and psychoanalysis. European Graduate School; 2012.
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trauma theories. In: Capreo PT, Boynton E, eds. Trauma and Transcendence: Limits in
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12. CSDH. Closing the Gap in a Generaon: Health Equity through Acon on the Social
Determinants of Health Final Report of the Commission on Social Determinants of Health.
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disease, psychiatric disorders and sexual behavior: implicaons for health care. In: Lanius
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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:
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hps://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.
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April 9, 2024.
hps://archive.nymes.com/www.nymes.com/books/00/11/12/specials/miller-
common.html
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19. Di Nicola V. “Atado a una rueda de fuego”: Reexiones sobre una vida en los estudios de
trauma. Bolen CRISOL (Centro Posgrado de Terapia Familiar, Mexico), Febrero 2024;1:3-6.