(Sam Vaknin) There is one place in which one’s privacy, intimacy, integrity and inviolability are guaranteed: one’s body, a unique temple and a familiar territory of sensa and personal history. The process of chronic disease invades, defiles and desecrates this shrine. It does so publicly, enhancing the sufferer’s sense of helplessness and utter humiliation. Hence the all-pervasive, long-lasting, and, frequently, irreversible effects and outcomes of long-term, intractable illness.
In a way, the torture victim’s own body is rendered his worst enemy. It is corporeal agony that compels the patient to mutate, his identity to fragment, his ideals and principles to crumble. The body becomes an accomplice of the affliction, an uninterruptible channel of communication, a treasonous, poisoned territory.
It fosters a humiliating dependency of the abused on medicines, doctors, and bureaucracies. The impersonal character of modern healthcare objectifies the patient, further adding to his or her alienation. Bodily needs denied in the course of the ailment – sleep, toilet, food, water – are wrongly perceived by the victim as the direct causes of his degradation and dehumanization. As he sees it, he is rendered bestial not by the inadequacies of society and medicine but by his own flesh.
The concept of “body” can easily be extended to “family”, or “home”. One’s sickness often affects kin and kith, compatriots, or colleagues. The inexorable processes of degeneration and decrepitude disrupt the continuity of “surroundings, habits, appearance, relations with others”, as the CIA put it in one of its torture manuals. A sense of cohesive self-identity depends crucially on the familiar and the continuous. By attacking both one’s biological body and one’s “social body”, the patient’s psyche is strained to the point of dissociation.
Beatrice Patsalides describes this transmogrification thus in “Ethics of the Unspeakable: Torture Survivors in Psychoanalytic Treatment” (it applies equally well to hospital settings, for instance, or to the patient’s death-bed):
“As the gap between the ‘I’ and the ‘me’ deepens, dissociation and alienation increase. The subject that, under torture (read: disease – SV), was forced into the position of pure object has lost his or her sense of interiority, intimacy, and privacy. Time is experienced now, in the present only, and perspective – that which allows for a sense of relativity – is foreclosed. Thoughts and dreams attack the mind and invade the body as if the protective skin that normally contains our thoughts, gives us space to breathe in between the thought and the thing being thought about, and separates between inside and outside, past and present, me and you, was lost.”
Illness robs the patient of the most basic modes of relating to reality and, thus, is the equivalent of cognitive death. Space and time are warped by sleep deprivation. The self (“I”) is shattered. The chronically sick have nothing familiar to hold on to: family, home, personal belongings, loved ones, language, name. Gradually, they lose their mental resilience and sense of freedom. They feel alien: unable to communicate, relate, attach, or empathize with others.
Terminal or debilitating illness splinters early childhood grandiose narcissistic fantasies of uniqueness, omnipotence, invulnerability, and impenetrability. But it enhances the fantasy of merger with an idealized and omnipotent (though not benign) other: the medical doctor, often the inflictor of agony. The twin processes of individuation and separation are reversed.
Being treated for an illness is the ultimate act of perverted intimacy. The medical professional invades the victim’s body, or probes his psyche (if he is a psychiatrist). Bed-ridden, deprived of contact with others and starved for human interactions, the patient bonds with his caregiver (hence pathological phenomena such as the Munchhausen Syndrome). “Traumatic bonding”, akin to the Stockholm Syndrome, is about hope and the search for meaning in the brutal and indifferent and nightmarish universe of the hospital or the outpatient clinic.
The medical doctor becomes the black hole at the centre of the victim’s surrealistic galaxy, sucking in the sufferer’s universal need for solace. The victim tries to “control” his caregiver by becoming one with him (introjecting him) and by appealing to the practitioner’s presumably merely desensitized humanity and empathy.
This bonding is especially strong when the doctor and the patient form a dyad and “collaborate” in the rituals and acts of treatment (for instance, when the victim is asked to select the implements and the types of surgery to be inflicted or to choose between two equally vile and agonizing “cures”).
The psychologist Shirley Spitz offers this powerful overview of the contradictory nature of torture in a seminar titled “The Psychology of Torture” (1989). Substitute the words “chronic and terminal illness” for “torture” in the following text:
“Torture is an obscenity in that it joins what is most private with what is most public. Torture entails all the isolation and extreme solitude of privacy with none of the usual security embodied therein… Torture entails at the same time all the self-exposure of the utterly public with none of its possibilities for camaraderie or shared experience. (The presence of an all powerful other with whom to merge, without the security of the other’s benign intentions.)
A further obscenity of torture is the inversion it makes of intimate human relationships. The interrogation is a form of social encounter in which the normal rules of communicating, of relating, of intimacy are manipulated. Dependency needs are elicited by the interrogator, but not so they may be met as in close relationships, but to weaken and confuse. Independence that is offered in return for ‘betrayal’ is a lie. Silence is intentionally misinterpreted either as confirmation of information or as guilt for ‘complicity’.
Torture combines complete humiliating exposure with utter devastating isolation. The final products and outcome of torture are a scarred and often shattered victim and an empty display of the fiction of power.”
Obsessed by endless ruminations, demented by pain and a continuum of sleeplessness, the patient regresses, shedding all but the most primitive defence mechanisms: splitting, narcissism, dissociation, Projective Identification, introjection, and cognitive dissonance. The sick person constructs an alternative world, suffering in extremis from depersonalization and derealisation, hallucinations, ideas of reference, delusions, and psychotic episodes.
Some patients come to crave pain – very much as self-mutilators do – because it is a proof and a reminder of their individuated existence otherwise blurred by the incessant process of disease. Pain shields the sufferer from disintegration and capitulation. It preserves the veracity of his unthinkable and unspeakable experiences. Pain is like a decoration for valour and courage under fire: something to be proud of and flaunt.
These dual processes of the patient’s alienation, on the one hand and his addiction to anguish on the other hand complement his view of himself as increasingly “inhuman”, or “subhuman”. The medical doctor assumes the position of the sole authority, the exclusive fount of meaning and interpretation, the source of both evil and good. The patient is self-vitiated.
Illness can be perceived as a reprogramming the patient to succumb to an alternative exegesis of the world, proffered by the medical profession. It is an act of deep, indelible, traumatic indoctrination. The sick typically swallow whole and assimilate the doctors’ point of view and their opinions (regarding the patients as objects, statistics, or corpses-in-the-making) and at times, as a result, are rendered suicidal, self-destructive, or self-defeating.
Chronic disease has no cut-off date. The sounds, the voices, the smells, the sensations reverberate long after each episode has ended: both in nightmares and in waking moments. The patient’s ability to trust the rationality and benevolence of the world has been irrevocably undermined. Social institutions are perceived as precariously poised on the verge of an ominous, Kafkaesque mutation. Nothing is either safe or credible anymore.
Long-term patients typically react by undulating between emotional numbing and increased arousal: insomnia, irritability, restlessness, and attention deficits. Recollections of the traumatic events intrude in the form of dreams, night terrors, flashbacks, and distressing associations.
The sick develop compulsive rituals to fend off obsessive thoughts. Other psychological sequelae reported include cognitive impairment, reduced capacity to learn, memory disorders, sexual dysfunction, social withdrawal, inability to maintain long-term relationships, or even mere intimacy, phobias, ideas of reference and superstitions, delusions, hallucinations, psychotic microepisodes, and emotional flatness.
Depression and anxiety are very common. These are forms and manifestations of self-directed aggression. The sufferer rages at his own victimhood and resultant multiple dysfunctions. He feels shamed by his new disabilities and responsible, or even guilty, somehow, for his predicament and the dire consequences borne by his nearest and dearest. His sense of self-worth and self-esteem are crippled.
In a nutshell, the terminally and chronically ill suffer from Complex Post-Traumatic Stress Disorder (PTSD). Their strong feelings of anxiety, guilt, and shame are also typical of victims of childhood abuse, torture, domestic violence, and rape. They feel anxious because the disease’s “behaviour”, progression, and trajectory are seemingly arbitrary and unpredictable – or mechanically and inhumanly regular.
They feel guilty and disgraced because, to restore a semblance of order to their shattered world and a modicum of dominion over their chaotic life, they need to transform themselves into the cause of their own degradation and the accomplices of their torment.
Inevitably, in the aftermath of bodily trauma and protracted illness, the victims feel helpless and powerless. This loss of control over one’s life and body is manifested physically in impotence, attention deficits, and insomnia. This is often exacerbated by the disbelief many patients encounter when they try to share their experiences, especially if they are unable to produce scars, or other “objective” proof of their ordeal. Language cannot communicate such an intensely private experience as pain.
Spitz makes the following observation:
“Pain is also unsharable in that it is resistant to language… All our interior states of consciousness: emotional, perceptual, cognitive and somatic can be described as having an object in the external world… This affirms our capacity to move beyond the boundaries of our body into the external, sharable world. This is the space in which we interact and communicate with our environment. But when we explore the interior state of physical pain we find that there is no object ‘out there’ – no external, referential content. Pain is not of, or for, anything. Pain is. And it draws us away from the space of interaction, the sharable world, inwards. It draws us into the boundaries of our body.”
Bystanders resent and shun the sick because they make them feel anxious. The ill threaten the healthy person’s sense of security and her much-needed belief in predictability, justice, and rule of natural law. The patients, on their part, do not believe that it is possible to effectively communicate to “outsiders” what they have been through. The torture chambers known as hospital wards are “another galaxy”. This is how Auschwitz was described by the author K. Zetnik in his testimony in the Eichmann trial in Jerusalem in 1961.
But, more often, continued attempts to repress fearful memories result in psychosomatic illnesses (conversion). The patient wishes to forget the pain, to avoid re-experiencing the often life threatening episodes and eruptions and to shield his human environment from the horrors. In conjunction with the patient’s pervasive distrust, this is frequently interpreted as recalcitrance or hostility.