Wounded by Reality: Understanding and Treating Adult Onset Trauma

woundedGhislaine Boulanger
Psychoanalysis in a New Key Book Series, Volume 6, 0-88163-430 • 225pp.

The Analytic Press, Inc.APlogo40

When catastrophic events overtake adult lives, they often scar the psyche in ways that psychodynamically oriented clinicians struggle to understand. For Ghislaine Boulanger, the enormous challenge of working with these patients is unsurprising. Survivors of major catastrophe — whether a natural disaster, a life-threatening assault, a serious accident, or an act of terrorism — experience a near-fatal disruption of fundamental aspects of self experience. The sense of agency, of affectivity, of bodily integrity, the capacity for self-reflection, the sense of time, and the ability to relate to others – all are called into question. And the questioning persists long after the crisis has passed, leaving many adults who have endured catastrophic trauma uncertain that they have psychologically survived their ordeal.

The culmination of three decades of studying and treating survivors of adult onset trauma, Wounded by Reality is the first systematic attempt to differentiate adult onset trauma from childhood trauma, with which it is frequently confused. Integrating recent findings in the neurobiology of stress and developmental psychology with relational psychoanalytic concepts, Boulanger provides psychodynamically oriented clinicians with a comprehensive guide to recognizing the symptoms, understanding the psychodynamics, and working productively with these individuals. Extensive clinical material attests to the difficulties as well as the clinical promise of this demanding work.

Table of Contents:

  1. Toward a Psychodynamic Understanding of Adult Onset Trauma
  2. Catastrophic Dissociation and Childhood Trauma: Some Distinctions
  3. The Cost of Survival: Historical Perspectives on Adult Onset Trauma
  4. Wounded by Reality: The Relational Turn
  5. The Core Self in Crisis: Deconstructing Catastrophic Dissociation
  6. The Relational Self in Crisis: Further Deconstructing Catastrophic Dissociation
  7. From Voyeur to Witness: The Crisis in Symbolic Functioning During Catastrophic Dissociation
  8. The Ancient Mariner’s Dilemma: Constructing a Trauma Narrative
  9. The Strength Found in Innocence: Resistance to Working Psychodynamically with Survivors of Adult Onset Trauma
  10. The Psychological Politics of Catastrophe: Local, Personal, and Professional


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Advance Comments:

Ghislaine Boulanger’s remarkable book begins a new era of trauma therapy. She has overcome difficulties in psychoanalytic metapsychology to make two significant contributions: She clearly distinguishes the consequences of adult onset catastrophic trauma from childhood trauma; and she spells out the details of treating adult trauma. She shows how, in confronting sudden death and other overwhelming situations, the self is shattered; its component parts, such as memories and affect, are broken up and scattered. They become shield-like obstacles rather than tools to enhance the capacity to experience life and happiness fully. The life-maintaining resources are rendered ineffective. Boulanger demonstrates the obstacles that an analyst (or other therapist) encounters. She supplies the techniques to make treatment effective. She gives us a whole new way to help people whose problems are very difficult to treat.”

-Henry Krystal, M.D., Author, Integration and Self-Healing:Affect, Trauma, Alexithymia
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Ghislaine Boulanger has filled a critical gap in our knowledge with this beautifully written, exhaustively researched, highly readable book on catastrophic trauma in adulthood. Even those of us with secure childhoods, it turns out, are much more fragile than we would like to believe. Boulanger explores this harsh reality gently but authoritatively, in the context of a wealth of scholarship, and draws wise and clinically useful conclusions about helping the traumatized and those who love them. Because therapists of all orientations and interests may find themselves working with traumatized adults, and because prior approaches to the traumatized person have mostly neglected those wounded in adulthood by literally unbearable realities, this eloquent work deserves a place on the bookshelf of every clinician.”

—Nancy McWilliams, Ph.D., Author, Psychoanalytic Psychotherapy: A Practitioner’s Guide

Ghislaine Boulanger offers a useful and necessary review of how classical and recent psychoanalysts have conceptualized adult onset trauma. The rewards of this demanding and relentless interrogation are clear when Boulanger describes the transferential and countertransferential themes that emerge in clinical encounters with patients who have survived massive psychic trauma. These patients are themselves witnesses in search of a reliable witness for their testimony, so that it can be converted into history that can be remembered and therefore forgotten — at least for a while. Every psychoanalyst should be aware of these new patients, who are, in fact, as old as psychoanalysis itself, but who now knock at our door with increasing urgency. It is better to be prepared for that difficult but potentially rewarding encounter.”

-Jean-Max Gaudillière & Françoise Davoine, Authors, History Beyond Trauma: Whereof one cannot speak…thereof one cannot stay silent

Wounded By Reality is an exceptional work. Scholarly and inquiring, it integrates many theories and disciplines to address a neglected issue: adult onset trauma. Boulanger has a unique and expansive vision of dissociation; she challenges psychoanalysis even as she cherishes it. Her clinical material reflects a commitment to her patients’ darkest times.”

-Sue Grand, Ph.D., Author, The Reproduction of Evil: A Clinical and Cultural Perspective


An extraordinarily rich and helpful guide to conceptualizing the emotional and mental state of the adult trauma survivor and to treating such an individual in psychodynamic therapy. Boulanger writes clearly and with passion, offering many illustrative clinical vignettes that demonstrate dedication, expertise, bravery and imagination in her work with trauma survivors. Her technical suggestions stress the importance of following the patient’s material without straining to place it within a particular theoretical context. … an impressive accomplishment that provides a coherent theoretical and technical approach to the psychodynamic treatment of the adult who has experienced massive trauma.”

—Marie G. Rudden, International Journal of Psychoanalysis, 89, pp 899-903, 2008
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an eloquent, beautifully written, and much needed book illuminating an often overlooked topic: the dissociative impact of trauma suffered by adults. It puts adult-onset trauma on the map. …Wounded by Reality is informative, clarifying, and moving; and it is a breakthrough. Boulanger’s insistence that we recognize the “adult type” of dissociative response to trauma is vital for us to heed. She illuminates a problem that pertains to so many people who seek treatment for symptoms stemming from their trauma: how often they do not get the treatment and the kind of recognitition that they need because their dissociatively organized experience is not understood. She explains this problem in an entirely new way for adult-onset trauma. She realises very important points that have not been adequately understood in the past, including, but not limited to, the twin issues that dissociation is often not well understood by traumatologists and that psychoanalysts are too often blind to the reality of trauma….Wounded by Reality is a must read for clinicians treating traumatized patients, and expecialy those treating people who have suffered osttraumatic dissociation in adulthood. And that is a lot of people.”

—Elizabeth Howell, Ph.D., Author, The Dissociative Mind. Review in: Contemporary Psychoanalysis, 44.4, 2008

One of the pleasures in reading this book is how well it is organized…Information does not appear in clusters of facts, simply stated and left to the reader’s zeal in making connections. Insights from various disciplines, once explored, become part of discussions of case material. With great frankness about her reactions to her patients, Boulanger both enlivens her discourse and encourages the reader’s thoughtfulness about the reader’s own clinical experience. Beautifully stated and direct, her descriptions make palpable what it means to work with people who can manage to go on after terrible trauma only by numbing themselves, unable to construct a trauma narrative, at the mercy of harrowing bits and pieces of isolated memory. Despite its scholarly value, this book passionately entreats the reader to see what a traumatized adult must resort to in trying just to go on.”

-Johanna Krout Tabin, Ph.D., ABPP, Psychoanalytic Psychology, 25.1, 2008

Valuable and comprehensive as the theoretical richness of this book is, the most precious and spiritually moving part is Boulanger’s ability to share her clinical self. For the purposes of teaching about trauma to psychology students, Wounded by Reality is a perfect example of the theoretical masterwork that does not lose its touch with clinical reality. In addition to correcting the course of development of the theoretical understanding of trauma in every chapter, it fleshes out the voices of the subjects, both the patient and the author/analyst who discover meaning together. The clear, strong writing make it suitable for all: advanced undergraduates, graduate students, psychoanalytic candidates, and practicing clinicians. She has written a book that poses the explicit and implicit questions to us as clinicians – where can we find the courage to enter into the world of the shattered adult? And how can we live with ourselves if we don’t oppose the forces that make it happen? Boulanger shows the way, for she has been there.”

-Elizabeth Hegeman, Ph.D., Psychologist-Psychoanalyst, Fall 2007

As a psychoanalyst and psychotherapist for some forty years, I approached this book eagerly seeking explanations for numerous experiences I have had with patients trapped in catastrophic, unthinkable traumas, ranging from those involved in the Nazi Holocaust—who would lose consciousness in my presence rather than recall the tortures and humiliations they had suffered—to, more recently, those who experienced trauma through the tragedies of 9/11 and the aftermath of devastating hurricanes. Newspapers suggest that every day severe traumas are present, occurring increasingly more frequently. Less than 50% of homicides are solved, and many seem to involve torture and mutilation, as well as often unspeakable cruelty to young children. One whole page of a newspaper I recently read was devoted to a list of multiple killings, tortures, and mutilations that had been visited on ordinary citizens. Boulanger’s book is not about rare occurrences, then; it describes everyday reality. …I recommend that every psychoanalyst and psychotherapist read Wounded by Reality.”

—Twemlow, S.W. (2008). Psychoanalytic Quarterly, 77:1291-1297

Wounded by Reality, as its provocative title suggests, inspires the reader to follow the author Ghislaine Boulanger into the pain, horror and grief that is the emotional like of surviving ‘the extremes of experience.’ Written with sensitivity, grace and honesty, the ideas, insights and suggestions clear enough to be accessible to non-analytically oriented readers, clinicians from varying backgrounds and experience with trauma will find this book heartwarming and instructive.”

-Elizabeth Goren, Ph.D., Trauma Psychology Newsletter, 3.1, 2008

This book is both fascinating and rewarding and provides the reader with a rich source of ideas and insight into a topic that is so relevant to the twenty-first century and clinical work.”

Journal of Analytical Psychology, 53, 2008

She is an original and creative thinker who steers clear of psychoanalytic dogma … Boulanger’s monograph is timely and insightful, particularly in its analysis of the subjective experience of adults who have survived devastating trauma, and it will be of interest not only to therapists who treat adult trauma survivors but also, more generally, to scholars hoping to understand the psychological consequences of traumatic events.”

-David Manier, PsycCritiques: APA Review of Books, 3/12/2008