Hell is Other People
How we're doomed to the gaze of others
There is an old, well-worn (overworn?) trope in many sitcoms, certainly in the 1990s and 2000s, that centers on the beleaguered husband having to deal with his demanding and sometimes overbearing wife who, despite his trouble, loves her and will not leave her. (See Married With Children, King of Queens, and Everybody Loves Raymond for source material.) This is summed up in the made-for-bumper-sticker sentiment, “Women – can’t live with ‘em, can’t live without ‘em”.
As sexist as this trope is, it occurred to me that a similar, albeit non-gendered sentiment is captured by the declaration that “Hell is other people!” – the iconic line that comes from the denouement of No Exit, one of the most famous plays by the existentialist philosopher, Jean-Paul Sartre. The essence of the play (and maybe I should give a tiny spoiler alert here) centers around three characters, Garcin, Inez, and Estelle. They are all ushered into a hot, windowless room where they are to spend eternity together – in hell. Each character finds themselves in a dilemma – they dearly seek the validation and approval of at least one character, while feeling scorn and disdain from the other. With no mirrors in this room, they look to the others to define themselves. One character literally thinks she will go mad without being able to look at herself in a mirror ever again. There is a reason this play is so iconic – I challenge you to read it and not feel the heat rise within you, the claustrophobia of the walls closing in on you. If this is living forever, who the hell would want this? (Side-note: if this plotline sounds familiar, you are correct – the Netflix show The Good Place is indeed inspired by No Exit; well, at least Season 1.)
As soon as I heard that, I thought, “that could be the bumper sticker for every complex trauma survivor!” Complex trauma is defined by abuse and/or neglect that is prolonged, repeated, and inescapable, and typically in an interpersonal context. Relationships – and other people – are the source of complex trauma, yet it is in relationship that the seed of salvation and healing is to be found. As a wise therapist once said to me, “what is broken in relationship must be healed in relationship”. If a survivor is lucky, they only need to find that one person – or even a pet, or a place in nature – to develop earned secure attachment, an experience of redemption, that yes, I do indeed belong in the ecology of things after all.
Of course, some survivors do decide that the cost of admission to relationship is too great, and that they would rather avoid relationships and remain alone to mitigate the risk of being hurt yet again. But others do not have that offramp to opt out of relationship – they have spouses, children, parents, jobs, and friends that cannot be avoided indefinitely.
Interestingly, it has been said that this line – “Hell is other people” – is one of Sartre’s most misunderstood. It does not simply mean “other people suck” (as much as we might admit that is, in fact, true at times). There is much more nuance to it than that. The play provides a showcase for many of Sartre’s key philosophical ideas, but the one most prominent in the play is how our sense of self is defined by the inescapable gaze, judgments, and perceptions of others, trapping individuals in a cycle of self-deception (or what he calls “bad faith”), which presents as a perennial obstacle to true self-definition on our own terms.
For complex trauma survivors, in a true Sartrean sense, there is “no exit” from relationship. One’s whole sense of self is bound up in a persistent and pervasive bid for survival, which centers the gaze of the other. Decisions both big and small, conscious and unconscious, are made along the axes of safety and danger in relationship to other people. “Was that the look they just gave me?...I can feel a bad vibe in this room, I wonder what I did wrong…I can’t be myself here, I guess it’s time to leave because there’s no point trying to assert my needs and be invalidated yet again…” Asking survivors simple questions like “what foods do you like, how do you take care of yourself, what movies and music do you like, what are your hopes?” can all draw a blank. Having an answer to those questions would imply a reprieve from the mirrorless, windowless confines of relationship defined on survival alone.
The Hell of Complex Trauma
Complex trauma, as a syndrome, has suffered the same affliction as survivors themselves. It has been – and continues to be – a battle to have CPTSD recognized as a problem distinct from classical PTSD, the PTSD that occurs following a single event such as a car accident, assault, natural disaster, or witnessing a traumatic event. Great strides have been made in developing and delivering therapies that attend to trauma symptoms such as fear, sense of threat, and re-experiencing through nightmares and flashbacks. However, that is not all there is to CPTSD. There is a second cluster of wounds that come alongside the PTSD symptoms, collectively referred to as “disturbances in self-organization” or DSO. These include a negative self-concept or view of the self, difficulty regulating emotions, and problems in relationships (surprise surprise).
PTSD treatments can often help CPTSD survivors, but not necessarily these DSO problems. If someone has developed a good-enough sense of self, and had good-enough relationships, and then experiences a single traumatic event, with good support and good therapy, they can heal that trauma and then make meaning around it, folding it into a broadened and deepened sense of self. It can sometimes even lead to benefits through post-traumatic growth, such as a renewed appreciation for life and greater affection for others. But what if you never had a “pre-self” to begin with? What if the only self you’ve ever known has been bound up in one core mission – survival? Think about if you were a child who grew up experiencing abuse or neglect, or lived in a warzone, or were subject to forced migration or colonization. That is “normal” for you. If you experience a discrete trauma, then it only confirms what you already know about the world – it’s a dangerous and unreliable place. It reinforces your already existing negative view of self and the world. Treating the trauma symptoms can bring some measure of relief, but it doesn’t do anything to challenge this core sense of self that has been built up over years, sometimes decades.
Dr. Lori Herod, who is a complex relational trauma (CRT) survivor and founder of Out of the Storm, an online educational website and forum for survivors, approached our team last year to collaborate on a project based on years of hearing what survivors in her community were saying. That they could not access adequate trauma-informed care, either because they cannot find properly trained providers and/or because they lack access to funding to work with someone competent. We conducted a research study to articulate this gap in healthcare – the gap between what survivors say they need, and what is actually being offered. As a result of our work together, we created a digital education resource meant for providers, trainees, and healthcare administrators, teaching them about the need for good trauma-informed care for people with CRT.
That said, while trauma-informed care is a good start, it is not enough.
Complex trauma treatment – or even the treatment of people who have had chronic PTSD – can take a very long time, often years, even when people do access good care. Years and decades of trauma cannot simply be palliated in a 10-session course of therapy. (It’s darkly comical for me to even write this, but this is what the typical insurance plan allows for these days.)
That said, there is some hope on the horizon. A fairly recent innovation in trauma therapy is the emergence of what I refer to as Intensive Trauma Therapies, or ITT. Instead of the usual model of coming once a week for hourly therapy that can take years, ITT is typically offered several hours a day (e.g., 9-4pm) over a course of several days in a row. This can be done with an individual therapist, or within a structured program that includes other activities. The ITT model has been adapted for many of our evidence-based therapies for trauma, including Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and the one I use, Eye Movement Desensitization and Reprocessing (EMDR).
The emerging data look quite promising. I gave an academic talk on this last year and had an opportunity to take a deep dive into the research. This meta-analysis had a very large sample of participants and found, broadly speaking, that while ITT versus standard therapy did not differ in outcomes, people with ITT obviously made their gains exponentially quicker. Several studies looked at acceptability (i.e., can patients hack it having to do several hours of trauma therapy a day, several days in a row). They found that patients had low levels of dropout from ITT, albeit describing the experience in terms such as “exhausting, but necessary” and “brutal, yet worth it”.
Yet there was a catch. Because this is a rapidly evolving field, we noticed that the studies largely focused on safety and efficacy, and most follow-ups only went until about 6 months after the therapy. So we don’t know how long people maintained their gains, Also, there was some evidence to suggest that improvements were more measured in complex trauma survivors – specifically, some had experienced relapses in depression at 6-month follow-up. This study, which followed patients for 12 months, also found that while there was good resolution of PTSD symptoms, recovery rates were lower for domains such as mood and anxiety, work- and social functioning, and interpersonal problems. Domains related to those DSO problems I mentioned above, or, in Dr. Marsha Linehan’s words, what goes into “building a life worth living”. Just like a tomato is more than an assemblage of nutrients, human beings are more than just an assemblage of symptoms to be managed.
The Burden of Normality
If you have lived with a problem for years, decades, it can be utterly disorienting to figure out what your life is when you’ve been “cured” overnight. I wondered if this was some of what we were seeing in the data coming out on ITT. I have already seen this on a much longer timescale with my regular weekly therapy clients, so I could imagine how disorienting it might be to have such a rapid resolution of trauma you have carried sometimes longer than you can remember.
This phenomenon of secondary suffering from rapid resolution of a problem has been documented in other groups. For example, Dr. Sarah Wilson wrote about “the burden of normality” when patients who have suffered with debilitating epilepsy undergo brain surgery to remove the seizure focus, and overnight are seizure-free but now unsure how to understand this rapidly changed sense of self. For complex trauma survivors, yes, you might have the trauma symptoms alleviated, but how do you begin the hard work of trying to figure out how to relate to other people when the overarching leitmotif is no longer just about survival? Survivors may find themselves in a new ‘hell’, even if the décor is nicer and people are friendlier. A parallel phenomenon is also observed in the field of psychedelic psychotherapy, where patients can experience episodes of “ego dissolution” or “ego death”.
Complex trauma can be debilitating, and many survivors are desperate for support. Sadly, in this era of mental health ‘influencers’, there are a lot of unscrupulous people out there willing to make a quick buck to take advantage of vulnerable people. It’s hard to open up social media and not find some “trauma influencer” or other just ready and waiting to sell their latest brightest and shiniest cure. Clinical psychology (my field) provides itself on being an evidence-based discipline, with our therapies being put through rigorous research studies and monitored not just for efficacy but also safety. Yet in a bid for scientific credibility and legitimacy, we have become increasingly medicalized over time. And with that, I fear that we may have lost a bit of our soul in the process. I have always rankled against a symptom-focused approach to therapy. For me, at least, this profession is, at its core, a human one. What animates me is being able to affirm the essential value and dignity of the human person in my work. Ever since being introduced to Dr. Viktor Frankl and his work in 1999, I have always taken an existential approach to psychotherapy, and it has served me well in the folks that I have worked with. People who have life-altering conditions that cannot simply be “fixed”. Which is actually OK. To quote another existentialist, Søren Kierkegaard, “life is not a problem to be solved, but a reality to be experienced.” Realizing that we all suffer can be a much-needed bridge to our sense of common humanity.
My research team and me are in the process of launching a study to find out, how do people adjust to the burden of normality on the other side of ITT? In order to plan for this study, I felt it necessary to do a deep dive into the literature – not of Psychology, but of Philosophy. Existentialism and Phenomenology, to be exact. For about 8 months I have been completely immersed in the worlds of French and German thinkers such as Husserl, Merleau-Ponty, Sartre, and Camus, to name just a few. (Incidentally, that’s why you haven’t seen me posting much on here for a while, but hopefully this will change soon.) Phenomenology ask the question, “what is it like…”. What is your lived experience of something? In other words, what is it like to live on the other side of ITT, your world turned upside down, even if for a good reason? What is it like to be a complex trauma survivor, where your every waking moment is no longer about survival, looking frantically into the mirror of the other person’s gaze for cues for safety or danger? Conversely, Existentialism asks the question, how does one make meaning of all of this? For we know, in Nietzsche’s words, that “(s)he who has a why to live for can bear with almost any how”. Viktor Frankl found during his time in the concentration camps that the factor that determined whether people survived psychically or not was their capacity to make meaning out of unimaginable adversity. It’s my hypothesis that Existentialism and Phenomenology can be a novel lens to really help us understand what - and why - life is like on the other side of ITT.
Getting Out of Hell
Returning to No Exit, the play showcases several of Sartre’s main ideas about how we make meaning in an inherently meaning-free universe. To recognize the freedom we have in making choices, even in the most extreme situations, while also taking responsibility for those choices. To recognize how we are trapped in the gaze of the other, and how we struggle to define ourselves within the context of the intimacy with others we often crave. And the need to be honest with ourselves about who we are, in order to avoid self-deception and “bad faith”.
Time will tell how these themes may speak to the lives of complex trauma survivors who may be adjusting to the burden of normality.
Before deciding to embark on this project, I happened to pay a visit to Paris last spring. Something deep in my intuition was telling me I needed to make this trip, I kept calling it my “pilgrimage to Paris”. I know it’s a cliché to be in love with Paris, but sorry (not-sorry), I am. I speak French (albeit clunkily) and love the chance to go and practice my French there. I made a point to stay in Saint-Germain-des-Prés in the 6th arrondissement, where I have stayed in the past. I wanted to visit the old cafes (like Les Deux Magots) and bookstores where the existentialists hung out, to walk in their footsteps, to ask for guidance for some problems I was facing in my life. Midway through my trip, I visited the Palace of Versailles. Although it was a very hot day, cloudbanks would roll in and out as well as intermittent showers. At one point, I was walking through the grounds when everyone started scurrying for shelter in the opposite direction. Undeterred, I kept walking deeper into the grounds, entranced by the gardens and simply to be in that iconic place.
As I walked, I listened to At the Existentialist Café, by Sarah Bakewell. It’s a delightful book that traces the stories of the French and German existentialists and phenomenologists, their personal relationships, how they developed their philosophies. If you’re new to this topic, I highly recommend it. When she got to talking about Sartre, I vividly remember stopping dead in my tracks, hearing a loud crunch of gravel under my feet. As she started to unfold his ideas, and talked about No Exit, a wave of nausea washed over me, and a feeling that I was going to have a panic attack. (Incidentally, the name of Sartre’s most famous work is Nausea – how à propos). I stopped listening to the book immediately and ran for the café to get a cold drink and try to compose myself.
The following month, I had a conversation with an ethnographer who was intimately familiar with existentialism. He couldn’t help but laugh at my anecdote.
“I’m sorry to laugh, but it makes sense to me. If you want everything neat and tidy and organized, you read the Germans. If you want to fuck with your head, you read the French.”
Read the play and report back to me. It’s a short one, so a cozy afternoon with tea and blankets might ease the angst.
Your posts are always so interesting- glad to see you back writing here!