The discussion of certain blind spots in psychotherapeutic approach to war victims is based on the experiences in psychotherapeutic treatment of civil victims of war genocide. It also represents a possible systematization of countertransference in psychotraumatology. Underlined as blind spots are: frozen aggression, presence of ethnicity issue(including culture) as affecting psychotherapy, as well as the importance of projection and blame issues in transference reactions for the countertransference and psychotherapy in general.
1. SUBTITLE: General notions with respect to experiences and methodology
Content of this article is related to experiences in psychotherapeutic approach to civil victims of war genocide that was manifested in three forms: ethnic cleansing, concentration camps and other forms of detention, as well as sieges of towns and other areas. War genocide psychotrauma is essentially characterized by experience of anthropological absurd and nonentity with excessive war psychotrauma and biological distress.
Depending on the form of
war genocide, it varies in dimensions, influencing the development of a type of
pathological outcome and frequency of non-pathological outcome (1).
Experiences given herein are the result of individual psychotherapy focused on psychotrauma, referred to as "insight psychotherapy" (2) or "confrontation dynamic psychotherapy" (3).
In existing classifications of psychodynamic psychotherapies, this one is depicted as a form of suppressive-expressive psychotherapy aimed at reintegrating psychotrauma. In adittion, we must not forget that arised psychological disturbances are basically reactive and those of a type of "compensation neurosis".
2. SUBTITLE: An anecdote with a joke
Content of this anecdote is naturally related to the subject of our interest, i.e. the issue of countertransference. During the assessment phase wherein the indications for psychotherapy were to be defined, a female psychotherapist came up with the following information. It was about the client that already had two sessions.
He was at the age of 40 and belonged to one of the target groups for
treatment in the CTV. He was tortured in his own house in an occupied part of
Sarajevo. In addition to being humiliated, he was also physically maltreated,
threatened with death and forced to work in a work squad in dangerous areas.
Although scoring high in a group of PTSD symptoms (emotional unstableness, nightmares, occasional intrusions), he showed tendencies towards good self-organization, interest in social activities, house repair, renewal of earlier good relationship with friends. It was therein a client going through parallel processes of psychopathological and non-psychopathological trauma sequel. His feelings about psychological treatment were ambivalent.
He first
came because, as he said, he heard that "this PTSD can be very
dangerous". In the end of the second session, while agreeing on the term
of the next session, he asked his psychotherapist: " Do you know a joke
about a patient treated in psychiatric clinic? This patient was convinced that
he was a grain of maize.
After a while, he spoke with his psychiatrist and told
him he was satisfied with his own condition and by that time sure that he
wasn’t a grain of maize. He wanted to go home and was therefore dismissed.
After a few months the patient came back to the clinic. He was anxious and
nervous. The psychiatrist asked him what happened and whether he again believed
that he was a grain of maize.
The patient answered: " No, I am sure I am
not a grain of maize, but I walked down the street and I saw a cock. And I am
not sure whether the cock knows that I am not a grain of maize". During
the consultations the joke was understood as a joke only. (It would be wrong to
elaborate other levels of anecdote and joke, related to externalization etc.
for the client could not have had any insight in that kind of psychodynamics.
On the other hand, the obvious message would then be lost). Viewed from the
level of meaning wherein the story was told, the message was: I am dealing
relatively well with my problems. It is more important for you to treat those
who did this to me and to others.
The client was obviously not under such a pressure of psychological suffering as to ask for a full psychiatric assistance. He also therein forgets the primary task of psychotherapist - helping people with problems. He never came for the third session.
Externalization of contents related to those causing the
psychological injuries, is at first less present if the consequences are more
severe: such clients usually have to put their own physical and psychological
problems in the foreground if they want to be in psychotherapy at all.
As it often happens, only one of blind spots in countertransference is related to these problems. I will discuss this topic more thoroughly in the third part of the article. In the second part, I would like to give a general picture of countertransference as viewed in the work of the CTV Sarajevo.
There is presently, according to Sendler et all. (4) a number of definitions of countertransference with various accents on details as following:
The transference of the analyst to his patient.
The "resistance" in the analyst due to his/her activated inner conflicts, interfering with his/her understanding and conduct of analysis, and producing blind spots therein.
The interference in the analyst - patient communication caused by the anxiety that the patient-analyst relationship arouses in the analyst (Cohen, 1952).
Personality characteristics of the analyst influencing work, which may or may not lead to difficulties in his therapeutic work (Balint, Kemper).
Specific limitations in the analyst in relationship with particular patients; also specific reactions of the analyst to his patient’s transference (Gitelsen).
The "appropriate" or "normal" emotional response of the analyst to his patient, which can be an important therapeutic tool and a basis for empathy and understanding (Heimann, Money-Kyrle).
The countertransference problem in the field of psychotrauma is herein introduced based on our and experiences of others (5,6,7,8) as follows:
1.
DESIRABLE COUNTERTRANSFERENCE, consists of:
1.
1.1. Capacity for the object’s relationship, primarily according to working through "depressive position" (Winicott) or appropriate direct countertransference disposition.
1.
1.2. Sufficient level of maturity and necessary education: therapist must be receivly, pliable and flexible.
1.
1.3. General attitude: "Client should be treated on a more general humanistic basis. This is in accordance with modern ethical thinking, i.e. the principle that individual is irreplaceable under all circumstances and that destruction of individual is catastrophic. The client must be met with an attitude of acceptance, tolerance, and basic understanding that all persons are of equal value and irreplaceable" (2).
2.
ECHO OF EMPATHY
Countertransference reactions may be of a more general
character. Everybody may have them. As a matter of fact, these reactions are
the "echo of empathy". Namely, therapists are never passive, devoid
of compassion and pity. However, their empathic strain in therapy may
contribute to mobilization of serious emotional disturbances giving rise to
inadequate countertransference reactions.
3.
INADEQUATE COUNTERTRANSFERENCE REACTIONS
3.
INADEQUATE COUNTERTRANSFERENCE REACTIONS
The appearance of inadequate countertransference reactions is the aftermath of the above mentioned intensive
empathy and intensive process of induction going on between therapist and
client, which raises the anxiety level beyond toleration, blurring boundaries
between reality and fantasy. These reactions are of a more personal nature,
depending on one’s own history and personal build-up.
Therapist’s problems
related to areas of aggression, death, torture, hate, trauma and victimization
are herein very important as well. But as Lion stressed "As with the study
of aggression, denial plays a marked role in the study of victims" (5).
Denial of "echo empathy", especially emotional pain/outrage, wish for
active coping and feelings of helplessness and hopelessness, may produce
inadequate countertransference reaction. There is a common view that it is
possible to distinguish two main types of inadequate countertransference in
treatment of traumatized victims:
3.1. overidentification
3.2. avoidance
3.1. overidentification
3.2. avoidance
As Lansen (9) stressed, and according to the above notions, it is possible to draw a parallel between "intrusive symptoms" and "numbing symptoms" in victim. These two types of inadequate countertransference reactions have subtypes as follows:
3.1.
OVERIDENTIFICATION
3.1.
1. Overidentification with victim because of his/her suffering may cause sadness and mourning, guilt, shame and helplessness with therapist, with consequent burnout/break down, in form of a secondary traumatisation or secondary posttraumatic stress disorder.
3.1.
2. Overidentification with victim because of his/her political, ideological or religious ideas (the pitfall of solidarity)
3.1.
3. Overidentification with victimizer (the appearance of rage towards victim as reactive formation instead of an attitude of acceptance and pity).
3.1.
4. Ethnoidentification countertransference. The core of this countertransference is non-declared ethnocentric alliance with underlying identity and self-esteem conflicts, leading to various unfavorable consequences.
3.2.
AVOIDANCE
3.2.
1. Avoidance of the practical work (empathy and treatment/helping) with predominant or exclusive medicalization, predominant occupation with statistical analysis of syndrome; with highly theoretical discourse.
3.2.
2. Avoidance induced by client. There are two types:
a) According to Bustos (6) "The conspiracy of silence" (Danieli, 1980; Kristal, 1971.), a phenomenon studied in depth in relation to the Holocaust survivors, is a clear example where both therapist and patient, symbiotically attached, avoid, either altogether or in sufficient detail, the discussion of material related to trauma because of its incomprehensible, unbelievable or unbearable nature.
Willingen (10) however, uses the term "conspiracy of silence" in another meaning, i.e.
"The tendency to deny the existence of the problem
of organized violence and to avoid confronting its consequences sometimes
called the "conspiracy of silence" - is probably due to a reluctance
to face a gruesome reality which is liable to provoke feelings of complicity
and guilt".
b) "Forced silence" Lister (5)
b) "Forced silence" Lister (5)
Lister underlined: "Patients rarely complain about their reactions to human-induced violence. They present to clinicians with a variety of other psychological symptoms… but even the thorough clinician rarely asks about a history of personal violence, trauma or victimization".
Lister discussed
the forced silence as neglected dimension of trauma, describing it as a
"second trauma of enormous importance".
Specific deference of this
phenomenon towards "conspiracy of silence" represents the accent on
experiences of the victimizer, in circumstances of children abuse in the
family. Child, usually, ambivalent towards the victimizer (brother, father
etc.) avoids to talk about him/her.
3.2.
3.2.
3. Culturally determined countertransference(Ethno-rejected countertransference)It appears when therapist does not look for adequate psychotherapy i.e. psychosocial procedure due to ethnical and/or cultural characteristics of client.
3.2.
4. The colonial countertransference In the background of this countertransference reaction of therapist, there are omnipotence and colonial paternalism. In adition to the described types of countertransference reactions, there are also phenomena of sadistic gratification, seeing of victim as a hero, as a privileged voyeurism.
III ABOUT THREE BLIND SPOTS
Discussion of the following three blind spots is at the same time an invitation for their problematization.I herein intend to discuss:
1) Recognizing of frozen aggression with psychotraumatised clients/patients
2) Interference of the ethnicity issue, including culture, in the field of psychotherapy
3) Understanding of projection and blame in transference and their impact on countertransference.
1) Frozen aggression
In the two above mentioned examples, we saw how the psychotraumatised persons relate to others. Client from the anecdote expressed his relationship through humor. His psychological state was already described.
The second example is
related to the "forced silence" where the abused child, because of
ambivalent relationship with the victimizer (member of the family), avoids to
talk about him/her.
Similar thing happens still in another situation, i.e. to patients suffering from consequences of a severe psychotrauma, with identified "learned helplessness/hopelessness syndrome" consisting of an associative, motivational and emotional deficit.
The period wherein the therapeutic alliance
is established is usually long and often discontinuing. The client gradually
and through actual life circumstances goes through the process of the trauma
reintegration.
Up to the personality affair of definite victimizer is
approaching with exploration provoking an answer on physical injury and
psychotrauma. In the very beginning of traumatisation it appeared spontaneously
for returning of blow, movement was braked. With some, rage was raising. Some
remained daydreaming about revenge or they had such dreams.
After a while, as
the torture continued, the wish for dying would appear, followed by thinking
about suicide and finally emptiness and resignation. In dynamic approach, the
aggressive answer is turned to the victim and then frozen. Underlying it is
severe damage of personality by the victimizer but also by further
psychological self-hurts. The patient hardly ever talks about the past. The
protection of victimizer is only apparent.
2) Interference of the ethnicity issue, including culture, in the field of psychotherapy
This area, connected with counseling/psychotherapy and psychosocial support and help, was not given due attention worldwide until 10-20 years ago. In our country, it became important subsequent to the ethnic disintegration in the area of former Yugoslavia, and the horrible dimensions of war genocide that therein took place.
This area includes influence of ethnic (and racial)
characteristics on the possibility of use and/or accepting of psychotherapeutic
procedures. For the needs of this article, the definition of ethnicity by Rosen
(1964) is quite sufficient: "Ethnicity is group classification of individuals
who share a unique social and cultural heritage (language, religion, customs)
that is passed on from generation to generation". In a limited sense,
according to Linton, it is possible to define culture "as the
configuration of learnt behavior whose components and elements are shared and
transmitted by the member of particular society" (11).
Namely, numerous
variables can have significant impact on applicability and acceptability of
psychotherapies, as following, mainly according to Casas (11).
Some of the general factors limiting the applicability of psychotherapeutic theories to an ethnic/racial group are:
1. Common belief that most problems are solely intrapsychic.
2. The professionals focusing on ethic perspective, therein believing that all which is inherent to counseling/psychotherapy, has a universal value.
3. The continued existence of racist-disposed personnel and institutional xenophobia
Individual life experience
Educational factors
4.
Ethnicity: culturally rooted cognitive and psychological attributes and characteristics, such as:
1. Ethnicity: culturally rooted cognitive and psychological attributes and characteristics, such as: With respect to cultural styles, cultures, communities and families could be viewed on a continuum between traditionalism and modernism.
The traditional end of the continuum is typical of rural
communities, conservative religions and Third World cultures.
People with
traditional values have strong religious orientation in life. Putting the
emphasis on religious explanations of the mysteries of life, they are strongly
identified with their families and communities of origin. They usually believe
in separation of gender and age role, taking a strict, autocratic approach to
child rearing.
The modern end of continuum is more typical of urban communities, liberal religions and Western European cultures.
People with modern value systems usually concentrate on science when explaining the mysteries of life. They have individualistic orientation, give little importance to differences in gender and age roles, and emphasize egalitarianism in child rearing.
2. Psychosocial variables that have been found to differ cross-culturally include: self-disclosure, assertiveness, shyness, cooperativity, individualism, interpersonal style, introversion, cognitive style, achievement motivation (personal/family), learning and problem solving style (modeling/trail and error; cooperative or competitive learning).
3. Based on their significance, it is useful to consider cultural influences on the cognitive structure of illness separately. Herein included are: perception of physical and emotional states, their interpretation, help seeking.
For instance: Some (Hispanics) rely primarily on the family and may seek professional assistance only as a final resort. For others (African-Americans), the church is frequently the only extrafamiliar institution that many of them trust and feel safe with when they need help.
Chinese in psychosocial distress
often report experiencing physical symptoms and seek medical rather than mental
health services. African-Americans often blame themselves for their problems,
whereas Puerto Ricans often blame others.
5.
Social factors (as unfavorable, for example: prejudice, discriminations, racism)
6.
Economic factors (unemployment, poverty)
7.
Political factors (oppression, hegemony, segregation, genocide)
8.
Historical factors (slavery, persecution of ethnical or national groups) .
It was in our circumstances, also important to start the discussion of the place of ethnicity/culture as related to psychotherapy. With this respect, sophisticated prospective researches are also possible.
As we are here in the
area of countertransference, we have to emphasize that psychoterapist,
recognizing the presence of issues related to ethnicity, is not pinched between
myths about ethnic groups and denial of certain specifications in connection
with ethnicity. We can rather understand this as a contribution to problems of
countertransference.
3. On projection and blame
Buckley and al. (12) investigated the use of psychodynamic and process variables as predictors of outcome in psychoanalytically oriented psychotherapy (in the article "Psychodynamic Variables as Predictors of Psychotherapy Outcome").
They identified 10 statistically significant predictors from a
total of 91 variables grouped in a five rating scale (based on ego strength,
ego defenses, object relation, coping styles, and nature of interpsychic
conflict). Among the mentioned 10 variables, there are the following ego defenses:
reaction formation, undoing, rationalization, projection and its comparable
coping style of blame and isolation.
They concluded: "The greater the
tendency to use any of these defenses, the greater the degree of improvement on
the termination rating." The authors were not surprised by the view on the
significance of three ego defenses: reaction formation, undoing and
rationalization, for they belong to high level defenses based on definition of
Valliant in his book "Adaptation to the Life".
However, the presence
of the ego defense of projection and its comparable coping style of blame as
predictor of good outcome was surprising, since projection is regarded as a
low-level defense more typical for serious psychopathology. According to the
authors, it is conceivable that projection may reflect a capacity, albeit
distorted, for emotional account if it does not predominate.
(It is also interesting that the projection was presented greatly and by health control group members but in larger spectrum of ego defenses.)
However, these mentioned details are not unexpected. Namely, Meissner and al. in the article "Theories of Personality and Psychopathology, Freudina School", offered an eclectic classification of defenses, which is not predominantly related to basic developmental processes.
At the same time, the
defenses are not exclusively related to particular forms of psychopathology
wherewith they are commonly associated.
The above mentioned classification of defense mechanisms includes description "of some of the basic mechanisms that are most frequently employed and have been most thoroughly investigated by psychoanalysts". They have four levels:
1.
Narcissistic defenses, such as:
1.1. Distortion, grossly reshaping reality
1.2. Projection (frank delusions about external reality…)
1.3. Denial
2.
Immature defenses
2.1. Acting out
2.2. Blocking
2.3. Hypochondriasis
2.4. Introjection
2.5. Passive-aggressive behavior
2.6. Projection (attributing one’s own unacknowledged feelings to others; severe prejudice, suspiciousness,…)
2.7. Regression
2.8. Schizoid fantasy
2.9. Somatization
3.
Neurotic defenses
3.1. Controlling
3.2. Displacement
3.3. Dissociation
3.4. Externalization (it is more general term than projection which is defined by its derivation form and correlation with specific introject. It is a tendency to perceive in external world and in external object components of one’s own personality, including instinctual impulses, conflicts, needs, attitudes and styles of thinking.)
3.1. Inhibition
3.9. Repression
3.2. Isolation
3.10. Intellectualization
3.3. Rationalization
3.11. Sexualization
3.4. Reaction formation
3.12. Somatization
4. Mature defenses
4.1 Altruism
4.4 Humor
4.2 Anticipation
4.5 Sublimation
4.3 Asceticism
4.6 Suppression
It is in theoretical consideration especially underlined that projection and denial may function in the services of neurotic or even adaptive objectives. At the same time, basic developmental processes, such as introjection and projection, may assume defensive functions under certain specific conditions.
Otherwise, projection operates correlatively to introjection, so the projected material of the projection is derived from the internalized configuration of the introjects.
Within the theory of objective relationships, and considering dynamics of "borderline personality", Kernberg (14) has evaluated projective identification with defense mechanisms (for example: splitting, primitive idealization, denial, omnipotence and devaluation) which is central in manifestation of the transference.
He underlined that there is a strong projective trend with
"borderline personality". It is, however, not only the quantitative
predominance but the qualitative aspects as well. The main purpose of
projection is herein the projection to the all-bad, aggressive self and object
images.
Of course, this projection of aggression is rather unsuccessful due to
patient’s ego weakness and go on weakness ego boundaries. The danger is greater
because projection and introjection reinforce each other. And finally,
established projective identification results in the lack of differentiation
between self and object.
Presented review remind us on a very large diapason of projection meaning (from narcissistic to adaptive level) as well as on adaptation potential of projective - introjective cycle.
If we go back to the issue of war victims, with respect to the above mentioned, whether the conflict is only outside, or outside/inside conflict, it does not matter if the interpsychic conflict was manifested or often latent. Already mentioned entity, "borderline personality", is at any rate in very close connection with interpsychic conflict. Projection of any level of direct or derivative causes appearance of aggression, anger, hates etc.
As regards war victims, there is point which would be expected. Thus, Ochberg and Fojtik say: "Hatred is logical sequel to extreme abuse at the hands of another human being. Hatred is uniquely human emotion, evoked by betrayal of trust and by cruelty.
Dealing with repressed anger and hate is a familiar
ground for psychotherapists" (15). Already present projection and blame by
war victim, in the frame of countertransference attitude should be estimated:
as a part of the patient’s condition as a whole (outside situation and outside
conflict); as a reflection of capacity for emotional engagement; and finally in
diapason of his/her quality (from narcissistic to adaptive level).
In the use of "insight therapy" focusing on trauma reintegration, practically is the last expressed through contraindications which include personality disorders, weak ego boundaries and projection (strong projection with suspicious or paranoid ideas). They are included into the basic psychiatric treatment.
With patients survivors of severe psychotrauma, with "learned helplessness and hopelessness" and "frozen aggression", much patience and time is needed for them to express their projections and blame.
Preventing of
development of pathological projection-introjection cycle with a patients
already having projection and blame but without this cycle, is a great
therapeutic contribution.
Projection and blame are usually gradually decreasing
as a result of the following procedures: gradual expansion of the conflict free
ego sphere together with expansion of the observing ego in conditions of
acceptable working alliance.
Psychotherapist is always somewhere between "total dedication" (expressed through overidentification) and "micro-paranoid attitudes toward the patient" (expressed through certain forms of avoidance). Contributing to this are terrible experiences and suffering of patient/client or war genocide victim, the extent and depth of his/her mental disorder which concludes more than resignation with "broken will" and existential despair.
Experience of anthropological absurd and nothingness has far-reaching
effects leading to devaluation of one’s own life and life of others. Usual
existential despair is expressed related to recognition of injustice and
inhumanity of the world that permits such human cruelty. However, patient’s
recognition of opportunity and beauty and support of others during the
treatment, contribute to strengthening of ego functions and recovery.
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