CENTER FOR TORTURE VICTIMS, SARAJEVO
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.
Key words: countertransference, victims, aggression, ethnicity and projection
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 countertransference problem in the field of psychotrauma is herein introduced based on our and experiences of others (5,6,7,8) as follows:
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:
Discussion of the following three blind spots is
at the same time an invitation for their problematization.
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).
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:
4. Mature defenses
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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