The Biblical Book of Job: advice to clinicians.

Study of the Book of Job clarifies the particular adaptation to trauma that underlies the suffering of certain difficult patients. In addition, the misdirected efforts of Job's comforters in the Bible story help us understand why, with such patients, an analyst's attempts to address unconscious guilt and defenses against it will prove counterproductive. A case example is presented.     

Success and succession

The etymology of the word success and its relationship to succession is elucidated. Linkage is made to the consequences of unconscious "legitimate" and "illicit" fulfillments in life. This is explored in the writings of Freud and others. Emphasis is placed on guilt, a major factor blocking the attainment of success. This guilt derives from unconscious parricide, which permeates and contaminates themes of succession. How early objects, particularly oedipal ones, are "killed off" in the process of gaining autonomy and achievement without literally invoking unconscious murder is explored. The retaliatory aspects of failure are also addressed. Illustrations employing case material are used to highlight these theoretical constructs.     

Remembering Herb

Abstract

This paper discusses treatment of an incest survivor who suffered a crippling sense of guilt. The work of discovering and understanding the unconscious fantasies that accompanied the patient's early traumatic experiences led to the alleviation of her misplaced guilt and to more adaptive compromise formations. It is necessary to understand and address the unconscious fantasies attached to the incest, as intellectual awareness of inappropriate guilt does not suffice to diminish it.     

Helping patients by analyzing self-criticism

This paper is addressed to patients' need for help with punitive self-critical attitudes. Such help has not always been sufficiently provided by psychoanalysts, owing to an unrecognized failure of neutrality. Historically, a gradual overemphasis on the concept of an unconscious sense of guilt has acted as a barrier to the appreciation of shame. An alternative concept, punitive unconscious self-criticism, which stands in contrast to constructive self-criticism and is common to the painful affects of guilt, shame, humiliation, and depression, can facilitate helpful analytic treatment. Heinz Kohut's contributions are examined. His analytic stance is differentiated from his theories of development. In the former, characterized by an affirmative attitude, he takes a position of functional neutrality toward shame and pays consistent though unstated attention to the effects of punitive unconscious self-criticism. The affirmative attitude can be employed without adoption of Kohut's self psychology, i.e., without abandoning the basic psychoanalytic approach to mental conflict and development. The concept of punitive unconscious self-criticism and the concept of divergent conflict, provide sufficient explanatory power. Clinical examples are used to illustrate these ideas.     

Anna Freud and the Holocaust: Mourning and survival guilt

This article explores the period of Anna Freud's life after she was informed of the deaths of her aunts in Nazi concentration camps during World War II. Understanding of this period may be enhanced by consideration of the role of the Holocaust in her complicated mourning process. A series of her dreams is re‐examined from the point of view of survivor guilt and the complicated mourning of her father in the context of the Holocaust. It is argued that unconscious reproaches against her father led to an identification with him that included his ‘decision’ to leave his sisters in Vienna. Survivor guilt in relation to her aunts’ murders is seen as one of the complicating factors in the mourning process. In addition the article discusses the possible role of this period, particularly her work with child concentration camp survivors, in her post‐war writing. The noted duality in her work between innovation and conservatism is explored in terms of an outcome of the mourning process of this period. It is argued that her views on mourning, trauma, attachment, and the widening scope of indications for psychoanalysis were influenced by the outcome of her mourning process. Finally, an irony is noted in the fact that her attitude about altruism never changed despite the role of the altruism of others in her rescue from the Nazis.     

Trauma Informed Guilt Reduction Therapy With Combat Veterans

Guilt related to combat trauma is highly prevalent among veterans returning from Iraq and Afghanistan. Trauma-related guilt has been associated with increased risk for posttraumatic psychopathology and poorer response to treatment. Trauma Informed Guilt Reduction (TrIGR) therapy is a 4-module cognitive-behavioral psychotherapy designed to reduce guilt related to combat trauma. The goals of this study were to describe the key elements of TrIGR and report results of a pilot study with 10 recently deployed combat veterans.Ten combat veterans referred from a VA Posttraumatic Stress Disorder (PTSD) or mental health clinic completed TrIGR over 4 to 7 sessions. Nine veterans completed the posttreatment assessment.This initial pilot suggests that TrIGR may help to reduce trauma-related guilt severity and associated distress. Changes in trauma-related guilt were highly correlated with reductions in PTSD and depression symptoms over the course of treatment, suggesting a possible mechanistic link with severity of posttraumatic psychopathology.TrIGR warrants further evaluation as an intervention for reducing guilt related to traumatic experiences in combat.     

Trauma‐Related Guilt Mediates the Relationship between Posttraumatic Stress Disorder and Suicidal Ideation in OEF/OIF/OND Veterans

Posttraumatic stress disorder (PTSD) and trauma‐related guilt are risk factors for suicidal ideation (SI) in veterans. Components of trauma‐related guilt were examined as serial mediators of the relationship between PTSD and SI. In a sample of 53 OEF/OIF/OND combat veterans, PTSD had an indirect effect on SI through a serial mediation chain of guilt cognitions, distress, and global guilt, suggesting that trauma‐related guilt via cognitions, distress, and global guilt is a pathway from PTSD to SI. Attention should be given to assessing and addressing trauma‐related guilt in veterans experiencing PTSD to prevent SI.     

Individual and institutional defences against primitive anxieties: Counselling in prison

Abstract

This paper describes a counsellor's attempts to understand the unconscious dynamics affecting the process of counselling women in prison. The social system of the prison serves to defend both prisoners and officers against powerful anxieties about the potential for sadistic attack originating from primitive states of mind, that is persecution, helplessness and destructiveness. The implications of the rigid means of defence are considered, and die role of unconscious guilt motivating the need for external punishment is briefly explored. Emphasis is placed on the role of splitting and projection in the management of potentially overwhelming feelings of guilt, and fear of punishment. The author develops the premise that there is in effect an institutional requirement that prisoners remain in the paranoid-schizoid position because of the feared consequences were they to experience depressive anxieties.     

Trauma and the Unconscious: Double Conscience,The Uncanny and Cruelty

Relatively little has been written on the role of trauma in conceptions of the unconscious. This paper explores Freud’s conceptions of the unconscious, comparing his ideas with the original French notion of “double conscience” and exploring their implications for technique. Whereas Freud’s concept of the unconscious mainly depends upon a theory of internal drives, Ferenczi’s ascribed a central role to trauma, shifting the focus to the individual in the context of relationships. The comparison is illustrated with a case history.     

Trauma Following Termination of Pregnancy for Fetal Abnormality: Is This the Path From Guilt to Grief?

Termination of pregnancy for fetal abnormality (TOPFA) is a potentially traumatic event that may lead to intense grief symptomatology. The present study included 41 couples who were assessed 1–6 months after TOPFA. No gender differences were found regarding the intensity of trauma symptomatology or the prevalence of clinically relevant trauma symptomatology, present in about a third of the sample. Most couples were congruent regarding trauma symptomatology. Women experienced guilt with significantly more frequency than men. For both genders, guilt influenced both trauma and grief symptomatology. For women only, guilt influenced grief symptomatology indirectly, through trauma symptomatology. Clinical implications are discussed.     

Opening the closed heart: affect-focused clinical work with the victims of early trauma

This paper begins with the understanding that early trauma leads to powerful dissociative defenses which injure the capacity to feel. It further explores ways to restore this capacity through body-centred attention to affect-in-the-moment in the psychoanalytic situation. Using the author’s personal experience while in analysis as well as a case of severe early trauma, he demonstrates the consciousness-killing effect of primitive defenses and shows how body-sensitive techniques hold the promise of restoring the patient’s sense of aliveness and hence, opening the unconscious to those affect-images that are the building blocks of the human imagination. A final section focuses on the neglect of feeling in Jungian psychology and suggests that the “creation of consciousness” which Jung described as his personal myth, is quintessentially a process of emotional transformation – of bringing unconscious suffering into consciousness – as feelings.     

Religious roots of antisemitism

In agreement with Freud, the author characterizes the unconscious structure of ecclesiastic and of contemporary racist anti-Semitism as paranoid projections of unconscious guilt feelings and of profound narcissistic injury. Chasseguet-Smirgel's thesis concerning the perverse character of anti-Semitism and Ostow's attempt to relate anti-Semitism to apocalyptic ideas are discussed as well.     

Anatomy of Regret: A Developmental View of the Depressive Position and a Critical Turn Toward Love and Creativity in the Transforming Schizoid Personality

This article deals with critical psychic transformation in a schizoid personality disorder that evolves in an object relations psychoanalysis in which "developmental mourning" plays a central role. Within a mourning process that allows for the grieving of loss related to arrested separation-individuation development, the analysand confronts the existential grief of regret that had always unconsciously haunted her. The unconscious guilt related to the existential grief of regret had caused much dissociation of self-experience and affect states. The analysand acknowledges her own part in the destruction of primal and current relationships after the traumatic impact of her early life is understood. This allows her to repair current relationships, both within her internal and external worlds so that she can open to capacities for love and creativity. The analysand's courage to consciously grapple with her regret (loss and guilt combined) allows her to relinquish self-sabotaging character defenses such as contempt and emotional withdrawl. Consequently, a second marriage is salvaged and enriched, and the analysand's relationship with her two children is dramatically improved.     

An interruption in unconscious communication in the analytic couple

The authors describe an interruption in communication in the analyses of two patients, which gradually brings the analytic process to a halt/standstill. They propose several hypotheses for understanding this situation. One explanation is mutual identification of primitive superegos in the analytic couple which generates a moralizing effect thereby hindering investigation and discovery. They emphasize the importance of countertransference involvement which partly provokes this particular type of impasse. They also suggest the idea of shared acting out, with complementary participations of analyst and patient. In this way the analytic couple supports a 'bastion' which protects against the risk of breaking the omnipotence of patient and analyst or contributes to this omnipotence. Their shared unconscious phantasy feeds collusion linked to unconscious persecutory guilt. The authors also describe movements to break free from this impasse. The enclave created by the analytic couple is detected and subsequently worked through by way of the patient's contribution of dream material and the analyst's work with her countertransference.     

„Alles,was ich liebe,muss ich zerstören“

This clinical article describes the treatment of a patient with a severe neurosis. The elucidation of the transgenerational transmission of unconscious shame and guilt played a decisive role in the processing of the negative therapeutic reaction. The treatment process showed how the psychopathology of the patient is embedded in the context of the specific German past. The internal wall of silence which can be overcome by finding and narrating one’s personal history plays a special role at the personal as well as the cultural level. Because both patient and treating physician emanated from similar cultural backgrounds, this meant wrestling with the heritage of our common Nazi past which continuously needs (needed) “messengers” from outside. In a long psychotherapeutic process unresolved conflicts on shame and guilt against the background of the Nazi past of the parent and grandparent generations could be transgenerationally uncovered. The detailed processing of these associations allowed the patient to find access to his very own experiences and existence.     

The Psychological and Spiritual Efficacy of Confession

Several aspects of confession are discussed. A distinction is made between personal narrative and confession in the analytic setting, focusing on the emergence of the psychogenic secret: that secret which is hidden from the analysand's ego consciousness. Such an unconscious secret can lead to emotional and psychological guilt and distress. The transference is seen as an essential dynamic for psychologically efficacious confession.     

Profiles of Peritraumatic Emotions

Researchers have identified peritraumatic emotions as important predictors of who will develop posttraumatic stress disorder (PTSD) symptoms. However, such investigations have not examined full profiles of emotions, perhaps because of the typical emphasis on fear or other Criterion A2 emotions. Such an examination could help us identify which peritraumatic emotions are prominent, and how they relate to important posttrauma outcomes. Thus, the aim of this study was to identify distinct profiles of peritraumatic emotions and their correlates using a comprehensive survey of peri- and posttraumatic reactions. We conducted a latent profile analysis of peritraumatic emotions in 398 undergraduate students who reported a DSM–IV A1 trauma and then compared the resulting profiles on trauma type, PTSD, depression, and posttraumatic cognitions. Six distinct profiles emerged: 3 had consistently low, medium, or high levels across the range of emotions, with 3 others primarily characterized by low shame and guilt, high anger and guilt, and low guilt. These profiles significantly differed in terms of trauma type, PTSD, depression, and posttraumatic cognitions. In particular, profiles with high levels of anger, shame, and guilt were consistently related to overall worse functioning. Importantly, fear and associated emotions did not differentiate between profiles. These results have important implications for the phenomenology of posttrauma emotional reactions and strongly suggest that the clinical assessment of traumatic experiences go beyond fear-based conceptualizations.     

Weiblicher Trotz

Female defiance is described in association with girls’ development during the anal phase in which aggression and eroticism are closely connected to the physical inner world. For women, for mothers and daughters, destructive phantasies and aggressive emotions can be such tabus that they remain unconscious as well as the associated guilt. Defiance is therefore sustained as a more or less socially accepted compromise in these moral conflicts and acts as a means of separation from inner and outer authorities.     

Long-Term Guilt and Hostility Underlying Posttraumatic Stress Symptoms in War Combatants and Ex-Prisoners of War

The link between posttraumatic guilt and posttraumatic stress disorder has gained recognition over the past decades and was recently expressed in the modifications made to the diagnostic criteria for the disorder under the DSM-V. Yet, the psychological dynamics underlying this relation are still not fully understood. The present study introduces a model whereby different dynamics between guilt and hostility are related to posttraumatic stress disorder symptoms (PTSS), following different traumatic war experiences. One hundred and forty-four former prisoners of war (ex-POWs) and 143 comparable combatants participated in the study, 30 years after the war, reporting on their PTSS, guilt, and hostility. Moderation analyses revealed a three-way interaction, where high hostility buffered the effect of guilt on PTSS only among ex-POWs. This finding suggests a distinctive dynamic among guilt, hostility, and PTSS following diverse traumatic events. Specifically, it appears that hostility can have a mitigating effect on the negative outcomes of guilt for ex-POWs following trauma, but not for non-POW veterans. The theoretical reasoning and the clinical implications of these findings are discussed.     

History of a Childhood Neurosis and Its Relation to the Adult Superego

The purpose of this paper is to find meaning for the “presence of conscience” observable in the psychoanalytic setting and corresponding evidence for the origins of such ways of thinking, feeling, and remembering. I apply this perspective to the case study of a man who presented as constricted, inhibited, anxious, and self-critical. He was outwardly successful but internally tormented with what can best be described as an obsessional neurosis. His initial symptomatic neurosis was supplanted by a transference neurosis reflecting a childhood obsessional neurosis. In my theory of mind during this analysis, I often saw the original ideas of Freud at work—unconscious sense of guilt, ego ideal, and conscience. The analysand represented over and over the dynamics of the Oedipus stage of development. I made additional observations about character formation and guilt. The analysand terminated his work with me symptom-free. From this case study, I learned that the presence of conscience (guilt and self-denigration), or of superego structure and function in classical terms, is best approached as to origin by following the development of self in reference to the other.