"Enactment" in the lives and treatment of Holocaust survivors' offspring

This paper explores an aspect of "enactment" often seen in Holocaust survivors' offspring: the compulsion to re-create their parents' experiences in their own lives through concrete acts. At the core of this compulsion is a psychic hole, a gap in the child's emotional understanding, stemming from identification with the parents on one hand, and the parents' denial or repression of the trauma on the other. The compulsion to enact can be transformed into a cognitive mode when such offspring are helped to find the meaning of the trauma in their parents' lives, as is illustrated here by clinical examples.     

Recognizing the infant as subject in infant-parent psychotherapy

Drawing on Winnicott's view of infants as subjects entitled to an intervention in their own right, infants as the referred patient have been seen in infant-parent psychotherapy for 20 years at the Royal Children's Hospital, Melbourne, Australia. This is a radically different view of infant symptomatology than viewing it as only expressing an aspect of the mother's unconscious. The clinical pathway differentiates the therapy from much parent-infant psychotherapy. The author describes the theoretical model of a twofold approach to understanding the infant's experience through interactive dialogue between therapist and infant, and sharing this understanding with the parents, and illustrates it with cases of failure-to-thrive infants. She discusses two criticisms: first, that infant-parent psychotherapy may undermine the parents and, second, that brief parent-infant psychotherapy does not alter parents' insecure attachment status. Videotaped sessions often show rapid improvement; parents generally feel relieved. This approach potentially shapes not only parents' and infants' representations, but also their implicit knowledge of relationships-partly, it is suggested, through activating the mirror neuron system to bring about implicit memory change. Change may therefore be longer lasting than psychoanalytic theory presently conceives. The approach is relevant in an outpatient setting: gains were maintained long term in 90% of out-patient cases.     

Testimonies in the Treatment of Genocidal Trauma

This article describes an approach to the treatment of genocide survivors that addresses both the personal and communal/historical dimensions of their experiences. I begin by outlining the characteristics of massive psychic trauma as background for using video testimonies in the treatment of Holocaust survivors. I then discuss videotaped interviews with perpetrators as an illustrative contrast to survivors' testimonies. The third section explains my position as a psychoanalyst encountering historical trauma and its relationship to my own experiences as a survivor. Following a brief history of videotaping as a medium for recording testimonies, I conclude by demonstrating the ways in which active listening can lead to the revelation of new dimensions of historical as well as personal truth.     

The Self in Pain: The Paradox of Memory. The Paradox of Testimony

Using the 7-year psychotherapy of a Holocaust survivor, this paper explores the sometimes contradictory aspects of approaches to trauma. Conceptualizing a “self in pain” as an alternative to contemporary conceptualizations of the traumatized person as having a damaged, dissociated or collapsed self leads to a corresponding alternative clinical approach. The paradoxes of traumatic memory and testimony necessitate an adaptational emphasis and the emergence of a “doubled” in contrast to a dissociated self. The decision to respect this “doubled” self involves a privileging of “reality” over “psychic reality” which then, paradoxically enables this patient to develop a phantasy life.     

Meditative Dialogue: Cultivating Compassion and Empathy with Survivors of Complex Childhood Trauma

Complex childhood trauma often affects the capacities of survivors to experience empathy and compassion toward themselves and others. Recent mindfulness literature recognizes meditation as an evidence-based practice that is able to change the brain, increasing one's capacities for empathy and compassion. This article offers an exploration of selected literature on complex childhood trauma and on mindfulness practices related to the development of compassion and empathy. A case study illustrates the use of a meditative dialogue practice in psychotherapy with a survivor of complex childhood trauma that serves to increase her ability to have empathy and compassion for herself and others.     

Configurational approach to manifest dream analysis: Possible acceleration of the patient's communication in psychoanalytic psychotherapy

This paper presents an approach to dream analysis utilizing the manifest content of a number of consecutive dreams from the same patient. Following a review of the literature, it is noted that in once-a-week psychotherapy there is often very little time for exhaustive dream analysis to unravel the buried meanings within the latent dream content. Twenty categories have been established for the configurational analysis, which is applied to the analysis of the first eleven dreams of a patient in psychoanalytic psychotherapy. The authors independently analyzed the patient's dreams using each of the 20 categories with high reliability, then combined their contributions. This data was then compared with the treating analyst's independent clinical observations about the twenty categories.     

Trauma‐Informed Programs Based in Schools: Linking Concepts to Practices and Assessing the Evidence

When children experience stress and adversity in their homes and communities, schools become a critically important setting in which to intervene and foster their resilience. Changing practices within schools so that vulnerable and traumatized children are better understood and more compassionately served is a goal shared by many school professionals, yet schools remain poorly equipped to address the needs of these children. Any number of school‐based programs have the potential to benefit children with an elevated risk for academic difficulties and mental health disorders, although questions remain as to which programs are most promising, effective, and sustainable. Questions also remain about which programs best serve diverse populations and which have potential to reach the largest number of children, including those who do not outwardly manifest behaviors consistent with an underlying disorder but nonetheless require support. In this review, we take stock of existing programs used in schools to address the social, emotional, and academic needs of children with trauma histories. We summarize components of a various trauma‐focused programs, categorized as: (a) individual and group‐based approaches, (b) classroom‐based approaches, and (c) school‐wide approaches. For each category, we review and comment on the state and quality of research findings and provide illustrative examples from the literature to show how programs address trauma in the school context. Findings of the review suggest that empirical evidence currently favors individual and group‐based approaches, although classroom‐based and school‐wide programs may be better positioned for integration, access to services, and sustainability. Implications and recommendations center on future research, practice, and policy.     

The Impact of Neighborhood Factors on the Well-Being of Survivors of Intimate Partner Violence Over Time

Intimate partner violence (IPV) is a pervasive social problem impacting the psychological well-being of millions of US women annually. The extant literature draws our attention to the devastating mental health effects of IPV, but largely overlooks how ecological factors may further explain survivors' well-being. This study examined how neighborhood disadvantage may contribute to survivors' compromised well-being, in addition to the abuse women experienced. Neighborhood disorder and fear of victimization significantly impacted survivors' well-being, over and above abuse. Although between-women effects of neighborhood disorder and fear were unrelated to change in women's depression or quality of life (QOL), significant within-woman effects were detected. Change in neighborhood disorder was negatively associated with change in QOL, and this relationship was fully mediated by fear. While no direct relationship between change in neighborhood disorder and depression was detected, an indirect effect through survivors' fear was revealed. Implications for future research and practice are discussed.     

A Case Illustration of Combined Treatment Using a Psychodynamic Group for Women Sexual Abuse Survivors to Address and Modify Self-Punitive Superego Trends

Adults with childhood sexual abuse histories tend to experience severe states of guilt and shame related to their abuse, especially when the parent or caretaker had failed to intervene. In the absence of protective and loving interventions aimed at helping the child understand what happened, the adult survivor may feel inordinately culpable for the traumas rendered, as well as for resulting sequelae which may include revictimizations and victimizations of others. Homogeneous psychodynamic groups can address and modify primitive and punitive aspects of superego functioning and reduce feelings of shame and guilt. These groups also facilitate the development of benign superego functioning, thereby helping the patients become empathic toward their pasts and responsible for their current lives. While this article focuses on women, the author believes similar principles may also be applied in treatment with men.     

Facilitated and real trauma in the psychoanalysis of children of Holocaust survivors

The author investigates the effect of retraumatization on the children of Holocaust survivors who have appropriated their parents' trauma through unconscious identification. The author proposes that the working through of the real trauma results in a mitigation of the transmitted trauma in the psychic reality and mobilizes the work of mourning that facilitates the mastery of the real as well as the transmitted trauma. Two case examples are cited as illustration.     

Comorbidity of attention Deficit Hyperactivity Disorder and Post-Traumatic Stress Disorder

Attention Deficit Hyperactivity Disorder (ADHD) and Post-Traumatic Stress Disorder (PTSD) show a high degree of comorbidity in traumatized children. Two hypotheses may help explain this relationship: children with ADHD are at higher risk for trauma due to their impulsivity, dangerous behaviors, and parents who may have a genetic predisposition for impairment of their own impulse control; and hyperarousal induced by severe trauma and manifested by hypervigilance and poor concentration may impair attention to create an ADHD-like syndrome. Four illustrative cases are presented, and implications for treatment are discussed.     

The reception of Holocaust research in the world of psychology

After having spoken to lay and professional audiences in Germany, Switzerland, Austria, England, France and in the United States on the effects of the Shoah on people in psychotherapy today and found varying reactions, I decided to pursue the question in a more consequential way. I devised a questionnaire which I sent to a large number of international psychoanalytic societies. My initial impressions were confirmed: Freudian societies generally devote more work to the topic. Some Jungian societies with especially interested individuals have also devoted a substantial amount of work to the Shoah and its aftermaths. The Jungian hesitancy has to do with our often more archetypal approach and with shame about Jung's statements on the Jewish archetype. On the collective level, the presence of a survivor population seems to make research on the topic more difficult. A certain amount of time must evolve before a society (be it professional, individual or political) deals with collective trauma, be it the Shoah or political oppression. On the personal level, intimacy (also in future, adult relationships) seems blocked when fantasies about parents' implications in the Shoah prevail. The bottom line of both phenomena is taboo, a prohibition against touching tameh. I propose that the IAAP supports research projects on the Shoah. They could also, as the Freudians do, offer a special prize at each international conference for the best piece of research on the topic of collective trauma.     

Attachment style, traumatic bonding, and developing relational capacities in a long-term trauma group for women.

Adults with histories of severe childhood abuse often experience considerable difficulties with interpersonal trust. At the same time, they may strongly desire to be less alone with the painful aftereffects of their traumatic pasts. Psychotherapy groups have often been recommended as important components of treatment for reducing survivors' feelings of isolation and shame. We propose that an understanding of attachment styles and of traumatic bonding helps to clarify the specific manifestations of interpersonal distrust as they may emerge in a survivors' group. In addition, we suggest guidelines for determining what kind of group may be appropriate for a given individual at a particular point in treatment.     

Transgenerational processes and the trauma of sexual abuse

The process of the unconscious transmission of trauma between generations has been written about within the psychoanalytic field since Freud. the concept was further developed by psychoanalysts in their work with second generation survivors of the Holocaust. the particular characteristic is that it is a transmission that takes place silently and in secret, but actively. It is especially found in families where there is an inhibition against thinking. It is suggested in this paper that the concept could be usefully considered in families where a parent is a survivor of child sexual abuse but has kept the trauma a secret. Clinical examples illustrate how children in such families may carry the unconscious dynamics which can emerge into consciousness through symptomatology in the child.     

The Traumatized Patient’s Word and Temperament as Elements of Successful Psychotherapeutic Treatment

I will review the case presentation by Ron Bodansky of two treatments of a primitively organized patient who endured childhood trauma. Drawing on the material, as well as work by Fairbairn and Verhaeghe, I offer two proposals to help explain why some deeply traumatized patients improve in psychotherapy. First, inborn temperament may be more important than the nature of the trauma or the specifics of the treatment itself. Second, the mitigating effect of the treatment may be found in the nature of the relationship between the therapist and patient. By abandoning assumptions regarding the patient’s prognosis, and by providing sustained attention to, and committed interest in, the patient’s stated experiences, all within a specifically therapeutic boundary, patients may develop the language and representation capacities needed to live beyond trauma, and thus be taken at their word.     

Dimensionality,identity and security: finding a home through psychoanalysis

This paper suggests that Meltzer’s understanding of the development of inner space can be thought about in relation to how a state of ‘being at home’ can be impaired through early trauma and developmental failure. It shows how a very young child developed a greater capacity for recognising inner and outer experience and consequently a greater awareness of inner space through intensive psychotherapy. Clinical material is presented in which this two-year-old boy moves from profound disorientation and disconnection, through physical containment and moments of communication, to some shared expression and symbolisation of his preoccupations. The author uses episodes from the psychotherapy to illustrate links between Meltzer’s thoughts on impaired interior dimensionality and a resulting terror of the ‘breaking of surfaces’ with Winnicott’s understanding of the necessary ‘gravitational pull’ of a good internal object and the negative retreat which may be caused by overwhelming anxiety. The paper suggests that a developmental approach to psychotherapy with young children has some technical ramifications which might include physical containment, emphasised attunement, simple observational commentary and developmental interpretation. The relationship between interior and exterior spatial awareness is discussed and brief reference is made to a study of psychotherapy with homeless adults regarding their capacity to make use of a physical home. Finally, Bion’s encouragement to abandon memory and desire is discussed in relation to the need traumatised children may have for environmental hope and hopefulness in the person of their therapist.     

Testimony work with Bosnian refugees: living in legal limbo

Mental health professionals working with refugees are often confronted with traumatised survivors who are living in legal limbo. Complicated asylum procedures or provisions of only 'temporary' protection trigger existential fears, reexperiencing of trauma and feelings of hopelessness and deep despair and can actively contribute to further destabilise survivors. Mental health centres have to reconceptualise their provided services for these clients. The paper introduces a testimony project for traumatised Bosnian refugees in Frankfurt, Germany, who were living in legal limbo for many years. The testimony method was used in combination with supportive therapy and informed advocacy to try to reduce the survivors' feelings of humiliation and demoralisation which for them were at the centre of their survival. By giving testimony, survivors benefited psychologically and became better able to cope with the difficult present. Feelings of self-worth and dignity could be regained and a trusting relationship between the survivor and the listener facilitated the therapeutic process. The testimony material documented human rights abuses both in the country of origin and in exile, helped us to perform informed advocacy for this group and informed a larger public on the psychological costs of refugee resettlement policies.     

The psychological effects of parental mental health on children experiencing disaster: the experience of Bolu earthquake in Turkey

Disasters affect families as a whole, and symptoms displayed by a family member may lead to secondary traumatizations for other members of the family, especially the children. This study examines the effects of parental psychopathology and family functioning on children's psychological problems six months after the earthquake in Bolu, Turkey. Forty-nine children aged between 7 and 14 and their parents were randomly chosen from among 800 families living in a survivor camp in Bolu. Both the children and parents were assessed by trained psychiatrists and psychologists using self-report measures for posttraumatic stress disorder (PTSD), depression, and anxiety symptoms six months after the earthquake. Family functioning in survivor families was also assessed using the Family Assessment Device (FAD). The results showed that the severity of PTSD in children was mainly affected by the presence of PTSD and the severity of depression in the father. State and trait anxiety scores of children were related to general family functioning. The constellation of PTSD symptomatology was different in fathers than in mothers: the most common type of symptoms was "externalizing" in fathers with PTSD. This study supports the notion that the mere presence of PTSD in parents may not be enough to explain the relational process in families experiencing trauma. Our findings with earthquake survivors suggest that when fathers become more irritable and detached because of PTSD symptoms, their symptoms may affect children more significantly.     

The use of brief focal psychotherapy in the treatment of chronic pain

Material is presented from brief focal psychotherapy used in the treatment of four patients with chronic pain refractory to multiple forms of treatment. The value from therapy for each patient is described in terms of actual pain relief, in improvement in understanding the interpretation of past trauma into present bodily symptoms, and in subsequent ability to cope with the pain. Three reported treatment to have improved their pain; one reported an improvement in her ability to cope with it and consequent improvement in lifestyle. The place of pathological mourning in the aetiology of such pain is considered, together with a discussion on the constant finding of denial or displacement of intense anger towards important past figures and its manifestation in the transference. A discussion of the place of brief focal psychotherapy as a time- and cost-effective intervention in the treatment of chronic pain is presented.