Dr. DAVID SENESH, CLINICAL PSYCHOLOGIST

13 BAT-HEN STREET P.O.BOX 645 TEL- MOND 40600 ISRAEL Tel 972-9-7961480.

e-mail:  senesh_99 @ hotmail.com

__________________________________________________________________________________ICCP CONGRESS

Sweden June 16, 2005  

A Former Prisoner of War as Therapist: The Role of PTSD in Psychotherapy

David Senesh, Ph.D.

Levinsky College of Education

Tel Aviv Israel

I was often asked whether the time that I spent in Egyptian jail was formative in my later becoming a clinical psychologist and a psychotherapist, specializing in trauma and abuse. This far-fetched association between the experience of imprisonment and that of therapy has often puzzled me and made me curious about my own choices in  becoming a psychotherapist and provided me with insights into the striking similarities between intimacy of psychotherapy and the intense feelings that I had some 30 years ago as an Israeli  captive in an Arab jail. I wonder, whether personal encounters between enemies in a battlefield, and especially in the proximity of captivity, are paradoxically similar in their emotional intensity to those of parties who are actively engaged in psychotherapeutic relationships.

Psychotherapy and prison are worlds apart, and yet, having the opportunity to live through both empowers me with a unique vintage point. The world view that emerges from traumatic experiences results in role diffusion fading the barriers between a parent and a child, a teacher and student, a psychotherapist and a patient – in time, they all trade places in revolving roles and ever changing tasks, sometimes complementary, sometimes consequential – but always conditional, transitory and temporary. The shattering experience of a trauma breaks down the “constants of experience” shaking the mechanism of protective self-deception, a make-believe that things are permanent and solid. For the traumatized individual basic premorbid conditioning and contingencies fail to give meaning to his or her traumatic lived experiences, disturbing the way they are assimilated in the overall  experiential web.  From that point on, the deepest schemata of the world and others,  turn out to always be fragile and conditional. This is especially valid in the trauma of captivity as a world of invulnerability and omnipotence breaks down into chaos. The imprint of such intensive experiences between an omnipotent parental figure in the form of a parent, therapist or a prison guard vis-à-vis the helpless childlike captive has the potential to foster regression, dependency and identification with the aggressor. Even cruel and abusive parents, harmful therapists, same as guards and torturers are emotionally significant for their subordinate victims. This is probably the reason why abused children continue to attach to their parents, battered wives to their abusive spouses and traumatized persons to the haunting image of their past perpetrators.  In my mind, despite the pain and bruises, the enemy who captured me was also the one to give me the gift of life, just as a maltreating, poisoning parent is also the one who gave birth and provision to her abused child. As I emerged from such abusive experiences I became aware of these contradictory sentiments that were co-habiting within me  binding those nightmarish experiences alongside with intense positive affect – that of affirmation of life, an empowering recognition to have been living through hell and surviving it. This awareness is in itself a part of the healing process to set oneself free from chains of both humiliation and pain and those of rescue and survival, to reconstitute a secure life of trust and serenity.

Imprisonment simulates a primary scene of bad infancy – one of absolute dependency and helplessness, reinforced by total control mechanisms in the form of fear and pain. Hunger and thirst, physical discomfort, ambiguity and confusion are all means of psychological warfare. Intrusion in the form of psychological brainwash and violent interrogations are all aimed at breaking the victim’s spirit, claiming his selfhood and   controlling his or her free will. Abusive milieus, whether in infancy or in later life distort and cripple the internal working models of attachment among people. On the other hand, the therapeutic process is one that aims at an optimal level of anxiety and need gratification, to motivate explorative processes of growth within accepting, empathic and containing relatedness. Same as corrupted relationships in prison can harm the sense of balance and integrity in later life, so is the power of a corrective  positive emotional experiences in therapy to “mend a broken heart”. Such transformations for better or for worse, may only occur within the framework of intense relationships, such as those between agents of complementing roles - a parent and a child, a therapist and a patient, a teacher and a student, and, unfortunately also between a an offender and a victim, a prisoner and his guard.

This state of affairs, puts the burden on the therapist to handle the therapeutic process with utmost care. He or she should navigate therapy in between the policy of minimal necessary intervention and the omnipotent wish for salvation. Aiming too high or too fast might rekindle the patient with overwhelming affect. Posttraumatic therapists might be more respectful of the patient’s own trauma-protective defenses that work as a trauma membrane (Lindy & Wilson, 2001) to shield off stimuli that might trigger the re-awakening of the original trauma. In vivo flooding of the patient with traumatic material may abreact the original scene of abuse, identifying the therapist with the abuser. Therapists should therefore match their clients’ pace with “appropriate doses” of affect that can be contained in the therapeutic relationship (Lindy, 1996).

In his 1955  essay “Beyond the Pleasure Principle” Freud asserted that at moment of trauma and very soon thereafter, there is a breach of the stimulus barrier leading to affective flooding and a total breakdown in all biopsychosocial aspects of the experience. At that very moment, when self-integrity and self-continuity are at stake, there is a growing tendency for hypercathexis to occur that increases the valence of others, empowers them with unreal significance for the patient. The crucial question then is who are the other persons that the survivor meets?  Is it the enemy who is about to take advantage of his psychological fragility, to interrogate or dispose of his or her identity and dignity?  Are those bystanders, indifferent or too terrified to help who deny the experience decline to offer any help ?  Are those people who for their own purposes invalidate the victim’s painful stories or rather discredit his or her experiences? Are those caring individuals - family, friends or professionals, who take over some self-organizing and self-soothing functions for the patient and are willing to nurture him as much and as long as needed? It is quite possible for a traumatized patient to relate suspiciously even to the well-intending professional who is genuinely trying to help. Traumatized patients might consider routine procedures such as a diagnostic interview or a psychological assessment as an attack on their integrity, a threat on their sense of autonomy and an intrusion on their right for privacy.  Likewise, a psychiatrist or a psychologist inquiring about the trauma, may provoke in his traumatized patients an alarming sense of attack on their defenses in search for their underlying best kept secrets. An assuming, all-knowing, high-status professional who uses impersonal procedures may run the risk of reviving in his or her patients earlier experiences of abuse, imprisonment and interrogations. A defensive stand of the patient might well be a maneuver against his or her own self-persecutory projections, for surviving also means betraying the dead, failing a mission, giving away secrets’ etc’, resulting in what is best known as “survivors’ guilt”. Patients may consciously defend to keep their secrets, but at the same time subconsciously expect their so to speak “persecutory therapists” to reveal their pathogenic secrets and finally punish them. In the absence of such “relief”, self-hatred and self-harm may prevail. Therapists who are themselves survivors of life trauma, might be in a better position to handle such delicate materials with utmost care to gradually untangle their patients and relieve them off that unnecessary burden. 

Documenting the patient’s story is the corner block for any farther therapeutic work, for it gives credit to the story, to the narrator’s task of bearing witness to the horrors he or she had been through, and for the hope that these experiences may fit into the fabric of his or her life story as well as register with society as a valuable historical account.  Providing the historical and political context for traumatic personal stories, in conducting  “narrative exposure therapy” (NET) help victims and sometimes entire communities overcome a situation known as “imprisonment of speechlessness” especially in areas still afflicted by ongoing terror and trauma.

The moment of surrender is a moment of complete helplessness and hopelessness. It is the certainty of an unavoidable end that all unexpectedly marks a new beginning. Some patients come to treatment at that very moment of despair.  Such a moment of crisis has a unique power to imprint a sense of attachment and trust that will organize later experiences. As traumatized patients start to form the therapeutic alliance with their therapists, they are courageously willing once again to run the risk of losing their newly found love and sense of trust in themselves and in the other. A post-traumatic therapist knows best how to appreciate such a formidable task, and will hopefully be empathic and tolerant of his patient’s setbacks in the process. This therapist might be more conscious of his own and his traumatized patient’s anxiety and defenses make them act in a rather suspicious and at times even paranoid manners. These may appear in verbal discourse, dream material, works of art and in acting out. In accepting, containing and giving meaning to such expressions, the therapist provides his patient a safe place to work out his fears, losses and confusion.

Surviving traumatic experiences marks the victory of life over death. However, physical survival in and for itself just won’t do unless complemented by a sense of meaningful existence that transcends the trauma, on both cognitive and experiential levels. Therapy is one way of making such a victory meaningful. A posttraumatic therapist is well aware that it is the working relationship that can make the difference. He has already been through the experience of physically surviving a life threatening    event, now he may recognize the same existential need for meaning-making in his patient. For a posttraumatic therapist, his patient’s reflections on an inner world that is split, shattered and fragmented is all too familiar an experience. In sharing that commonality, therapist and patient may then embark on the painstaking task of collecting, assembling, and reconstructing the pieces together. The reconstruction of traumatic experiences in therapy may counter the emergence of later life symptoms of anxiety, dissociation and depression, known as the Post-Traumatic Stress Syndrome (PTSD),  and pave the way toward further psychological development known as Post-Traumatic Growth (PTG), which may well inspire hope in the lives of many other patients and therapists.            

A prisoner of war never serves his full term in jail, because he doesn’t have one. Upon his release, he starts his journey to liberate himself from the grasp of his past, from anything that might keep him in an internal prison. Committing oneself to a secure base in ideology or in relationships means committing oneself once again into a psychological prison, while at the same time running the risk of once again, abruptly losing it altogether due to another traumatic assault. This paradoxical position of ever searching a safe place but never running the risk of finding one may also characterize the therapist’s own quest for meaning and belonging in the post-traumatic era. A posttraumatic therapist is most likely to be understanding of his or her patient’s frustration and pain in realizing that there is no such “promised land” where security, freedom, reason and fairness rule. However, it is still possible for both posttraumatic therapist and patient to find these qualities within the framework of their own mutual relationship in therapy. Such realization is in itself the central block in braving their  own separate routes in a posttraumatic world.    

References

Freud, S. (1955).   Beyond the Pleasure Principle.  (pp. 29-33).   Standard Edition, Vol. 18. London: Hogarth Press (original pub. 1920).

Lindy, J. (1996).   Psychoanalytic psychotherapy of Posttraumatic Stress Disorder: The Nature of the Therapeutic Relationship. In: B. van der Kolk, A. McFarlane, & L. Weiseaeth (Eds.) Traumatic Stress: The effects of overwhelming experience on mind, body and society. (pp. 525-536)  New York: The Guilford Press.

Lindy, J. & J.P. Wilson (2001).   Respecting the Trauma Membrane: Above all, do no harm. In: Wilson J.P., Friedman, M.J. & J.  Lindy  (Eds.)   Treating Psychological Trauma and PTSD.  (pp. 432-446)  New York: The Guilford Press.

©  David Senesh

Research/ ICCP.doc