Psychoanalytic Psychotherapy with Traumatized Refugees: Integration, Symbolization, and Mourning
SVERRE VARVIN, M.D.**
The psychotherapeutic encounter may be experienced as threatening for severely traumatized patients because of fear of re-experiencing and retraumatization. This puts a focus on how different aspects of the transference and psychotherapeutic situation address different aspects of the patient's pathology. The discussion uses clinical material from psychotherapies with traumatized refugees. Vignettes illuminate the problems.
By playing painfully with memories, we re-create life and rediscover the pleasure of being alive.1
THE UNFULLFILLED TRAUMA AND THE PARADOX OF PSYCHOTHERAPY WITH TRAUMATIZED PATIENTS
In this paper, some aspects of trauma and its aftereffects as well as the influence of traumatic experiences on the relationship between therapist and patient are discussed. Certain conditions for working with the traumatic experiences in psychotherapy are outlined.
My basic assumption is that patients do not symbolize torture and other horror-filled experiences, thus producing "unfulfilled traumas."2 This means that the victims constantly re-experience the trauma either as imaginary or as real; i.e., as constantly intruding imaginary re-experiences or as real (hallucinatory).
This is exemplified by a patient who said that talking about the torture experience in the session would be like reliving it here and now. She lived in an imaginary torture-prison inner world, experiencing almost all relationships in the perpetrator-victim model. In addition she daily hallucinated about the torture. One of the inherent aims of psychoanalytic psychotherapy is integration, which implies placing the traumatic experiences in a symbolic order, i.e., making it part of the individual's history by placing it in a dimension of time; the actual trauma should be transmuted into something that can be remembered or repressed, but will not be relived as an actual experience.
Integration of the trauma experience implies its painful re-experiencing and symbolic reactivation. The trauma story is not only retold, but is experienced with affects and, most important, the nonsymbolized parts of the trauma may be relived in the transference to the therapist. More accurately stated, trauma derivatives are relived as "symbolic actualization" as an aspect of the integration process. It is the task of the therapist to acknowledge this "symbolic actualization" and, together with the patient, try to verbalize it.
Patient's ambivalence toward treatment is, therefore, often great and, in the case of refugees, it is further reinforced by additional stresses and traumas of exile, with its concomitant loss of cultural setting, lack of family ties, etc.
The therapeutic technique and the organization of the psychotherapeutic setting has to take these special circumstances into consideration.
TORTURE AND TRAUMATIZATION
The central point in psychoanalytic trauma theory is the helpless overwhelmed ego, or as Krystal puts it: " A paralyzed, overwhelmed state, with immobilization, withdrawal, possible depersonalization, and evidence of disorganization. There may be a regression in any or all spheres of mental functioning and affect-expression."3 Krystal stresses that in his experience, the final common path of traumatization is the development of overwhelming affects3(p.142).
Trauma will affect phase-specific problems and conflicts according to age and social situation, as was shown in a recent study,4 and also affect different layers of the personality according to the depth of regression produced and the individual"s coping ability in the traumatic situation.5 It may also work by mobilizing the ego's resources. As Krystal3 stresses, it is important to pay attention to the subjective meaning of the traumatic experience for the patient. As it is aimed at the destruction of the personality, it may result in structural or deep personality changes. …