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Clinical Case Conference   |    
War and Peace: Psychotherapy With a Holocaust Survivor
Andreea L. Seritan, M.D.; Glen O. Gabbard, M.D.; Lloyd Benjamin, M.D.
Am J Psychiatry 2006;163:1705-1709. doi:10.1176/appi.ajp.163.10.1705

More than 60 years after the end of World War II, it remains difficult to fathom the experiences of Holocaust victims. Atrocities and dehumanizing conditions, loss of bodily integrity and lives, families broken apart, destruction, and death were common occurrences. Survivors were few, enclosing within their hearts endless pain and suffering. Their experiences altered their view of the world, themselves, and others. Here I present a case of brief psychodynamic psychotherapy with a patient with major depression and posttraumatic stress disorder. Exploration of early trauma during the Holocaust linked to current stressors took center stage. The transference and countertransference that developed informed the treatment, while a subtle relationship unfolded between patient and therapist.

Identifying a focus is at the core of brief psychodynamic psychotherapy. The focus of this treatment was loss because the patient had lost her mother and brother at an early age. Additional losses shadowed her subsequent life: her father’s death and her husband’s medical illness, leading to worsening health. Moreover, anticipating the termination of her psychotherapeutic relationship after 5 months precipitated acute issues of loss, which needed to be worked through.

“Ms. A” was a 68-year-old Jewish woman of European origin who was referred to our outpatient geriatric psychiatry clinic by her internist. She had a long history of depression and anxiety, currently exacerbated by concerns over her husband’s health and her own medical problems. She reported a depressed mood, fatigue, initial insomnia, and poor-quality sleep interrupted by recurrent nightmares. She reported intrusive thoughts, such as ruminating over news of someone’s death or suicide. She had a history of panic attacks that included tremors, tachycardia, profuse sweating, and anxiety, attacks that had resolved spontaneously 30 years previously. Although she reported no current suicidal ideation, Ms. A had contemplated suicide when she was younger. Her first major depressive episode was at age 17. Two others followed, with the longer one lasting 8–10 months and occurring approximately 15 years before our meeting. She had felt sad most of the time, even when her depression had lifted, but she had been able to enjoy her life with her family to some extent. She also exercised regularly and had an active social life.

Ms. A has never been hospitalized nor had she attempted to harm herself. The mainstay of her past treatment was psychotherapy, and she was taking a low dose of a selective serotonin reuptake inhibitor the time I first saw her. Her medical history included mild hypertension, hyperlipidemia, and questionable fibromyalgia. Ms. A had several years of college education and a marriage of 50 years. Besides raising her two children—now successful adults—she had worked outside of her home. One of her jobs involved being a counselor to children and teenagers who abused drugs. She also helped her own children process some aspects of the trauma she had suffered in her early years, and they all developed, as a result, a sophisticated understanding of psychological phenomena. Her family history was relevant for her father’s severe depression, although he had never been diagnosed or treated. Her daughters and one grandchild had different degrees of depression or anxiety. Ms. A had a difficult childhood during the war years in Europe, which continued to haunt her.

Ms. A had survived the Holocaust by hiding for 2 years with her family, beginning when she was only age 4. Her parents, two siblings, and 10 other family members were concealed in a neighbor’s barn to escape the Nazis. During those 2 years, her mother and younger brother had died. No one ever explained to her why or how they had died. She could only recall that her mother was ill and then one day disappeared. Having been unable to grieve for her, she felt an irreparable loss. Especially painful was the fact that there were no photographs left of her brother. She remembered him well but felt she needed time to mourn him, too.

During the time they had spent in hiding, soldiers would periodically come to the neighbor’s barn to get food. The patient and her family lived in terror; they could not move or make a sound for fear that they would be discovered. They were afraid to even breathe because their warm breath might melt the snow on the roof and lead to discovery by the Nazis. She felt that their lives had stopped, and she was not allowed to go on living.

A sense that one’s life has stopped is a common sequela of severe trauma of the sort that Ms. A experienced. Psychiatrists who interviewed Holocaust survivors after World War II reported that many survivors felt as though it were still 1945 and that there had been no movement in their lives since. This notion of being developmentally frozen is highly relevant to this woman. Even though Ms. A is 68, we should not be deceived by her chronological age. Within her, there is a frozen child who has never been able to move beyond the trauma, and we will undoubtedly see this aspect of her internal world emerge during the course of psychotherapy.

After 2 years of hiding, the neighbors asked Ms. A and her family to leave because they feared that their lives were in danger for concealing a Jewish family in their barn. All of the belongings they had possessed before the war—if not looted or destroyed—remained in the farmer’s possession. Ms. A and her family crossed the Alps on foot and found refuge in a “displaced persons” camp in Italy, where they spent several more years waiting for the country to accept them after the war was over. Ms. A recalled these years as good times, when they were respected and could observe their religion. They did not return to their country of origin because they felt unwelcome there. At age 8, Ms. A became ill with rickets and tuberculosis but received proper care and recovered. Her father was thoroughly demoralized after the war. He never talked with her about her mother’s death or what happened in their hideout.

Ms. A came to the United States at age 12 and eventually adjusted to school and the new culture but only with considerable difficulty. Her father remarried another Holocaust survivor, who was harsh and unkind to Ms. A and her older sister. However, Ms. A’s sister appeared better equipped to deal with these changes. Ms. A adjusted to the new family over time and became less of a target for the stepmother’s wrath. Two half-brothers were born, and the minimal attention that Ms. A was receiving from her father and stepmother deteriorated into nothing. She was expected to take care of herself, to never complain, and to avoid mistakes. She often heard statements such as, “No one wants you; you are lucky you have a home,” or, “Who do you think you are? You are nobody.” She became increasingly despondent. When she was 17 years old, after graduating early from high school, she suffered her first major depressive episode. She started working so she could pay for her psychotherapy. Soon thereafter, she met a young man, married him, and moved away from her parents. Her husband was very supportive and helped her fight her intense depression.

This is a useful illustration of the pathogenesis of depression. From the elegant Virginia twin studies of Kendler et al. (1), we know that genetic factors play a substantial, but not overwhelming, role in the pathogenesis of depression. Childhood trauma may be a key factor, especially when a stressor later in life reactivates that trauma. Traumatized children frequently develop a hyperreactive hypothalamic-pituitary-adrenal (HPA) axis as a result of chronic childhood abuse (2, 3). A common result of this overly active HPA axis is that the child is hypervigilant in unfamiliar situations, scanning the environment with the expectation that something bad will happen at any moment. Such chronically depressed patients who have profound childhood trauma appear to fare better with psychotherapy and medication than with medication alone (4). Imagine how this patient’s trauma will affect her subsequent approach to the outside world. Having lived in a barn, where any moment a family member could die or she herself could be discovered and killed, she had to develop a kind of radar that would help her survive. Then she had to cross the Alps, like the von Trapp family, to escape to the United States. After being relocated, she encountered a life not too different from that of Cinderella, knowing that her mean stepmother preferred the other children to her. It is possible, of course, that this horrific childhood experience may reappear in the transference to Dr. Seritan. Tell us about your initial impressions of her.

Ms. A first stepped into my small windowless office on a wintry afternoon. She appeared poised and elegantly dressed but timid. Her expression, under the vivid gaze and slight smile, was a mixture of pain and dignity. Articulate and eloquent, she described her difficulties by telling her story through a veil of tears. Upon an initial mental status examination, she reported a depressed mood. Her thoughts were coherent and well organized, and she was fully alert and oriented. At the end of her appointment, Ms. A asked if I could be her therapist. It was a direct word-sparing question. Because she correctly discerned that I was originally from Europe like her, she may have requested me because she felt some form of kinship with me. I knew that I had less than 6 months of training left, and I would move to another town after graduation. I did not think that it would be a good idea to commit to an in-depth exploratory treatment that would soon be over. After sharing this dilemma with Ms. A, she still felt that she wanted to work with me, and I accepted. I liked her, and I pictured her as a famished little girl in a dark barn, paralyzed with fear—a still life, surrounded by grown-ups as terrified as she was. This image seized my imagination, and it has stayed with me ever since. I was also moved by the fact that one of her daughters is actually my age. This daughter’s children, in an almost uncanny way, are actually my children’s ages. Ms. A was even a counselor at one point. She and her daughter were working on a book about her Holocaust experience.

She has a daughter your age, and her granddaughters are your children’s ages. One of the ways we understand transference and countertransference is that they are based, in part, on the real characteristics of the therapist and patient. Ms. A is of European origin, as is the therapist. They even have similar accents. This similarity will present a countertransference issue for Dr. Seritan because she must constantly sort out what is being projected into her from the patient and what might be a real aspect of the relationship. Moreover, it would be easy for Dr. Seritan to reenact the role of the patient’s daughter and overidentify with that figure. Ms. A may also have an idealized expectation that Dr. Seritan will understand her better because she was from an area of the world that she herself is from. This can be highly misleading because we can meet people from our own area of the world who do not understand us at all.

We began weekly psychotherapy, haunted by the shadow of termination from the start. I was hoping to see transference emerge that would place me in a maternal role, where we could more easily explore her feelings related to her mother’s death. Knowing that I would soon have to part from her, I realized that our upcoming termination might precipitate acute feelings of loss. On the other hand, my departure was a palpable reality, a concrete deadline, which we knew about from the beginning, unlike the mystery of her mother’s disappearance. I was fascinated with her psychological complexity and intrigued by the resilience that allowed her to overcome the terrible trauma of wartime and the early loss of her mother.

To better prepare for my work with her, I started reading a book by Viktor Frankl (5) and asked for consultation from supervisors on aspects of Holocaust-related trauma. I felt I did not know enough about that time period.

Beginning therapists often feel inadequately prepared to discuss aspects of the patient’s life with which they are unfamiliar. However, historical data and cognitive knowledge about the patient’s past are not nearly as important as staying emphatically attuned to the patient’s emotional experience.

Although Ms. A could tell from my accent that I was from a similar area of Europe, she never asked me where I was from.

We can speculate that her early traumatic experiences had made her wary of making waves or creating a disturbance. She might have been concerned that if she asked a personal question, Dr. Seritan would be offended, and she would lose her as a therapist. I have the impression that she is quite concerned about doing things properly so that nothing disastrous happens. Based on these early observations, what would we predict might happen in therapy as part of this developing psychodynamic formulation? I’ll give you a hint: Ms. A’s father never discussed her mother’s death. She grew up with a code of silence.

We would assume that there will be some topics that she will be afraid to reveal in therapy.

Yes. The therapist must always be curious about what is being concealed. Ms. A had internalized a great deal and survived by keeping silent so she could get through adverse events. This characteristic defensive style will emerge as resistance in the psychotherapy process. Keep in mind that even though Dr. Seritan is the age of her daughter, she will still receive some elements of maternal transference. The patient will be afraid of losing this therapeutic “mother” just as she lost her real mother. Hence, she will be careful about what she says. So one manifestation in the transference may be the emergence of a frozen child who hides herself from the therapist amid fear that catastrophic consequences will result from opening up. She may also feel a good deal of survivor guilt that leads her to think, “I do not deserve to be here. Why did I survive, and not my mother and brother?”

This is a very good point. She did talk about her guilt and feared that she would lose me if she said the wrong thing. She was always careful to be pleasant and to compliment me on how I dressed. I even noticed myself dressing differently on the days I saw her because I knew she would be commenting on what I was wearing.

We have been predicting that a therapist like Dr. Seritan is going to feel a special kinship with Ms. A. Hence, she might be overly cautious not to shame or retraumatize the patient. She feels she must be careful about an intervention that attributes agency or responsibility to this patient. Because Ms. A had endured so much trauma, Dr. Seritan may feel that she has to walk on eggshells with her, and one would have to monitor one’s countertransference carefully. Fundamental to the notion of transference is the idea that patients experience the therapist as part of an unconscious recapitulation of their early experience with their families. So here the patient may be reexperiencing a situation in which she walked on eggshells much of the time as a way of avoiding the rage of her “wicked stepmother,” who repeatedly said that she would have to get out of the house unless she behaved herself. Dr. Seritan may be observing that same object relationship externalized onto the transference-countertransference dimensions of the therapy. Remember that what the patient cannot repeat in words, she will repeat in action, in the way that she relates to the therapist.

Ms. A asked me to be her therapist, and I actually offered to refer her to a psychologist for therapy. She said, “No. I want you.” This is part of the kinship that I felt was developing. I think she felt that I would be able to understand her better. She even said that she did not think that she would find somebody like me. She was already seeing me as the idealized mother that she longed to have. And, as Dr. Gabbard said, I think she was repeating the experience of the frozen 4-year-old. I was a little intimidated by her. Could I work with her as well as others had? I was a beginner, but she seemed to be comfortable, and I certainly liked her. She clearly wanted to talk about what had happened during the 2 years in hiding and about her mother’s death. Later on, she brought out some experiences that she said she hadn’t been able to share with previous therapists because of their male gender. Some of these had to do with sexual abuse. She also reported a dream early in the therapy in which she was partly an adult and partly a baby who needed help. The dream took place in a barn like the one in which she had hidden and her mother had died.

This depiction of herself in the dream as partly an adult and partly a baby is, of course, the way she presents herself in therapy. Because her mother’s death in the barn is an association to the dream, we might wonder if, in some way, she has seen that her stepmother has died and that a good mother is now available to take care of her for some time.

I was already worried that I would be retraumatizing her by ending the therapy at 5 months.

It might be useful to say to her, “I’m concerned that it might be a form of trauma for you at the end of 5 months because you are going to lose me the same way you lost your mother. You have had a lot of losses in your life. We should probably talk about that throughout the 5 months and not put it off until the very end because we both know that you are going to lose me in a few months.” It is a way to demystify the abandonment theme by bringing it right out onto the table as an agenda for the entire brief therapy, and make a point of focusing on the termination from the beginning. The countertransference anxiety you feel may make you postpone dealing with it, because you may feel guilty about hurting her by stopping the treatment.

I think processing termination right from the beginning is important. I told Ms. A in the first session that we had 5 months and that we ought to keep that in mind. It placed a good deal of pressure on me, and I also was thinking I wanted to write a case report.

Thanks for sharing that with us because there is a special kind of countertransference associated with a case that you want to write about for publication. You might call it “writing countertransference” because you find yourself particularly attentive to those areas of the patient that are most relevant to the topic of your report.

Is it actually possible to do in-depth work in 5 months? There might be a risk of opening up more than the patient can handle. Alternately, might the patient not already have a sense of this and therefore use the limited time together to defensively restrict how much is explored?

That is an important point. We cannot open Ms. A up more than we can put her back together again at the end of the treatment. We must respect the adaptive nature of her defenses and not attempt to bulldoze them. Brief dynamic therapy must always combine support with exploration.

By talking about how her mother disappeared one day, I felt that Ms. A was also talking about the uncertainty connected to herself. She was plagued with tormenting questions: “Who am I really? Do I really exist?” Hence, at some level, she wondered if she herself had actually disappeared when her mother vanished. She reflected on this fantasy and connected certain memories to it: when she was a bad girl and had done something that her stepmother would punish or criticize her for, she would sit in a corner punishing herself until she made herself small and invisible.

We could see this kind of defense as a form of dissociation or depersonalization. She took herself out of the traumatic situation and thought to herself, “I’m not really there, so nothing bad is happening to me” (6).

I might be concerned when she told me this that she was foreshadowing what could happen in the therapy when the therapist touched on deeper issues.

I carefully orchestrated my interventions to avoid being too aggressive. I was concerned that this very thing might happen—that I would say something that would traumatize her and cause her to retreat into her invisible defensive posture. I also noted that she would idealize me as a nonjudgmental caretaker. She made such comments as, “You are so young, but you have so much experience.” She would also say, “You are wise beyond your years.”

By treating you like an idealized mother, she was both assuring your continued involvement with her and shoring up your ability to treat her. Many patients try to treat their therapists in some way. Ms. A probably sensed Dr. Seritan’s anxiety, and she may have attempted to make her feel better about having to undertake the treatment of someone much older than she who has had experience with many therapists.

In the same vein, our discussion has been almost entirely on the positive transference in this case. There are undoubtedly negative transference concerns as well.

Ms. A insisted on being the good patient who would keep “badness” out of the picture. With her trauma history, it would be terrifying for her to think of expressing negative feelings because of the risk that she would lose her therapist.

One manifestation of the negative transference came up when termination approached. Ms. A actually took vacation at the time that we were originally supposed to terminate as a way of taking over the control of who left whom. Thus, it shortened our work by 2 weeks.

Tell us about the end of the therapy.

Ms. A expressed a wish to be friends and wanted to take me out to lunch. I politely said, “No,” but it sounded like a previous therapist had done that with her at the time of their termination. She had a precedent, so it seemed reasonable to her. I wondered if she wanted to feed me or to simply give me something in exchange for my services. She came with a small gift to the last session, and I began by saying, “I cannot accept this gift because we’re not allowed to accept gifts from this clinic.” She brought a big bag of small gifts and said, “Come on, I have to take care of you.” I accepted the gift after we explored what this meant to her.

She wished to take control of the session because she wanted to actively master a passively experienced trauma. In other words, she would be in charge of the ending of the therapy and the circumstances under which it occurred. This is probably why she went on a trip shortly before the scheduled termination. I’m pleased that Dr. Seritan ultimately decided to accept the small gift. Dynamic psychotherapy has evolved far beyond the days when refusing gifts was routinely recommended. There is now a broad consensus that turning down a small gift at the time of termination may be a technical error. Of course, one still explores the meaning of the gift.

I pointed out to Ms. A how much work she had done and how much she had accomplished.

Why did you feel the need to point out how much work she had done?

That is my style. It was important for her to receive that validation.

Keep in mind that this is a resilient woman, and even though she appeared to be a frozen 4-year-old, she is also a survivor of extraordinary trauma. Nonetheless, through projective identification, each patient unconsciously shapes the therapist into the kind of therapist they want. She related to you in such a way that you became transformed into a good mother—not the wicked stepmother—and you wanted to respond in the way that she needed you to respond. Every patient does that to some extent. You gave her validation because you sensed that she was stuck and frozen and needed that validation to move on developmentally.

In this poignant clinical presentation, we have seen how early trauma serves to shape a person’s internal object world, sense of self, and constellation of defenses. The case also illustrates how a central focus in brief dynamic therapy may touch equally on childhood experiences and the current transference-countertransference dimensions of the psychotherapy. The loss of the therapist resonates with the echoes of the patient’s many losses in the past.

+Received April 26, 2006; revision received July 1, 2006; accepted July 10, 2006. From the Department of Psychiatry and Behavioral Sciences, University of California–Davis; and the Menninger Department of Psychiatry, Baylor College of Medicine, Houston. Address correspondence and reprint requests to Dr. Seritan, Department of Psychiatry and Behavioral Sciences, University of California–Davis, 2230 Stockton Blvd., Sacramento, CA 95817; andreea.seritan@ucdmc.ucdavis.edu (e-mail). Drs. Seritan, Gabbard, and Benjamin report no competing interests.The authors thank John A. Sargent III, M.D., for his consultation on aspects of Holocaust-related trauma.

1.Kendler KS, Kessler RC, Walters EE, MacLean C, Neale MC, Heath AC, Eaves LJ: Stressful life events, genetic liability, and onset of an episode of major depression in women. Am J Psychiatry 1995; 152:833–842
 
2.Heim C, Newport DJ, Heit S, Graham YP, Wilcox M, Bonsall R, Miller AH, Nemeroff CB: Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA 2000; 284:592–597
 
3.Nemeroff C: The pre-eminent role of early untoward experience on vulnerability to major psychiatric disorder: the nature-nurture controversy revisited and soon to be resolved. Mol Psychiatry 1999; 4:106–108
 
4.Nemeroff C: Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci USA 2003; 100:14293–14296
 
5.Frankl V: Man’s Search for Meaning. New York, Touchstone, 1984
 
6.Gabbard GO: Challenges in the analysis of adult patients with histories of childhood sexual abuse. Can J Psychoanal 1997; 5:1–25
 
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References

1.Kendler KS, Kessler RC, Walters EE, MacLean C, Neale MC, Heath AC, Eaves LJ: Stressful life events, genetic liability, and onset of an episode of major depression in women. Am J Psychiatry 1995; 152:833–842
 
2.Heim C, Newport DJ, Heit S, Graham YP, Wilcox M, Bonsall R, Miller AH, Nemeroff CB: Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA 2000; 284:592–597
 
3.Nemeroff C: The pre-eminent role of early untoward experience on vulnerability to major psychiatric disorder: the nature-nurture controversy revisited and soon to be resolved. Mol Psychiatry 1999; 4:106–108
 
4.Nemeroff C: Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci USA 2003; 100:14293–14296
 
5.Frankl V: Man’s Search for Meaning. New York, Touchstone, 1984
 
6.Gabbard GO: Challenges in the analysis of adult patients with histories of childhood sexual abuse. Can J Psychoanal 1997; 5:1–25
 
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