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.

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.

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.

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.

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.

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.

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?”

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.

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.

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.

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.

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.

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.

Tell us about the end of the therapy.

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.

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

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.