To The Editor: The clinical case conference by Andreea L. Seritan, M.D., Glen O. Gabbard, M.D., and Lloyd Benjamin, M.D., published in the Oct. 2006 issue of the Journal(1), is much appreciated. Several aspects of the case conference deserve comment.
“Ms. A” is a child survivor of the Holocaust (2, 3) who was hidden with her family, not separated from them. She did not have to assume a gentile identity nor was she adopted. Furthermore, she is not a death camp survivor, one of the “living skeletons” liberated from such places as Auschwitz, Buchenwald, and Dachau. Nevertheless, the deaths of her mother and brother were incalculable losses, sustained while she lived in constant danger of being caught and killed by Nazis. She was also suspected of being sexually abused, possibly as part of the “cost” of being protected.
The indelible impact of such genocidal persecution could not be ameliorated in short-term therapy, and while I do not believe any such claims were made, this point was not clearly delineated. Furthermore, there was no posttermination follow-up to determine whether the patient’s trauma was “worked through” (1, p. 1705) as opposed to “opening up more than the patient can handle”(1, p. 1708).
Despite Dr. Seritan’s sensitivity, did she inadvertently get drawn into a masochistic enactment that could have re-traumatized the patient by inflicting another loss upon her? Ms. A was appropriately informed that Dr. Seritan was moving in 6 months and had reservations about the treatment. But was Dr. Seritan so impressed by the patient that she proceeded nonetheless? Perhaps the wish to write about the patient also influenced her. Nonetheless, the patient’s resilience, ego, strength, and presentation were positive factors not to be minimized.
However, Ms. A’s persona and idealizing maternal transference not only recreated the long-lost mother who suddenly disappeared, but also concealed the terrified child who had to be invisible to the Nazis, invisible to her stepmother, and perhaps somewhat invisible to her lovely therapist with a European accent. In the patient’s unconscious mind, the therapist could have been a Nazi also.
Dr. Seritan read about the Holocaust and consulted knowledgeable supervisors. While Dr. Gabbard correctly points out that empathic attunement is more important than factual knowledge, our research (2, 3) suggests that clinicians working with survivors of historical trauma are well-served by knowing about the actual circumstances that their patients’ endured. The reconstruction of the traumatic period and the opportunity to develop a coherent narrative—often for the first time—may be one of the important achievements in therapy. Perhaps Dr. Seritan alluded to this when she states, “I pointed out to Ms. A how much work she had done and how much she had accomplished.”
1.Seritan AL, Gabbard GO, Benjamin L: War and peace: psychotherapy with a Holocaust survivor. Am J Psychiatry 2006; 163:1705–17092.Kestenberg JS, Brenner I: The Last Witness: The Child Survivor of the Holocaust. Washington, DC, American Psychiatric Publishing, 19963.Brenner I: Psychic Trauma: Dynamics, Symptoms and Treatment. Lanham, Md, J. Aronson, 2004
Dr. Brenner reports no competing interests.