Am J Psychiatry 163:1705-1709, October 2006
doi: 10.1176/appi.ajp.163.10.1705
© 2006 American Psychiatric Association
War and Peace: Psychotherapy With a Holocaust Survivor
Andreea L. Seritan, M.D.,
Glen O. Gabbard, M.D., and
Lloyd Benjamin, M.D.
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Introduction
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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.
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Case Presentation
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"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.
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Dr. Gabbard
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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.
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Dr. Seritan
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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.
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Dr. Gabbard
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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.
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Dr. Seritan
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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.
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Dr. Gabbard
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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.
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Dr. Seritan
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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.
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Dr. Gabbard
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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.
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Dr. Seritan
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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.
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Dr. Gabbard
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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.
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Dr. Seritan
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Introduction
Case Presentation