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It thought this was interesting. I found it on the US National Center for PTSD

PTSD and Transference

By Jacob D. Lindy, M.D.
NCP Clinical Newsletter 3(2): Spring 1993

In our clinical work with trauma survivors we know that the specifics of the traumatic experience are never far away. Whether it is the scanning of the horizon (for certain Vietnam veterans) or the frightened glance of potential danger from the rape victim, we appreciate that our patients are vigilant lest the dreaded event recur. We take the repetitions of specific traumatic events and the conscious and unconscious efforts to ward off these repetitions to be the hallmark of PTSD. Yet, we sometimes fail to notice how it is that a particular circumstance of the visit with us acts as trigger for the trauma itself.

A woman Holocaust survivor, dissociated every time she reported to her doctor for "rounds." She took several laborious steps, squinted as if blinded by the sun, reached out, and uttered a muffled cry. While the doctor inferred that the dissociative state was likely a split off memory of her concentration camp experience, the doctor did not ask what in the current context might be setting this off. At the time we were unfamiliar with the now well described scenes which occurred when Nazis threw open the doors of cattle cars as Jews arrived after days of travel at the death camps. The sudden sunlight blinded the victims as they exited the trains and entered the camp. At that very moment a Nazi doctor made the decision to divide the new inmates into workers and those who would be killed immediately. In such moments Nazi doctors were responsible for separating mothers from children, an event encapsulated by this motoric memory in which a supposedly neutral event, the doctor's "rounds," evoked the most intense pain imaginable.

Indeed, every facet of our appointment environment and every aspect of our personal interaction with the survivor is a potential starting point for the callback for traumatic memory. Appointments at nightfall may feel dangerous to Vietnam veterans while those at sunrise may feel safer; promptness may stir confidence while tardiness may evoke a tragically failed rendezvous. A shift in time of appointment may turn the familiar into the unfamiliar even if it is only by altered shadows or different cars in the parking lot, stirring reminders of sabotage. Furniture which may block an exit or force a veteran to sit with his back exposed may evoke danger situations where enemy was all pervasive.

Silence may predict attack, interventions may be the dangerous commands of an arrogant inexperienced lieutenant. A posture or accent may be that of a friend who is killed.

For many therapies such events "interrupt" the openly agreed upon plan of the treatment, setting into motion dysphoric affect, emergency defenses and distraction from the manifest task. Depending on the type of therapy we engage in, we may choose to deal differently with such repetitions within the transference. The clinician engaged in pharmacotherapy may include transference enactments within the purview of parameters being followed in terms of symptom severity. The behaviorist might consider revising a script of most dangerous situations in light of new data from transference enactments; the hypnotherapist may gain clues as to areas to explore or to avoid in guiding survivor's narrations; the group psychotherapist may wish to note such behaviors for further work later if they pertain to the general theme of the group. But by and large such transference enactments are seen as interrupting the plan of the therapy. Often they are not explored fearing that to do so will endanger the alliance.

For focal psychodynamic psychotherapy such enactments become the focus of the therapist's attention and a pivotal part of his work. Each transference bound traumatic configuration contains certain landmarks:

1. The stimulus configuration (simple or complex) represents a current day form of the threatening situation itself.

2. The stimulus evokes a specific, usually highly complex affect experience associated with the trauma.

3. There is a plausible explanation within the trauma experience which links this specific stimulus with this complex affect.

4. The therapist occupies some role within, or extruded from the trauma configuration described by the near enactment.

Together, survivor and therapist in focal dynamic psychotherapy identify and clarify these four components in the current transference event. The therapist may then choose one of several directions, given the specific clinical picture with which he is confronted.

Where the intrusions threaten to disorganize the survivor's cognitive control, activating severe anxiety and dread, it is important to link the transference event back to the trauma in clear, simple, and plausible language. For example, in the preceding session a woman survivor of an industrial explosion and fire remembered waiting hopelessly but peacefully on a segment of the building as she prepared to die. In the next session the therapist was several minutes late. The patient entered in a panic stating a horrible dread had overcome her as she waited for him. "That moment of dread (waiting for me in the waiting room), is part of the same moment we spoke of when you realized the building (on fire) had collapsed around you and death was nearly certain. Now that you are safe you can afford to feel the panic that went with that moment.""

Sometimes chronic intrusions may be defensively guarded as a resistance to engaging a problem in current life. Here the therapist may link the transference event to the current difficulty being avoided. "You are so angry at me today at being late that memories of violence from Vietnam come back in which you retaliated against those who betrayed you. This is like the frustration and anger that you are feeling with your wife. It is so difficult to respond in a measured way, choosing instead to respond explosively or hold it all in."

Some traumatized survivors give us many clues as to the traumatic origins of their difficulties, yet these patients remain consistently numb and avoidant rather than disorganized by their intrusions. These survivors' psychic organization is fixed on the consuming task of disavowing the trauma. Here the therapist must exhibit empathy for the resistance rather than prematurely force a breakthrough. "We both need to appreciate how important it is for you into keep the specifics of the event away from your awareness.""

Traumatic events encoded in automatic memory repeat themselves mercilessly without integration or meaning in our patients. Allowing the stimulus of the relationship to the therapist to become part of these enactments and commenting on them in a plausible way within the context of the trauma may provide one avenue to open such events to narrative memory and to new schemata for integration and meaning.
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