Psychiatric experience with perpetrators and countertransference feelings in the therapist.

Abstract

Therapeutic work on man-made disaster victims is work which leaves no one untouched. It is the kind of work that, in many ways, frequently involves therapists personally. It may also be the cause of vehement disagreements about treatments, resulting in fights and splits in treatment teams. The work may end tragically. I think this also applies to treatment of that other category of people involved in man-made disaster, the perpetrators. However, we know much less about this. Danieli (1) made a study of the countertransference feelings of about 60 Holocaust survivors' therapists. She came up with, among others, the following themes: guilt, rage, dread and horror, grief and mourning, shame, inability to contain intense emotions, and utilisation of defences such as numbing, denial and avoidance. It is remarkable to find in her description the way in which therapists are inclined, with regard to Holocaust survivors, to act as their 'parent(s)' or their 'child'. Acting the part of the parent, in terms of Transactional Analysis, the Negative Nurturing Parent, the therapist especially wants to prevent, out of fear and guilt, the patients from suffering again. The therapist may also move into the position of the Negative Controlling Parent when he/she gets infuriated by the patient because of his/her very obstinate complaints, or because the patient attributes the part of the persecutor (the Nazis) to the therapist. In terms of Transactional Analysis one may also watch the therapist taking up the Child-part. This is expressed in many ways in the above-mentioned thematical row and the reason behind this is that the therapist wants to behave like a good child, with respect to the parents who have already suffered very much and who have to be spared by all means. Furthermore, the therapist is a fearful child, because he cannot cope with these horrible stories. The therapist is also ashamed because he has not experienced anything of this suffering himself. Moreover, the therapist may act like a strong child that would preferably quickly save its parents by means of its power (and impatience!). Eventually, the therapist may come to look at these helpless, unsavable parents, as being quite tiresome. Also the danger exists that a sadistic child will look for sensational stories that may offer extra suspense: the 'child' in the therapist will continue to ask exaggerated and needless questions about persecution and war stories. The psychological effects of working with victims are described in a different way by McCann and Pearlman (2). The significance of their account is that because of the material the patient's state of being traumatised the therapist risks the danger of becoming traumatised himself. Therapists themselves get nightmares, fearful thoughts, intrusive images and become suspicious towards their fellowmen. These authors think the nature of the material itself is dangerous to several basic securities that the therapist, as a human being, has concerning himself and the world. Under the influence of the powerlessness of the patients the idea arises that having a grip on life is an illusion. In addition, the therapist working with victims may become estranged from his family, his friends and his colleagues, because he is exposed to tales of horror and confonted with a cruel reality. Perpetrators of violence against their fellowmen are numerous in our world. At first sight, it is remarkable that we do not know much about the psychological effect that treating dangerous criminals, torturers and war criminals of major or minor calibre has upon a therapist. Part of the explanation may be that treatment is often restricted to somatic treatment by a general practitioner, a jail practitioner or an internist; as far as psychological or social guidance is concerned, it is frequently of a psychotechnical or psychosocial nature. From forensic psychiatry we know something of the psychological effect on therapists treating perpetrators. Nevertheless, one might expect more literature on the topic, besides that to do with the treatment method and psychodynamic observations. Treating those who commit incest will, for example, indubitably provoke several reactions from the therapist. The following may be looked upon as a series of impressions gained over the last 25 years or so. These are mainly related to psychiatric examinations, psychiatric-medical, and social psychiatric contacts, as well as psychotherapeutic treatment. Being a consultant in the field of psychosomatic diseases, and, later on, working for the Jewish community and for victims of World War II, I came into contact with