Giving deeply traumatized refugees the space they need in which to reconstruct the boundary they have lost between reality and fantasy, while they face language and cultural barriers

Abstract

Germany faces a critical issue regarding how to deal with the high numbers of refugees coming from Asia and Africa; nearly 40% of them are deeply traumatized and in need of urgent psychological treatment. Cultural differences as well as language differences turn any psychological treatment with this vulnerable population into a challenge. Moreover, due to the increased number of refugees fleeing to Germany, many psychosocial centres have been struggling to attend these clients’ needs in an effective and efficient way – sometimes leading to the necessity of a short-term therapy which cannot address their full needs.

In this context,  psychoanalysis per se seems largely unpractical to be effectively applied to this vulnerable population, despite the valuable features it generally offers in the treatment of trauma. This paper brings an innovative technique grounded in the psychoanalytic theory of transitional objects– the use of a transitional object – where the transference work can be focused upon.  The transitional object helps to facilitate communication and assists with the psychological stabilization of traumatized refugees, as it allows the reconstruction of the boundary between reality and fantasy – lost during the experience of the traumatic event. This process enables the clients to deal with their internal world without fearing the splitting and disorganization of their internal world, therefore being able to internalize the transference work.

Keywords: communication, transitional object, trauma, interpreter

The refugee crisis in Europe has drawn attention to those who have been struggling to feel safe and to rebuild their lives in a ‘dream country’. Migration always embodies three phases: pre-migration, migration and post-migration, which together may result in a series of adverse experiences. Prior to migration and during the migration process, refugees may experience traumatic events such as war and violence, followed by torture and persecution.  Following migration, refugees are confronted with other challenges.  Issues playing a key role in contributing to other levels of distress include the length of the relocation, the degree of similarity between the home country and the country to which they are fleeing, language differences, and access to social support systems, employment, and educational opportunities, as well as acceptance by the new culture. From the need to leave home to the perils of migration, refugees and asylum seekers experience an extremely high prevalence of psychiatric disorders, usually depression and/or post-traumatic stress disorder – PTSD (Slobodin & Jong, 2015).   Nearly 40% of refugees are deeply traumatized (Bo Søndergaard, 2013; Burnett & Peel, 2001) and are thus in need of urgent psychological support. Nevertheless, the psychological centres in Europe are overcrowded and are unable to assist all of the refugees. Given the length of time and the expense of psychoanalytic treatment, it would not be feasible to apply psychoanalysis to such a large number of vulnerable people, despite its valuable contribution to the treatment of trauma. Recent studies report positive outcomes for short-term interventions, like narrative exposure therapy (NET) and cognitive behaviour therapy (CBT), when it comes to reducing trauma-related symptoms. Nevertheless, hardly any clients are in fact free from PTSD at the end of such interventions. So far, an intervention cannot merely focus on isolated symptoms, since other dimensions of personality, such as improvements in relationships, and social/cultural identity, should equally be included as indicators of intervention (Slobodin & Jong, 2015).

This essay proposes a novel form of intervention which is grounded in the principles of psychoanalysis.  It focuses on stabilization-work as a safe way to engage with this vulnerable population – the use of transitional phenomena to build communication while reconstructing the boundary between reality and fantasy which is lost during the experience of the traumatic event.

The Psychoanalytical Theoretical Background

In 1895, the term ‘trauma’ is presented in Freud’s work as an experience that may be caused by either a single central event or by the amalgamation of several partly traumatic events (Freud, 1895). With trauma implicated in the aetiology of neuroses, treatment intervention was based on catharsis as well as on the psychological processing of traumatic experiences. In 1920, as an excess of external stimuli which overwhelmed the protective barrier against overstimulation, therefore causing a lasting disturbance in ego functions, including a loss of ego integrity (Freud, 1920). Later, he understood trauma as a balance between internal and external danger (Freud, 1926b) – the ego was assaulted from within (instinctual excitations), as well as from without (adverse experience).

The features of an individual’s reaction to the traumatic experience are grounded in feelings of helplessness, which in turn are rooted in the trauma experienced at birth, alongside the loss of the ‘containing object’ (Grinberg & Grinberg,1989). Unquestionably, immigration consists of leaving behind one’s roots and moving in search of something still unknown and unclear. For this reason, a deprived refugee, metaphorically speaking, may be compared to what Winnicott referred to as the ‘deprived child’. Without doubt, any form of immigration not only involves a withdrawal from the ‘mother country’ for the individual, but also a loss of something good that has been positive in one’s life up to a certain point in time. In most cases, the withdrawal might last for a period of time which is longer than the containment feeling can be kept alive (Winnicott, 1971, 1984). When that occurs, the transitional space needed for ‘interplay’ between the culture of origin and the new culture (between the past and the future) remains restricted. Indeed, the new country obviously will be unable to fulfil all idealized expectations built on the losses left behind. Hence, the feeling of not being contained is to a certain extent real and not just phantasy. Due to different circumstances and depending on each individual’s personal experience, this can also trigger the feeling of not belonging anywhere – the feeling of being an outsider (Franieck & Günter, 2010) – which in turn challenges ego cohesion (Freud, 1895). Undoubtedly, by undergoing adverse situations, refugees and asylum seekers will probably experience their phantasies in a concrete, non-symbolic way that will inhibit abstract thoughts and symbol formations, while sparking fears of ego disintegration and disillusion. Consequently, the boundaries between the inner world and the external world (phantasies and external/real objects) become blurred, and the ego feels threatened (Caper, 1997; Grinberg & Grinberg, 1989).  Symbolization necessarily arises when separation from the object, ambivalence, guilt, and loss can be experienced and tolerated – (symbolization is used to overcome loss). Indeed, symbols are needed not only in communication with the external world, but also in internal communication (Winnicott, 1984).

The capacity to communicate with oneself by using symbols is, I think, the basis of verbal thinking—which is the capacity to communicate with oneself by means of words. Not all internal communication is verbal thinking, but all verbal thinking is an internal communication by means of symbols—words.” (Segal, 1957: 395-396)

Nevertheless, language issues present a challenge for refugees and asylum seekers. Indeed, often compelled to cope with mourning processes without experiencing a container object their ability to use symbolization might be severely diminished, bringing about a lack of communication – one of the key issues in the onset of psychosis. Needless to say, in any form of migration, a pattern of factors emerges which triggers anxiety and sorrow: individuals are forced to cope with mourning processes over and over again while facing future uncertainties. Immigration seems, therefore, to put an individual’s whole identity at risk (Grinberg & Grinberg, 1989), since some values from the previously introjected cultural ideal have to be sacrificed and/or altered (Franieck & Günter, 2010). Metaphorically speaking, this experience is almost an act of regression towards a primitive state where self-symbolization and language skills still need to be developed.

In this context, a psychoanalytically based intervention would still be the most suitable therapy for this particular population, since the analytical process is per se a process of communication. However, language issues pose another challenge since an interpreter has to be present.  Dealing with a triangular relationship leads to an unusual psychoanalytical setting. The interpreter needs to be integrated as an element belonging to the setting (it is often the case that he/she is a symbol of security for the refugee), however he/she does not belong to the client’s internal world, nor have an impact on it. Thus, the psychotherapist must be able to turn this triangular setting into a scenario in which the therapist is the leader (group psychology is being referred to here and not group psychotherapy). There are two things that need to be dealt with in this regard. The first is related to the triangular setting where the therapist should remain aware of the fact that the client and the interpreter share a similar cultural background – in most cases, they share the features of interdependent cultures (Franieck & Günter, 2010)  – and respect it. In other words, the therapist needs to not only be able to perceive him/herself as the third person in a triangular relationship, but also  to master his/her ambivalence (hatred/jealousy) while rediscovering his/her personal impulses (Winnicott, 1958). In doing so, the client can identify him/herself with the therapist through feelings of loneliness – a therapeutic bond can be constructed. The second aspect that needs to be dealt with is the immediate relationship between client and psychotherapist, which is independent from the interpreter and is the focus of analysis, with its verbal and non-verbal forms of communication. “This means that the recognition of projective identification is central to the understanding of the psychoanalytical material … The client does not only express himself through words. He also uses actions, and sometimes words and actions. The analyst listens, observes and feels the client’s communications. He scrutinises his own responses to the client, trying to understand the effect the client’s behaviour has on himself, and he understands this as a communication from the client.” (Riesenberg-Malcolm, 1999: 39-40]. “…[T]he analyst must have the capacity to be affected by the client’s projection- to form countertransference- in order to be sensitive to the client. But he must also be able to distance himself from the projection, so he may observe the countertransference … The analyst is indeed in a triangular relationship with the client, on the one hand, and his internal object, on the other” (Caper,1997:48).  Once again, coping with a triangular relationship is a key part of the process. Although it may appear that in this setting with clients who are refugees or asylum seekers there is an analytic dyad, there is in fact an analytic triad.  Metaphorically speaking, the immigration process evokes quite similar psychological responses to those found in the Oedipus complex, since when immigrating one has to abandon one’s ‘mother country’ in favour of a ‘new object’[1].

Creating a potential space as a technique

This technique aims to offer a potential (safe & structured) space (Winnicott, 1971, 1984), while trying to rescue symbolizations. Clients might feel their traumatic and awful phantasies are condoned as well as contained, whilst they also undergo a process of individuation.  An external object, such as a picture with very specific themes and drawings, is presented as a neutral point of communication between therapist and client (Winnicott, 1984). All communication between the client and the therapist will be done via this object and will not be based on direct intervention[2]. So, the client’s internal communication is projected onto the external object, while the therapist tries not only to understand what is being said, but also focuses on his/her counter-transference.  The interpretation needs to be less verbal, short and more concrete, which could, for example, be achieved by representing what the therapist understands through a picture.  Also, the transference needs to be understood as an emotional relationship experienced in the present – that is, the “here-and-now” [3](Riesenberg-Malcolm, 1999).  Two examples of this external object are presented below:

Discussion

The use of this technique has shown some improvement in the client’s emotional state after 10 months of treatment, based on fortnightly sessions[4]. Although the clients reported that they still had some PTSB symptoms, such as physical reactions, difficulty concentrating, and difficulty falling or staying asleep they also reported that they felt more self-assured in their daily lives. Of all[5] the clients who underwent this technique, only one abruptly interrupted a session (due to aggressive behaviour) and another two forgot the appointment on one occasion. Apart from these incidents, there were no other absences, no delays to the session, and no interruptions. In some cases, the clients were able to spontaneously talk about their traumatic event without fearing their ego disintegration. Depressive clients who used to wear only black clothes in the end came to the session wearing colourful clothing. Impulsive clients who used to leave the session began to stay for the whole session[6]. By the end of the treatment, most of the clients could understand my “verbal thinking” before the interpreter was able to translate it; however, they still depended on the interpreter to express their own “verbal thinking”. With regards to the interpreter’s role in this context, this technique gives more freedom to the therapist, since the basis for communication between client and therapist takes place using the external object.Discussion
A major concern for this technique is that the therapist needs to be able to come into contact with, as well as be receptive to, the client’s feelings, wishes, and phantasies (including the traumatic ones) without being dominated by them  – neither splitting, denying , nor projecting them (Caper, 1997) – which is quite demanding[7]. Indeed, the focus of the work, unlike the typical analytic session, must be based on a triadic relationship. It is true that most refugees and asylum seekers suffer from psychiatric disorders due to what they have experienced. Nevertheless, despite these adverse circumstances and traumatic events, they are all survivors, which suggests that they might have some singular psychological resources. I understand that many are unaware of their own potential. From my own point of view, the primary purpose of any kind of intervention is to help them to rediscover their potential, their sense of ‘self’.

ACKNOWLEDGEMENT

I would like to thank all clients who allowed me to communicate with them.

ABOUT THE AUTHOR

Maria Leticia Castrechini Fernandes Franieck, PhD, grew up in Ribeirao Preto, Brazil and studied psychology at the University of Sao Paulo. She practised Psychoanalysis as a Clinical Psychologist in Brazil for many years before moving to Germany in 2000. There, she carried out studies into cultural issues, leading to the award of her PhD in Natural Sciences (Psychology) in 2005, at the Faculty of Information and Cognitive Science, University of Tübingen. She carried out a study on Brazilian street children and has published several articles on this topic. Indeed, her studies have been funded by the International Psychoanalytical Association (IPA). Her clinical practice is focused on the work with very at risk populations, such as forensic patients with personality disorders and traumatized refugees. In addition, she supervises individuals, groups and teams. Dr. Castrechini Fernandes Franieck is a registered Counselling Psychologist with the Health & Care Professions Council in the UK (HCPC); she is a Chartered Member with the British Psychological Society (BPS), a member of the International Association for Forensic Psychotherapy (IAFP), and an Associate Member of the German Society for Supervision e.V. She is the author of   ‘On Latency: individual development, narcissistic impulse reminiscence and cultural ideal’; and ‘Communicating with and Outsider’ (to be published in 2018), Karnac Books, London.  Please contact: dr.franieck@gmail.com

REFERENCES

Bo Søndergaard Jensen (2013). Treatment of a Multi-traumatized Tortured Refugee Needing an Interpreter with Exposure Therapy, Case Reports in Psychiatry, vol. 2013, Article ID 197323, 8 pages, 2013. doi:10.1155/2013/197323.

Burnett, A. & Peel, M. (2001). Asylum seekers and refugees in Britain: The health of survivors of torture and organized violence. British Medical Journal, vol.322, 606-609.

Caper, R. (1997). Symbol Formation and Creativity: Hanna Segal’s Theoretical Contributions. Bell, D. , Reason and Passion: A Celebration of the Work of Hanna Segal. New York: Routledge.

Franieck, M.L.C.F. & Gunter, M. (2010). On Latency: individual development, narcissistic impulse reminiscence, and cultural ideal. London: Karnac Books.

Freud, S. (1895/1975). Studies in Hysteria. Standard Edition II (pp. 183-253). London: The Hogarth Press.

Freud, S. (1920/1975). Beyond the Pleasure Principle. Standard Edition  XVIII (pp 1-65). London: The Hogarth Press.

Freud, S. (1926b/1975). Inhibitions, Symptoms and Anxiety. Standard Edition XX (pp 75-177). London: The Hogarth Press.

Grinberg, L. & Grinberg, R. (1989). Psychoanalytic Perspective on Migration and Exile. London: Yale University Press.

Riesenberg-Malcolm, R. (1999). On Bearing Unbearable States of Mind. London: Routledge.

Segal, H. (1957). Notes on Symbol Formation. International Journal of Psycho-Analysis, Vol. 38, pp. 391-397.

Slobodin, O. & Jong, JTVM (2015). Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy? International Journal of Social Psychiatry, Vol. 61(1) 17 –26.

Winnicott, D. W. (1958). The Capacity to be Alone. The International Journal of Psychoanalysis, vol. 39, Sep-Oct, pp. 416-420.

Winnicott, D. W. (1971). Playing and Reality. London: Tavistock Publications

Winnicott, D. W. (1984). Deprivation and Delinquency. London: Tavistock Publications.

Leticia Castrechini-Franieck may be contacted at: leticia.franieck@uni-tuebingen.de

[1] It is no wonder that the Oedipus tragedy begins with Oedipus’ immigration.

[2]One needs to keep in mind that due to what they have experienced, most of the time, any direct interventions might trigger mistrust as well as shame. Mistrust between therapist and client can reinforce an alliance between client and interpreter, which changes the setting.

[3] The aim is not to give interpretations of the client’s past history; since this could evoke more flashbacks as well as intense feeling of distress. The “here-and-now” needs to be worked out as an expression of the client’s past in multiple transmutations (Riesenberg-Malcolm, 1999).

[4] A fortnightly session is not enough; however, in the current context it is a luxury.

[5] Around  20 clients.

[6] This technique is also very useful for pacifying personality disorder clients during crisis intervention.

[7] In practice, a precondition for this technique is that the therapist needs to have undergone an analytic treatment and/or is closely supervised.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: