**3. Results**

Using the IPA, three themes emerged from the therapists' narratives about their countertransference: (a) personal therapy as a condition and theoretical views on neutrality; (b) attack of the therapists' thinking capacity triggering shame, guilt, and change in worldview; and (c) therapist's issues concerning patients' cultural difference. We will document in the following these three themes reporting when necessary excerpts from certain therapists verbatim. Each therapist is identified by the letter T. followed by a number.

#### **3.1. Personal therapy as a condition and theoretical views on neutrality**

The interviewed therapists highlighted the importance of personal analysis as a condition that promotes countenance capacity and elaboration of the countertransference reactions. For instance, T.10 considers that "*the essential part in therapeutic work in general, but especially with persons who have underwent traumatic experiences, is the personal analysis of the therapist. It is about being constantly vigilant and conscious about everything that is happening, of what we are experiencing with the patient, because the narratives are usually very heavy. A narrative loaded with death drive, aggressive drive, a lot of violence, a lot of themes about death and loss. I consider it to be a very dense narrative that the patient can throw in our face, and if we are not protected enough, it is not an obvious task to really treat the verbal expression, the patient's narrative and help him/her elaborate on his/her experience by himself/herself"*.

Therapists head into the journey of trauma clinic with theoretical a priori deployed to anticipate more or less such encounters, mobilizing defense mechanisms that are eventually constructive and useful for their thinking and elaboration capacities. "Theoretically," or as some interviewees would say "ideally," the therapist should be in a neutral and welcoming listening position as T.10 explains: "*I believe that in my practice the following was essential: how to be able to dissociate my inner experience of the patient's narrative from his/her experience, in order to be neutral in my work, to have a benevolent listening as they say, to be interiorly available for the patient's account."* In response to the question about being affected by a certain situation reported by the patient, some painted a caricature of the affects that could overwhelm the therapist, such as T.9 who says: "*to be affected and say: oh my god, and start crying with the patient? No, no. I don't believe this is what the patient came to look for, or that it could be of any help. So if it is a demonstration, then no. To let yourself get affected by all cases isn't of any help"*; others imagine a pragmatic schema to protect themselves, such as T.1 "*well, I believe that if you are already well protected, it won't affect you. You come, you already have your barriers and so you have your stuff with you that are solid enough. You are able to separate things, have empathy with the patient, help her, and then clean yourself up afterwards, and you are fine."*

The narratives of humanitarian workers are informative on two levels: (a) the countertransference reaction is one that occurs on-the-spot, in an unusual environment and within an unfamiliar framework for the therapist, and usually in a context wherein certain traumatic events have happened); (b) it allows the observation of a "disquieting strangeness" in the making, throughout the course of the therapeutic relationship, leading to creativity at some times, or to a deadlock in the therapeutic elaboration at other times, and consequently, resulting in a disrupt, or even in the loss of empathy [16, 18]. Finally, it is specifically interesting to see the evolvement of the therapist's narrative and changes in their positions throughout the whole

170 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

The objective of our research was to approach the subjective experiences of therapists as closely as possible, through their own narratives. Each interview encompassed the therapist's theoretical background and training, the story of his/her personal traumatic experiences, the context of his/her work, and finally, the description of a specific situation he/she had with a patient. In the last part, the therapist reported the situation, his/her emotional, physical and cognitive reactions, in addition to his/her dreams, and the emergent scenarios towards the

Using the IPA, three themes emerged from the therapists' narratives about their countertransference: (a) personal therapy as a condition and theoretical views on neutrality; (b) attack of the therapists' thinking capacity triggering shame, guilt, and change in worldview; and (c) therapist's issues concerning patients' cultural difference. We will document in the following these three themes reporting when necessary excerpts from certain therapists verbatim. Each

The interviewed therapists highlighted the importance of personal analysis as a condition that promotes countenance capacity and elaboration of the countertransference reactions. For instance, T.10 considers that "*the essential part in therapeutic work in general, but especially with persons who have underwent traumatic experiences, is the personal analysis of the therapist. It is about being constantly vigilant and conscious about everything that is happening, of what we are experiencing with the patient, because the narratives are usually very heavy. A narrative loaded with death drive, aggressive drive, a lot of violence, a lot of themes about death and loss. I consider it to be a very dense narrative that the patient can throw in our face, and if we are not protected enough, it is not an obvious task to really treat the verbal expression, the patient's narrative and help him/her elaborate on his/her*

Therapists head into the journey of trauma clinic with theoretical a priori deployed to anticipate more or less such encounters, mobilizing defense mechanisms that are eventually constructive and useful for their thinking and elaboration capacities. "Theoretically," or as some interview-

therapist is identified by the letter T. followed by a number.

**3.1. Personal therapy as a condition and theoretical views on neutrality**

interview.

trauma narrative.

*experience by himself/herself"*.

**3. Results**

In the same interview for instance, we can notice the gap between the theoretical stance and the lived experience. On that note, T.10 says: "*well yes, during that moment, the limit wasn't clear anymore. For a while, maybe for a minute, I was myself absorbed by what she was saying. It was as if I was in the scene, I was looking at the scene from an outside perspective. And really, there was a feeling of revolt, a feeling of rage. She was sad and I was revolted."* We can also observe this feeling of being within the scene of the traumatic event in T.1's narrative, who, while recounting his experience of the patient's traumatic event narrative, says: "*I saw all the scene happening, I saw all of that, I was there."*

#### **3.2. Attack of the therapists' thinking capacity triggering shame, guilt, and change in worldview**

T.1 describes his experience while listening to the trauma narrative of his patient *"in this situation, feelings were all confused. There were my feelings, actually the feelings the patient would give me, and then the feelings that a therapist is not supposed to have: injustice, the need to stop the therapy, disgust, the need to vomit, things like that, well, a therapist is not supposed to feel this, but at that moment, I had them*." He repeats twice that a therapist is not supposed to experience such feelings, thus, leading us to the issues of shame within the community of peers and guilt regarding what the professional superego imposes. He continues "*my stomach was knotted with the need to vomit, I felt disgusted, I was horrified and all. I believe that this is all the countertransference of the other, and the need for injustice."* Herein, we witness an obvious disorganization of the narrative that exposes two Freudian slips: the "countertransference of the other" and the "need for injustice."

The theme of shame recurs in another sequence—in the frame of a post-trauma therapy group interview: a young therapist had of her patient, the image of a Minotaur, a devouring monster. She contemplates the emergence of this image as follows: *"I had a feeling of shame, of disgust by myself, to have had such a feeling that I am not supposed to have. I was a trainee in a learning position, confronted by something that was very disturbing; I know somehow, from what I have learned during my studies, that what I feel towards the patient is good, in the sense of a countertransference reaction that is generally useful working with the patient. But the intensity to that extent was disrupting. In a* *supervision group, I would express this experience in a more intellectualized way, in terms of dehu‐ manization. I wouldn't have been able to express it as is. I am dealing with an image of an aggressor, to whom I am supposed to be welcoming. I see the patient as an aggressor, like the Minotaur who is aggressive, it devours."* The therapist here is deeply disturbed by her discovery of certain cruel sensations in herself towards this patient and by being prompted into an archaic fantasy of devouring. T.1 had also referred to "something archaic" that was awaken in him in the situation he reported.

In this sense, T.9 says: "*On the long term, it is inscribed in us (…). Thus, it is repetitive, and indeed, we are much more sensitive to what happens in the world around us."* This heightened sensitivity is also reported by T.8 who describes a sense of a widening gap with others once she is back from her mission, she says: "*for example, I go to a movie that takes place in a shantytown. The movie contains lots of scenes happening in the shanty town where I had worked, of which I was an indirect witness with the children. And in the movie, it is so distant from the reality of the spectators, and I had this feeling that people around me were not in the reality. They could almost laugh or… well I had cried as if … I was crying out of shock. (…) It was terrible because the shanty town, at some point, is put on fire, and the shanty town where I was, had been put on fire by the authorities in order to empty the terrain (…) and there were children and families who died there (…). For me, it was serious; it is something that happens in real life. So, not only was there a whole gap between me and the people in the audience, but really I felt almost traumatized."* As shown in these illustrations, therapists report a change in their worldview once they return to their home country in the aftermath of a humanitarian mission.

#### **3.3. Therapist issues concerning patients' cultural difference**

In contexts of expatriation and inter-community differences, therapists tend to highlight the cultural differences as a difficulty or sometimes as an impediment to the therapy with the patient. In this sense, T.8 explains " *I am always afraid that they (the target population) see me as a traditional therapist or a priest or something. In my dream, I had that role in the ceremony*." This account clearly reveals a fear of self-loss, of depersonalization.

T.9 recounts a situation wherein she was confronted by a mother who—as T.9 puts it— "*preferred to let her child die"* of malnutrition. T.9 found herself incapable of helping the mother, or of providing her with therapy: "*when it is about a mother who is really 'closed,' I don't understand the culture she lives in, I don't know enough to understand this mother, what motivates this mother to do so. I don't know how to help her get out of this circle. Therefore, I passed it over."*T.9 refers to culture without grounding her account in any etiological theory or cultural genealogy. Moreover, she says: *"well, I mean, I can understand that for some mothers who have five or six children, and who live in economic situations, in some countries where they cannot find ways to nurture their children, the only way would be indeed to have one child who suffers malnutrition, as a way to benefit from food program's help for this child, and then share the food with the others, while letting this one die, because in all cases he is already malnourished, and thus 'uninteresting.' So, in a way, in such situations, mothers can be violent with these children. Well, I understand her functioning modality. I understand why she is like this. Nevertheless, what I can't always do is to find a way to make her understand that this is a child, this is a life. Wouldn't there be other means? Can't we together find other means to help feed the* *others without letting this child die?"* So for T.9, this mother had been forced to pick and choose between her children, as she was unable to feed them all. This functioning would be grounded in "cultural thing." To another question in the interview, the same therapist responds: *"well… actually, in general, whether it is within a humanitarian action or not, we arrive with a mandate and a specific project. Therefore we cannot accept all of the patients who had been traumatized, not when they do not fit our program. Therefore yes, there are persons that we do not accept in the program. And there are persons whom we accept, because, well, we know it entails other implications."* This statement highlights another cultural specificity that regards the non-governmental organization's culture of implementing programs.
