**2. Methods**

his/her interaction with the cultural difference of the other, who is in this case, the traumatized patient. Our objectives are to explore the mechanisms implicated in trauma transmission through countertransference reactions in therapists working with traumatized patients and to depict and analyze the processes that could potentially lead to vicarious

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

Countertransference is a concept originally coined by Freud [1], referring to the unconscious reactions of therapists to their patients' transference. The classical definition postulates that the implications of a therapist's unresolved childhood conflicts on their reactions require

A broader perspective on countertransference suggests a more totalistic definition [3] and includes the total emotional reactions of the therapist to the patient [4]. Such emotional reactions relate to a variety of factors, such as the therapist's life experiences, inherited internal unknown objects [5], personal psychoanalysis experiences, and theoretical affiliations [2] in interaction with the patient's transference. Therefore, countertransference reactions are bidirectional and refer to the inter-subjectivity of the psychotherapeutic dyad of patient and

In the totalistic perspective of the psychoanalytical theory regarding countertransference, the latter is an essential tool in helping the analyst better understand the patient. The analyst is expected to position himself/herself as a subject of observation and analysis, in order to acquire

Additionally, Balint examines countertransference reactions in non-psychoanalytical situations, focusing on the presence of subjectivity in all therapists and its countertransference mobilization in all types of therapeutic relations [7]. From the same perspective, Devereux [8] broadens the concept of countertransference to include the social sciences and their impact on the findings of research conducted in this domain. Devereux [8] introduces the concept of cultural countertransference, which is related to the position the therapist adopts towards the otherness of the patient and to the latter's cultural codes and perceptions of illness. According to this perspective, cultural transference and countertransference are also influenced by history, politics and geography. Thus, any non-examination of cultural countertransference will compromise the therapeutic alliance and will enhance the risks of aggressive, affective,

This aspect of countertransference seems to be of particular interest in the therapy of traumatized patients, although it has sparsely been investigated. Over the past two decades, many studies have investigated the impact of trauma work on therapists who work with trauma patients through the identification of emotional, cognitive, and physical countertransference reactions [9–14] and trauma transmission elements [15]. This accumulation of research has led to innovative concepts such as secondary traumatic stress and compassion fatigue [10],

traumatization.

therapist [6].

the required objectivity [4].

and racist acting-outs [8].

vicarious traumatization [11], and empathic strain [16].

**1.1. Countertransference and trauma clinic**

examination in order to be controlled [2].

The clinical material in our research was collected through interviews with ten therapists working with traumatized patients, in a humanitarian intervention context, within which the therapeutic encounter is mostly short and intense. The encounter can occur between an expatriate therapist and a patient, or between a foreign therapist and the patient's community of affiliation. The therapists were recruited through humanitarian institutions that provide psychological care programs in critical contexts (natural disasters, war zones) or within their development missions (malnutrition programs in precarious contexts). We have contacted the heads of psychological programs departments in the humanitarian institutions to explain the research. We have then sent an email explaining the research objectives, the interview procedure, and the possibility to withdraw their participation at any stage of the research. Therapists who were interested in participating to the research contacted us by email. All those contacted met the selection criteria as we had targeted NGO's providing programs in trauma clinic. We set an appointment for the interview that would take place at the researcher's office or the participant's office, at his/her convenience. In a later stage, the interview analyses were sent back to the participants to have their validation of the results.


**Table 1.** Participants' characteristics.

Our interviews lasted one and a half hours each, were recorded and transcribed, and then analyzed using the interpretative phenomenological analysis (IPA) methodology [17]. IPA provides a dynamic approach of the material and privileges a close access to the participants' experience of the studied phenomenon. The researchers' conceptions of the phenomenon are used to make sense of the participants' personal world through an interpretative activity. Participants' characteristics are described in **Table 1**.

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 interview.

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 trauma narrative.
