**4. Discussion**

*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

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

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

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

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*

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

account clearly reveals a fear of self-loss, of depersonalization.

he reported.

mission.

Our research's results draw attention to some of the established theoretical concepts that therapists acquire through their trainings and hold in their background while working in trauma clinic. Representation of neutrality in psychotherapeutic work refers to the first Freudian conceptualization of countertransference (1910) whereby he urges the analyst to have an attitude analogous to that of a surgeon [1]. Neutrality is to be understood here in the sense of the imperturbable, as Donnet highlighted in his article "Neutrality and the gap subjectfunction" [19]. Nevertheless, while exploring the therapists' elaborations on specific clinical situations, theoretical stances seem to fade in favor of the clinical experiences as experienced hands on. Therefore, we can note particularly intense countertransference reactions that seem to disrupt the therapist in his/her theoretical assets, consequently unsettling his/her professional identity.

The dread produced by the trauma entails a threat of self-annihilation, hence, mobilizing defense mechanisms that are immediately operated by the person. These defenses—actualized in narratives of traumatic experiences—induce a major part of countertransference reactions. In this sense, actualized defense mechanisms deployed by the patient during the session underpin the countertransference reactions of the therapist, a sort of countertransference that is specific to the encounter with trauma.

The fascinating encounter with the unthinkable of the trauma conveys traumatic substance through infra-verbal channels. This substance is deposited into the therapist's psychological system. Yet, as Bion [20] elaborated, this psyche is the means to transform the beta elements (raw, unthinkable, unlinked sensations) into alpha elements (representable, metabolizable elements). What happens then, within the therapist's psyche, when these unidentified sensations are deposited into him/her through projective identification mechanism, making him/her share the unedited transgressive experience? We witness then an attack of the thinking capacity of the therapist. For instance, the slips highlighted in the results seem to underline a strong resonance with two mechanisms deployed by the patient: one, dissociation, through the therapist's concordant identification with the patient's self; and two, an identification with the aggressor, in an attempt to escape the helpless state of the patient, through mobilizing complementary identification, in the sense that the therapist identified with the objectaggressor incorporated by the patient.

On one hand, trauma seems to revive the "unshaped substance" of an era associated with cruelty, which itself could be the origin of the feelings of shame, and the threat of unsubscribing from the peers community. On the other hand, archaic resurrections of cruelty are hardly bearable by the therapists, at least in the first phase. Such archaic resurrections seem to obstruct the thinking and elaboration capacities of the therapists, even within the framework of supervision, which is supposed to act as a holding and transforming space for these feelings.

As Heimann stated in [21], such elaboration spaces are supposed to render the analyst capable of containing feelings within him/her, instead of simply expelling them as the patient would do, in order to subordinate these feelings to analysis, whereby the therapist functions as a mirror reflection for the patient.

Nevertheless, it would be misleading to believe that the countertransference analysis grants the analyst the possibility to control his/her inner reactions, as Freud urges [1]. Margaret Little [22, 23] formulates the concept of countertransference analysis as an insufficient remedy with inevitable remains unconscious infantile countertransference.

Some of the interviewed therapists, described timidly and with a surprised tone, the resurrection of what they qualified as "archaic," despite the long personal analysis and regular supervision that they have engaged in. It is significant to note here that the supervision space is not always experienced as a room for free and spontaneous expression, but rather, as a space wherein the therapist is required to intellectualize his/her countertransference experiences. This brings to mind what Heimann [21] highlighted regarding the difficulties that analysts face to admit their errors and discuss the issue "we all have our private cemetery, but not all graves have tombstones."

Another aspect of countertransference which emerges in the interviews, is that related to cultural issues. In line with Devereux [8] and Nathan's theories [24], Moro [25] specifies that the cultural countertransference emanates from the inner stance of the therapist and influences this very stance regarding the patient's otherness. The stance is underpinned with the therapist's personal history, as well as the collective, political, geographic, and socioeconomic history. In contexts of expatriation, therapists sometimes describe a phase of loss of cultural references and know-how, and find themselves confronted by a double-layered otherness: the first being the trauma, and the other being cultural otherness. The difficulty facing trauma sometimes resorts in disregarding cultural interpretations and making generalizations to make sense of an utterly painful situation and put a protective distance with the patients' culture of origin. At first level interpretation, the cultural dimension seems to have obstructed the possibility of engaging in therapy: The therapist was confronted by a dead-end that of cultural difference. However, what we observe here is a displacement of the products of traumatic reality lived by the therapist, for instance the unbearable guilt and violence, and relocating them to the "stagnant" and "unchangeable" host culture itself, in a defensive move that consequently maintains security for the therapist, by masking social injustices and deferring the dread for reality until a further notice. The violent socioeconomic reality—which is probably a source of guilt for non-governmental organization staff (who live in relatively comfortable conditions in comparison to the context's reality)—is conflated with the violence of cultural otherness, and probably with the violence of the trauma problematic. Clearly, in humanitarian contexts, expats often find themselves obliged to "pick and choose" the patients they accept in their programs. They too, engage in prioritizing needs/demands, and thus, operate on basis of selectivity. What we observe here is a displacement mechanism: the therapist, deployed in a foreign culture, is confronted by a traumatic encounter with traumatized patients, from a target population that is enduring severe socioeconomic precariousness. Defensively, the therapist assigns to the host culture, the unbearable guilt of having to select and to prioritize. Thus, the culture becomes the platform within which this violence is contained and made sense of. The transgressive aspects of the trauma narratives are the most implicated in the disqualification of the patients' culture of origin. The transitory disruptions in the therapists' beliefs highlight the particularly intense mobilization of countertransference reactions to trauma. Exploring the disorganization in each therapist's narrative structure reflects the style of that therapist's defense mechanisms implicated in countertransference.

This double-layered otherness, trauma and cultural difference, questions the therapist's identity, both, the professional and the human, hence, disrupting their working capacity at certain times.
