40(4):466-472,1999

CLINICAL MEDICINE

Countertransference and Empathic Problems in Therapists/Helpers Working with Psychotraumatized Persons

Eduard Klain, Ladislav Pavi
Department of Psychological Medicine, Zagreb University Hospital Center, Zagreb, Croatia

Countertransference in therapists working with patients with posttraumatic stress disorder (PTSD) differs from countertransference in other psychotherapeutical settings. In this article we discuss the specificities of counter- transference in treating PTSD patients and its relation to empathy. The most difficult countertransference problems occur in treating multiply traumatized patients. Countertransference may occur towards an event (e.g., war), patients who have killed people, as well as to colleagues who avoid treating PTSD patients, or towards a supervisor who avoids, either directly or indirectly, supervision of therapists working with PTSD patients. Our recommendation for the prevention of problems in treating PTSD patients include : 1) careful selection of the therapist or helper, both in the personality structure and training; 2) prevention by debriefing and team work and peer supervision; and 3) education theoretical, practical, and therapeutical.
Key words: Croatia; defense mechanisms; ethnic groups; identification (psychology); psychoanalytic therapy; psychology, clinical; PTSD; psychotrauma; war

Due to the fact that patients with posttraumatic stress disorder (PTSD) have suffered one or more horrible experiences, countertransference in their therapists is differently stimulated than in other psychopathology therapies. PTSD patients also tend to have dangerous and terrifying reactions; their reality is very harsh and their destructiveness can be felt almost bodily. These patients exhibit a tendency to sadistic torturing of the therapist. For example, they present to the therapist with a horrible story and watch for his or her reaction. They are satisfied only when the therapist is horrified. From the very beginning of therapy they have great demands from the therapist. It is quite often that the therapist cannot endure this situation, allowing thus the countertransference to break out. This is then felt by the patient as a proof of the therapist's incapability and disinclination. Lack of confidence is one of the major characteristics of PTSD patients and is highly frustrating to the therapist's narcissism. Most often they reproach the therapist for not having gone through what they have, consequently producing the feeling of guilt in the therapist. Patients suffering from PTSD think that they are really ill legitimately and legally ill. They think to have that right because of what they have suffered, similar to psychosomatic patients. Both types of patients want to be different from psychiatric patients. Because of this, guidelines for clinical practice in treating these patients can be confusing. Some authors think that empathy is not the type of approach to a 466

difficult patient because one cannot empathize with him due to great differences in the emotional life between him and the analyst. His projective identifications can be accepted only through countertransference. Others think that only through empathy one can communicate with such patients. Before discussing this in detail, we should try to define several important issues. Freud wrote very little about countertransference (1,2). Countertranference is defined as a complete emotional relation of the analyst towards the patient; as a response to the transference reactions of the patient and as transference of the therapist towards the patient (3-7). In his discussion on the creation of counter- transference, Stein (6) starts from two opposing theoretical attitudes: a) countertransference is a creation of the analyst, and b) countertransference is a creation of the patient. If it is a creation of the therapist, says Stein, then it is an interactive process between two persons, and the analyst creates countertransference through the identification with the patient: ...transference is possible only if the analyst is sensible to these emotions (which the patient transfers). If the theory or his personality prevents him from having the same emotions (as the patient) in a clinical situation, then nothing can enable the patient to transfer his emotions onto the analyst. Another therapeutic approach (3) says that countertransference repre-

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sents a creation of the patient, which is transferred onto the analyst through projective identification. Empathy is both similar to and different from countertransference. It is an important factor for both participants in the psychoanalytic process. Like countertransference, empathy is the analyst's experience or his creation by which he communicates with the patient in analysis. Empathy and countertransference have in common that they are both emotional categories emerging in the relationship with the patient in the here and now situation. They primarily help the analyst, but also the patient, to understand emotionally the analytical process and to interpret it both to himself and to the patient. In this way, both empathy and countertransference contribute to the mutual development of both participants in analysis. It is known that Kohut's self-psychology gave a special role to empathy as a therapeutic factor. For Kohut, Goldberg, Wolff, and others, empathy is the emotional knowing and vicarious introspection, which can be explained as a projection of one's own personality into someone else in order to understand it better (8,9). Wilson and Lindy (7) say that empathy, identification, and countertransference are interrelated processes. Slatker (10) argues that the relation between empathy and countertransference depends on what he calls counter-identification, as well as on the identification with the client's inner world of affect and psychological being. He suggests that, through the process of counteridentification, the analyst both identifies with the patient and at the same time pulls back from that identifications so as to view the patient's conflict with objectivity. From this viewpoint, empathy is based on counter-identification; indeed it is counter-identification that permits our empathy to be therapeutically useful. But counter-identification is also a component of countertransference, and if it operates imperfectly, whereby objectivity is not achieved, then the analyst's negative countertransferential reactions can cause empathy to diminish or to vanish altogether. Specificities of Countertransference towards PTSD Patients The transference-countertransference sequence is an interactive process and may stimulate reactions (e.g., emotional states, memories, fantasies, and creative insights) in both the patient and the therapist. As noted initially by Winnicott (11), the interactive processes of treatment makes counter- transference inevitable, including objective and subjective forms of reaction. Gorkin (12) has reviewed this distinction between objective and subjective reactions. What is of primary interest to me, he writes, is that type of response which is the counterpart, or expectable, response to the patient's personality and behavior objective countertransference. I distinguish this type of countertransference from the kind of response that is due to the analyst's personal conflict or idiosyncrasies subjective countertransference. Maroda (13) has revived Racker's (4) seminal concept of dual unfolding: Transference unfolds in conjunction with the countertransference... From an interpersonal perspective, the countertransference can be as important as the

transference, and the person of the therapist can be almost as important as the person of the patient. The concept of dual unfolding further states that countertransference is a multidimensional phenomenon that includes 1) affective reactions (e.g., guilt, shame, anxiety, and tension), which are a part of the psychobiological capacity for empathy; 2) cognitive reactions (e.g., fantasies and mental associations); and 3) dispositions to act in idiosyncratic or need-based ways toward the client as a part of an ongoing interpersonal process (e.g., prosocial advocacy and rescuer reactions). In the treatment of PTSD and allied conditions, the potential for developing both objective and subjective countertransference is quite significant because of the intensity of the transference process presented by a trauma survivor (14-18). Survivors of extremely stressful life events disclose trauma stories that are loaded with affective intensity and description of human experiences that often far exceed the boundaries of a just, equitable, and fair world, so that they cause the therapist to be taken aback and temporarily dislodged from an empathic, objective, and nurturing professional role. Willson and Lindy describe the complexity of the countertransference towards the PTSD patient (7): Within the trauma role paradigm outlined here, the therapist's inner position may be 1) concordant or in consonance with a given survivor's role, such as outraged but helpless victim; 2) complementary to the survivor position, such as condemning judge as complement to guilty survivor; or 3) disjunctive with the survivor position because the therapist's inner position derives from unique personal trauma circumstances, such as counterphobic comforting and rescuing response that fails to appreciate the survivor's position of avenging rage at the perpetrator. The therapist may be cast in potentially positive roles within the trauma membrane, such as protector, rescuer, comforter, or fellow victim, or in negative roles outside the trauma membrane, such as perpetrator or fellow victim turned enemy (e.g., Nazi prison guard/kapo). The therapist may be feared as a judge, or aspects of the therapist's attitudes or working conditions may be seen as noxious extensions of the same social, environmental, and/or governmental policies that permitted or encouraged the trauma. Paradoxically, in the unconscious effort to turn passive into active, a therapist may find himself/herself attacked by a patient in such a way that the patient has assumed the perpetrator role and the therapist is now the victim. Determining which role is active within a given countertransference tendency plays an important part in permitting the treatment to resume its atmosphere of empathic enquiry rather than aborting in a repetition of the trauma. Specificities of Empathy towards PTSD Patients It is well known that empathy plays an outstandingly important role in treating PTSD patients. Empathy is one of the major therapeutic means in treating these patients, and through empathy a lot of healing exchange between the therapist and the patient takes place. There are several types of empathy of therapists treating PTSD patients. 467

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Empathic Withdrawal (Type I Countertransference) Therapists at risk from withdrawal tendencies are likely to have been spared from a personal catastrophic trauma; their view of the world preserves the ideas that life is decent and just. The client's traumatic stressors often include loss, disillusionment, and threat to life. Hearing about these experiences commonly evokes unpleasant affects, such as horror, dread, fear, hostility, or vengeance. In order to avoid pain and preserve their world view, therapists unconsciously distance themselves from this affect by mechanisms such as denial, disbelief, disavowal, and isolation. The therapist engages the countertransference coping mode of empathic withdrawal in several forms: blank screen facade, intellectualization, and misperception of dynamics. Empathic Repression (Type I Countertransference) Unlike withdrawal, therapists at risk from the repression mode are likely to be those who have experienced and continue to suffer from their own traumas. In fact, there is an overlap here between the work the therapist must still do and an area of the client's trauma wound. While other aspects of the trauma may become productively engaged in a treatment process, this area remains out of bounds in an unconscious collision between the two victimized survivors. For example, one unresolved traumatic stress might involve loss, so that grief, the corresponding affect state, is not engaged, acknowledged, or expressed. It is as though the therapist's inability to work through this component of his or her trauma is protectively identified onto the client. In the limited area of the psychic wound, the therapist exhibits empathic repression, featuring withdrawal, denial, and distancing. The therapist feels no need to explain the absent segment of work; he or she simply does not see it or appreciate its significance. Empathic Enmeshment (Type II Countertransference) Therapists at risk from the enmeshment mode countertransference are largely those with considerable trauma of their own. Typically such therapist's formal education may be incomplete, although they usually engage with trauma survivors quickly and well. In this case, it is not the story or image that evokes response so much as a current day reenactment of danger. As clients repeat their fears in current-day circumstances, they evoke feelings of fright, overprotectivness, guilt, and excessive responsibility in the therapist. Efforts to rescue the client feel rewarding and lead to a counter- transference coping mode of enmeshment, with special features including loss of boundaries, over- involvement, and reciprocal dependency. Here the therapist has unconsciously identified with the protective or rescuing role in the trauma predicament as a way of discharging the tensions that continue to come from his or her own wounds. Empathic Disequilibrium (Type II Countertransference) Therapists at risk here are primarily those who are naive about possible consequences of their work on themselves. Often the intrusion of grotesque images, multiple 468

traumas, and impossible choices will set empathic disequilibrium in motion. In some cases, especially in extremely stressful events, the inhumanity present in the trauma images evokes existential shame. Defenses elude the therapist as he or she reels in a state of uncertainty, vulnerability, and unmodulated affect. No explanation integrates this new reality, and the therapist's worldview is ruptured; there is only fatigue, despondence, and despair. Unlike other expectable reactions, empathic disequilibrium is less likely to be a stable state but more often will move toward empathic withdrawal or enmeshment.

Application of Countertransference and Empathy in Treating PTSD Patients Both countertransference and empathy can be successfully used in treating PTSD patients. They can play a very useful but also a very damaging role in the therapy. We would like to quote Willson and Lindy (7) here: Therapists listen in an empathic and non-judgmental way to client's descriptions and interpretations of what happened to them in the trauma (17). The creation of a safe- holding environment (11) is crucial to the establishment of mutual trust in the therapeutic process. We believe that the capacity for sustained empathy is pivotal for the recovery process - as the trauma unfolds, as new affect and imagery develops, and as trauma is placed in a newer meaning system. In our opinion, the clinician's capacity for genuine empathy is the sine qua non for laying the groundwork that enables the patient to perceive that the therapeutic context is a situation of security and protection, and a proper place to express anxiety and feelings of vulnerability. When an empathic break does occur, it may cause a pathological outcome such as 1) cessation of the recovery process, 2) fixation within a phase, 3) regression, 4) intensification of transference, and 5) forms of acting-out behavior. In PTSD therapy, the relationship between the therapist and the survivor is a complex and subtle interpersonal relationship that centers on trauma- specific transference. These transferences place the therapist in various roles, such as failed protector, and they give rise to modes of empathic strain. When countertransferences arise in therapy, they have the potential to disrupt recovery due to the therapist's loss of empathic role stance. If this rupture occurs, a new disillusionment with the therapist confirms the client's past disillusionment during and after the trauma, retarding his oh her ability to work through the many-faceted transference issues encountered in therapy. On the other hand, the successful management of empathic strain and countertransference facilitates the maintenance of an empathic stance. To suggest that this very human process is easily accomplished would be misleading; at the very least it demands that therapists be open to their own feelings and experiences and that they rely on collegial consultation and supervision to ensure a successful course of treatment. In a sense, this process requires of the therapist an honest self-scrutiny that parallels the client's struggle with the difficulties associated with victimization and traumatic exposure.

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Specific Situations Related to Countertransference towards PTSD Patients Countertransference to Different Groups of Psychotraumatized Patients These groups include: displaced persons and refugees, war veterans, handicapped, released prisoners of war, family members of killed or missing persons. The most difficult problems occur in treating multiply traumatized patients, such as war veterans who at one time were imprisoned and at the same time were displaced together with their families. Most of countertransference problems that we had was towards the family members of those killed and disappeared, for underneath all of their sorrow there was always a lot of destructive aggression to be found. Besides, they were always very uncooperative for any kind of psychotherapeutic treatment. Illustration 1: We worked with a group of eight women, mothers and wives of disappeared people from Vukovar, all wearing black, tensed, and angry. From the very start they manifested dissent with the arrangement, not seeing any reason to talk with the therapist. The only thing they wanted was for their loved ones to return home. During the session they became a bit more hearty and cooperative and came forward with some typical dreams. One of them said that all she wanted was for her husband to come home even with no legs and hands, so that she could take care of him just as she looks after her son, who returned from the war without legs. Another older woman told that her daughter in law, sitting next to her, had a miscarriage because of all these problems and sufferings. There were two patients who dwelled through the whole session how senseless it was and how incapable the therapist was to help them. We made arrangement for the further sessions, but none-of them came. We felt it was the two negativistic women who took the sway over the group. During the whole session we felt most helpless and guilty. As if for some reason their destructive aggression suited me and made empathizing with them impossible. We felt most sorry for only the young woman in the group, whom we experienced to be the victim of the destructiveness of the group. Later we learned that she went away and got married. Countertransference to an Event, Disregarding the Patient Some therapists tend to converse with their patients of what they, the patients, have gone through, but pay more attention to the enemy, politics, and everything else than to the patient himself and his problems. It is well known that therapists, when having difficulties in the work or when tired, can try to avoid analysis and indulge with the patients in discussing the reality, especially when they share the same interests or hobbies. When treating PTSD patients, therapists most commonly employ two ways to avoid the patient: either they criticize politicians and authorities for not taking enough care of the war victims, or discuss their political affiliation. Sometimes already in the session and more often afterwards we have found ourselves doing exactly the same.

Countertransference to the Colleagues Who Avoid Treating PTSD Patients At the beginning of the war, we had problems bearing such avoidance. Thinking about the situation afterwards, we reached the conclusion that there had to be personalities much too fragile to deal with psychotraumatized patients, that there must be those afraid of such patients. Further, there must be people who feel inadequate to treat these patients for their own political, national, or other feelings. Countertransference to Patients Who Have Killed People This kind of countertransference may be very frustrating for several reasons. The therapist may be afraid of such a patient, may have problems feeling empathy with him and may be reluctant concerning the success of the therapy. Nevertheless, with time the therapist will get used to this patient's suffering like with any other. Illustration 2: in group with difficult PTSD patients, one of them dwelled on how they all actually were Ustashas (followers of the Nazi puppet state during the World War II in Croatia), and how it would be the best if the Ustasha state was to resurrect again. Few group members agreed and one of us (E.K.) felt a strong anxiety with the usual bodily symptoms, although not understanding why. The very same day in the evening he remembered a story his father used to tell. It was a story from World War II describing how on one occasion in Italy he joined a group of soldiers talking Croatian. It was a while before he recognized the soldiers were Ustashas, and then he tactfully retreated. Afterwards he understood that it was only his reluctance to wear hats that saved him. If by a chance he had had his military hat on the soldiers would most certainly have killed him, because he was a Partisan officer. Not before this vignette came to the therapist from the past has he thought of all the atrocities they, the Jews, suffered from Ustashas in Croatia. Countertransference to a Supervisor Who Avoids, Either Directly or Indirectly, to Supervise Therapists Working with PTSD Patients This is highly disappointing for the therapists. The therapists cannot understand the supervisors who do not want to know anything of what is going on with these patients. It is the case of very experienced psychoanalysts who were not trained in treating this kind of patients and whose theoretical and also clinical education fails to accept the same. It is hard to grasp such a reality, hard to try to understand such an unelaborated psychotrauma. (7) The supervising therapists gave clues, subtly or grossly, that the trauma was too much for them to tolerate. Therapists were dismayed and turned away in disillusionment, thinking This person simply does not hear me. We felt chagrined by these stories of additional pain to already traumatized friends, and we sought to learn how and why these events had occurred. Diagnosis of Countertransference Diagnosing the developing countertransference tendency is often not an easy task. Indeed, because countertransference is largely an unconscious phenomenon, it is easily rationalized as professionally justified 469

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prosocial behavior. The supervisor, the peer study group, or even the patient may recognize its presence before the therapist. The symptoms of countertransference are many and diverse. Willson (7) points out: When the empathic strain is strong, countertransference symptoms may emerge in the therapist working with trauma patients. The manifestation of these symptoms varies with the personality features and past trauma history of the therapist, but it also reflects the patient's failed effort to manage both his or her own intrusive symptoms and the denial components of the PTSD dilemma, and the symptoms may parallel the actual symptomatology of the client's PTSD. PTSD patients put in use archaic defenses, which can bring around psychotic parts in therapists. Either the resonance with the pathological in patient can occur, or the therapist can react with the fear and flee. The feeling of guilt is often present in the therapists treating PTSD patients, who have suffered a great deal more than the therapist ever did. One can end up here by apologizing, like our female colleague working in a group: I am aware that you have fought for me and I feel grateful for that, but we are here to try to talk this out a bit. The group reacted very positively. Therapists can also react very aggressively to such a situation, thinking It was his own fault to engage in the war, why would he torment me with that now. Feelings of helplessness and worthlessness can arise. The therapist can feel that he or she is incapable of helping the patient either psychologically or in reality. He or she tends then to identify completely with the patient and develops projections towards the enemy. It should be marked here that partial identification with the patient in these cases can work in a beneficial way. Different value-systems in the patient and the therapist can bring about such a culturally determined countertransference. Here, for example, we can find ethnic myths that are particularly dangerous if the therapist and the patient belong to different ethnical groups. The colonial countertransference has also been suggested, particularly in situations where the therapist considers the patient to be of much lower cultural standards, much less educated, much less worthy than he himself might be. We had similar experience with Dutch psychotherapists treating Bosnian patients. Bosnian refugees were located in Grningen, a city in the north of the Netherlands. Because of vast cultural differences among the two groups, in their work together they would often encounter problems and misunderstandings. Bosnians never read any written notations and were usually late for their sessions and this annoyed the Dutch therapists. Also, the question is if therapy through an interpreter is possible at all. Value of the therapy where the transference is created towards the interpreter and not the therapist is definitely dubious. Projections towards the patients are most often those that they lack the gratitude. The therapist can in response to this feeling of ingratitude react with his or her own acting out. This may result in terminating the therapy not only with the particular patient but also with all PTSD patients in general. Also, the therapist may develop different autoaggressive manifestations. 470

Feelings of shame evoked in the therapist by the humiliation and degradation of the PTSD patients often lead to a feeling of disgust. This feeling is reached through projective identification. The victim is weak and pitiful, Danieli (c.f. 7) gives her explanation of such a feeling of shame: I believe that psychotherapists who work with other victims and trauma survivors, particularly of man-made disasters, share this profoundly existential sense of shame, which constitutes, with the other countertransference reactions found in my study, an aspect of the larger conspiracy of silence that has existed between survivors, their offspring, and society. Reactions of the Therapist to His or Her Own Treatment-Acquired Psychotrauma The most common symptoms that precede the burnout syndrome are: uncritical overactivity, loss of concentration, instant mood changes, aggressiveness and outburst disposition, and depression with elements of suicidal behavior. Burnout It is a state characterized with feeling of tension that repeats until exhaustion. Bodily and emotional exhaustion, depression, anxiety, outburst disposition, stubbornness, loss of self-confidence, helplessness, all combined with the bodily symptoms such as fatigue, appetite loss, problems with sleeping and feeling of powerlessness (7). Break Down It can result in a therapist's psychosis or suicide. This is most often a reaction of a therapist very sensitive to vast human suffering. Wounded Healers Wounded healers are, using a metaphorical expression, the therapists who have survived a trauma themselves. We have borrowed this concept from the works of Kleinman (18), Maeder (19), Comas-Diaz and Padilla (20), and Jung (21). The problem of the wounded healer has been discussed from two different perspectives. On one hand, wounded healers are expected, through their own traumatic experiences, to have greater empathy with the suffering of their patients. They can transform their own wounds into the healing power and hope, as seen, for example, in certain types of shamanism (20). Many Christian saints have also used their own weaknesses and sufferings as a means to become more compassionate and strong (19). On the other hand, some wounded healers are found to have a compelling need to help others (18). They are unconsciously attracted to the psychotherapeutic profession in order to gain emotional release through their relationships with their patients. This relationship also becomes a way of avoiding their own trauma, which becomes isolated and encapsulated (19). From this point of view, it would be difficult for wounded healers to maintain a sustained empathic inquiry (7). Prevention of PTSD and Therapy of the Therapist Selection of a Therapist or a Helper Personality. The therapist (helper) should be extroverted, less narcissistic and vulnerable, with high em-

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pathic and containing capacity. This personality will endure higher intensity of frustrations and lacking gratification. It will also seldom react with vicarious traumatization and projective identification. They can endure the ambivalence of these patients. These should be personalities with the patience of a saint, which is quite necessary in treating PTSD patients. Training. There are five aspects of a therapist's training. 1. Professional psychotherapists trained in treating PTSD patients are quite rare. On the other hand, psychoanalysts and psychotherapists with substantial education engage in the treatment of psychotrauma very seldom. The reasons for such an attitude should be further explored. 2. Professional psychotherapists without any training in this field can prove quite useful when properly motivated. They have already strengthened their personality in the course of the training, and the new techniques and approaches can easily be adopted. 3. Trained paraprofessionals can also prove very useful, although they are in danger of developing the burnout syndrome, because they have not yet strengthened their personality. 4. Untrained paraprofessionals can very easily fall ill themselves. They must be under permanent control. 5. Professional and unprofessional wounded healers are always very risky. Most often it is themselves whom they want to treat in the course of the therapy. On the other hand, it is possible for them to suffer re-traumatization in the treatment of PTSD patients. Prevention Prevention includes: 1. Debriefing guilt and overresponsibility (Type II countertransferences) because they can interfere with responsible self-care, especially if a therapist places the needs of the client over his or her own. A multifaceted model of self-care addresses these issues. First, having avenues for debriefing of traumatic material is important for detoxifying therapeutic experiences, strengthening the healthy boundary between the professional and personal life, and reducing vicarious traumatization. 2. Team work and peer supervision we have excellent experiences in peer supervision of group psychotherapy of PTSD patients. Team approach may best address the needs of therapists treating PTSD and, provide a supportive community that can acknowledge countertransference issues. Structured peer supervision fulfils several key needs for the therapist. 3. Education theoretical, practical and therapeutical includes: (a) permanent consultation and supervision; (b) one's own experience of therapeutic processes in group and individually (first or repeated analysis); and (c) theoretical education in psychotraumatology. Treatment Treatment of therapists or healers working with PTSD patients include psychotherapy or eventual drug therapy. The basic obstacle is found in the reluctance of

therapists and helpers to accept the fact that they really are ill and need help. References
1 Freud S. The future prospects of psychoanalytic therapy. Standard Edition XI. London: Hogarth Press & Institute of Psychoanalysis London, 1957. 2 Freud S. Observations on transference love. Standard Edition XII. London: Hogarth Press & Institute of Psychoanalysis London, 1957. 3 Heimann P. On Countertransference. Int J Psycho- anal, 1950;31:81-4. 4 Racker H. Transference and countertransference. New York: International Universities Press; 1968. 5 Goldberg A. A shared view of the world. Int J Psychoanal, 1989;70:16-20. 6 Stein S. The influence of theory on the psychoanalyst's countertransference. Int J Psychoanal 1991; 72:325-34. 7 Wilson JP, Lindy JD. Countertransference in the treatment of PTSD. New York; The Guilford Press, 1994. 8 Kohut M. The restoration of the self. International University Press, 1977;42-3. 9 Kohut M. Narcissism and the analysis of the self. International University Press, 1971. 10 Slatker E. Countertransference. Northvale, (NJ): Jason Aronson; 1987. 11 Winnicott DW. Maturational processes and the facilitating environment. New York: International Universities Press; 1965. 12 Gorkin M. The uses of countertransference. Northvale (NJ): Jason Aronson; 1987. 13 Maroda KJ. The power of countertransference. New York: Wiley; 1991. 14 McCann IL, Pearlman L. Psychological trauma and the adult survivor. New York: Brunner/Mazel; 1990. 15 Mollica R. The trauma story: the psychiatric care of refugee survivors of violence and torture. In: Ochberg F, editor. Post-traumatic therapy and victims of violence. New York: Brunner/Mazel; 1988. p. 133-57. 16 Wilson J.P, Understanding the Vietnam veteran. In: Ochberg F, editor. Post-traumatic therapy and victims of violence. New York: Brunner/Mazel; 1988. p. 60-82. 17 Ochberg F. Post-traumatic therapy. In: Wilson JP, Raphael B, editors. The international handbook of traumatic stress syndrome. New York: Plenum Press; 1993. 18 Kleinman A. The illness narratives: suffering, healing, and the human condition. New York: Basic Books; 1988. 19 Maeder T. Wounded heaers. Atlantic Monthly 1989 January; 37-47. 20 Comas-Diaz L, Padilla A.M. Countertransference in working with victims of political repression. Am J Orthopsychiatry, 1990;60:125-34. 21 Jung C. G. Memories, dreams, reflections. London: Flamingo; 1963/1983. 20 Klain E. Mental growth of analytical couple in the psycho-analytical process. Psihoterapija (Zagreb) 1992; XXII:55-80.
Received: April 26, 1999 Accepted: October 15, 1999 Correspondence to: Eduard Klain Department for Psychological Medicine Zagreb University Hospital Center Kipatieva 12

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