Victims of political torture - Andreas SG.vo Wallenberg Pachaly

Andreas S.G. von Wallenberg Pachaly, Düsseldorf, Deutschland

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Group Psychotherapy for Victims of Political Torture
and Other Forms of Severe Ethnic Persecution
in: The Healing Circle:
Group Psychotherapy for Psychological Trauma
Andreas von Wallenberg Pachaly, Dipl.‑Psych.
Düsseldorf ‑ Germany

           “After torture, not to be able to feel at home any more in this world.” (Jean Amery, 1972, p.73).
           
           “What cannot be talked about can also not be put to rest, and if it is not, the wounds
           continue to fester from generation to generation.” (Bruno Bettelheim, 1982, p. 11).
When we work with victims of torture, we must always consider the two poles of 1) the utmost destruction of personality, including the destruction of the good internal holding group, which is one of the goals of torture, and 2) in order to achieve distance from and to demarcate against the internalized torturer it is necessary to repeat, re-live, and work through the pain of torture and the feelings of revenge within a protective therapeutic setting. The aim of therapy is to rebuild a good, containing, holding, and protecting internalized group to achieve an end to the devastating effects of torture on the victim (and ultimately, to his offspring).
           From a therapeutic standpoint, small and large groups (including social systems) constitute the most effective settings for containing and reversing the effects of trauma. In what follows, I shall explore the individual and group dynamics of political torture and of the victims of torture, and how they are revived and repeated within the group psychotherapy setting. I shall discuss the therapeutic possibilities which the group offers to alleviate the pain and heal the destruction which torture has done to a human being, though many of the findings can be applied to the group therapy of severely traumatized patients in general.
INTRODUCTION
           When treating narcissistically injured patients (including borderline, narcissistic depressive, and many psychotic patients) as well as victims of rape and sexual and physical child abuse, we regularly find in their histories cumulative violations of their bodily as well as psychic borders. We find multiple episodes of scapegoating, denigration by their most important figures of reference, and sexual, physical, and psychological exploitation. At a very early age, many of these individuals have been exposed to life‑attacking, life‑forbidding stimuli in a totalitarian manner. By this I mean the fact that such children are completely dependent for affection and love from the same figures that attack them. In the worst cases, there is no other human available, and the child victim experiences the traumatizing human and family environment as the universe in its totality.
           Importantly, these traumatizing atmospheres are easily re-established in the transference relationship with the therapy group, where hopefully they can be gradually countered by a more life‑sustaining, growth‑enhancing group experience.
           For example, in one such group, it was noticeable that Geraldine[1] spoke very quickly and that the longer she talked about herself, the more restless, nervous, self‑conscious and obviously uncomfortable she felt. She increasingly expressed the feeling that, because she seemed to monopolize the group time, she made others, especially the women in the group jealous and envious of her. Frequently she would tell the group of her sister who was much more intelligent, prettier, and more skillful than she was. Soon, she felt inferior to all but one woman in the group. Interestingly, her negative feelings were not accessible for correction by the shared perception of the other group members. That she felt inferior was beyond debate, and when the other women insisted that they were not jealous, she refused to believe it. Gradually, the group learned that she had been raised in a family where her mother, supported by the much more aloof father and her older sister, had made a dramatic black and white polarization. Her two years older sister had always been the intelligent star of the family while she had been the one who was thought to be “stupid” and backward in her development. In fact, she had been taught that she had an obviously inferior genetic disposition. Bit by bit, with the help of the group, she could look at her family history and began to recall many instances when she had been denigrated, denied recognition, and ridiculed. Eventually, a clear picture evolved of a parenting system in which the one daughter had become the container of the idealized unfulfilled wishes of the parents, especially of mother, whereas she, Geraldine, had become the container of the unwanted, despised, rejected sides of mother. This split had provided a comfortable balance of mind for the parents, who felt a permanent need to compare themselves with the rest of the world, because they as individuals were lacking a stable, true self.
           In such cases of family dysfunction and devaluation, as occurred with Geraldine, the traumatizing effects usually result from the inner psychic needs of the reference figures and are not intentionally planned. Torture, as an expression of organized state violence, however, is a planned attack on the identity and psychological life of the victim. It represents the most extreme and clear-cut form of traumatizing behavior. Since it is frequently exerted on individuals who were psychologically healthy before torture, it provides an opportunity to better understand the effect of traumatizing influences on previously relatively mature personality structures. (Bettelheim, 1982, p. 11). At the same time it enables insights also relevant in the treatment of other severely disturbed patients, who frequently carry with them the effects of traumas, because the psycho- dynamically and group-dynamically mechanisms resemble each other and function along similar rationales. Though in the one case a fragile self was exposed to maybe not so extreme traumatic feelings and in the other case a stable mature self was exposed to utmost traumatic impact.
DEFINITION
           Torture according to the UN resolution A/30/3452 of December 9th, 1975, “torture” is defined as follows:
           1. “.... every act, by which a person by a carrier of state power or, induced by it, is submitted to intentionally strong bodily or psychic pain or suffering in order to force him to give a testimony or a confession concerning a deed he committed or is suspect to have committed, or to punish him, or to frighten him or other persons.”
           2. “Torture is an extreme form of intentional, cruel, inhumane, or denigrating treatment or punishment.” (United Nations, 1975, p 91)
           In addition, it is important to emphasize that the act of torture is deliberately intended to destroy the victim’s personality.
           Torture is usually motivated by a desperate pathological striving to preserve the identity of a political, national, ethnic group. Torture tries to preserve the group identity at the severe cost of another group. Volkan (1991) has discussed the social and political dimension of this dynamic and explored the function of a national or ethnic identity “tent” which strengthens and protects individual and subgroup identities in times of identity diffusion or global threat to the sense of self. The metaphor of the “tent” suggests an enclosure-like ego protective function of identity as well as its tendency to be profoundly affected by environmental and cultural changes, just as a tent can be affected by stormy weather, etc..
           Also, on account of this aspect of identity disturbance, I have found that work with victims of torture is valuable and instructive for work with other extremely disturbed patients, who underneath a facade of severe symptomatology carry within themselves the psychic and bodily traces of traumatic and cumulative traumatic experiences.
           Work with victims of torture enriches our understanding of group psychotherapy by providing an opportunity to learn in depth how projective mechanisms are addressed, real trauma is explored, superego pathology is confronted, and the external and internalized dynamics of life-attacking group formations are countered by life-supporting and life-affirming group dynamics.
           I myself began psychotherapeutic work with victims of torture only after I had done extensive group psychotherapeutic work and research with battered children and child batterers. Through my cooperation with the German branch of Amnesty International (hereafter referred to as AI), where I have been collaborating for 15 years in the standing conference of physicians and psychologists for the therapy of victims of torture, I not only met many victims of torture, but I also had the chance to discuss with colleagues various approaches to the treatment of the Post-Torture Distress Syndrome (see below for a complete description.)
           I have done most of my work in Germany, and the reader should know that Germany takes in by far the highest number of political fugitives and, more recently, war refugees from former Yugoslavia of all countries (45.2 % in 1997) of the European Union. In 1997, 104,353 political refugees from many countries from all over the world came to Germany, compared to 70,309 to the USA, a much larger and populous nation (RP, 1998).
TORTURE: AIMS AND MEANS
           An essential part of torture is the total assault, not only on the entire personality, but even at the somatic integrity of the autonomous system. Attacked are not only the mind, but all the systems that coordinate and organize the biological functioning of the human organism. At a time, when the capacity for feelings and thoughts are already wiped out and a psychic state of numbing has been reached, the torturer’s attacks on the limbic system, on the autonomous nervous system continue.
           The political prisoner is a human being with strong beliefs and political convictions. In order to force him to give up his convictions, to change the relationship between ego and superego, the ego has to be brought out of balance. He has to be confronted with a dilemma: Either to submit to the torturer or to lose his mind. The director of the prison “Libertad” in Uruguay summarized it: “If possible, we do not kill them, eventually we have to let them go. Therefore we have to use the time, to rob them of their mind (Espinola, 1985).
           Through physical attacks and through ongoing psychological attacks the torturer eventually succeeds in:
           1. Depriving the “object” of torture of any sense of security, of any sense of reliability, and of any feeling of dependability. The victim’s internalized containing, holding group becomes destroyed. Amery (1977, p. 73) described the consequence of the loss of the good internalized group object as “not feeling at home any longer in this world.”
           2. Whether the torturer succeeds in this goal depends on his capacity to isolate the victim from his reference group, which provides holding in the here and now. Only then will the victim experience the world as offering no more alternatives to the world of the torturer.
           The mass rape of Bosnian woman and subsequently forcing them to carry out the pregnancies was intended to destroy their belonging to any group and to destroy their own and their children’s capacity to link. Their children will neither be Serbs nor can they any longer become accepted as Muslims by the Bosnian Muslim community. They are condemned to a life outside any identity-protective cultural tent and moreover, the entire cultural network of relationships of the Bosnians is attacked for generations to come.
           3. The victim’s basic beliefs about life are destroyed (Janoff-Bullmann, 92).
           4. Extreme torture generates an extreme yearning for dependency.
           5. Frequently, in our clinical practice with child and spousal abuse we are confronted with pathological loyalty to the family or partner who actually did harm the patient. The torturer, too, strives for this “loyalty” to his view of the world. It is my understanding that in our severely traumatized patients we may find the same processes on a gliding scale.
POST-TORTURE DISTRESS SYNDROME
           The Post-Torture Distress Syndrome I understand as a diagnostic entity in which victims of torture manifest at least several of the following symptoms: anxiety, depression, feelings of resignation, sudden weeping bursts, apathy, fear, suspiciousness, feelings of guilt, aggressivity, intensive rage, irritability, suicidal attempts, introversion, drowsiness, exhaustion, memory difficulties, lack of concentration, disorientation, sleeping difficulties, paraesthesias, sexual disturbances and psychosomatic disturbances like gastrointestinal disturbances, skin irritation, heart problems, specific pains after specific torture, etc. (Roth et al, 1987).
           These symptoms may occur immediately after torture but can occur even decades after the actual act of torture, along with paranoid ideas, hallucinations, and alcohol and drug abuse.
           The Post-traumatic Stress Disorder (DSM IV) in my understanding differs from the POST-TORTURE DISTRESS SYNDROME in so far as the latter is often more severe, since victims of torture have frequently been exposed to extreme stress over very long periods of time (years of persecution, multiple imprisonment, torture proper, period of escape, cultural shock of exile, retraumatization in the exile). We deal with an ongoing traumatic stress. We also must differentiate between:
           1. man-made disaster (torture, rape, hijacking, etc.)
           2. technological disaster (airplane crash, car accident, nuclear power plants, etc.)
           3. natural disaster (earthquake, hurricane, etc.)
           In an attempt to differentiate the Stress-Syndrome after torture from the Post-traumatic Stress Disorder J. Herman (1992) developed the profile of a “Disorder of Extreme Stress Not Otherwise Specified” (Complex PTSD) that takes into consideration the lasting repetitive traumata that occur within interpersonal relationships and lead to significant disturbances in the areas of:
           1. Regulation of emotions (continuous depressive moods, extreme repression of rage and aggression alternating with eruptions of these emotions, loss of sexuality or inadequate seductive sexual behavior);
           2. Awareness (amnesia, dissociation, depersonalization);
           3. Perception of the Self ( shame, guilt, self-accusations, isolation);
           4. Perception of the perpetrator (permanent thoughts of revenge, the paradox of thankfulness towards the perpetrator, taking over his value system and beliefs);
           5. Relations with others (isolation, withdrawal, destruction of relationships with spouse and family, suspiciousness, loss of the capacity to protect oneself);
           6. Systems of belief and faith (loss of faith and trust, feelings of hopelessness and despair).
           Van der Kolk et. al. (1992) further developed the profile of complex PTSD into a DES Profile (Disorder of Extreme Stress). He describes symptoms specific to victims of torture and other forms of extreme stress, including: difficulties coping with anger and rage; self-harming, suicidal behavior; impulsive risky behavior; chronic pain (psychosomatic pain); idealization of the perpetrator; taking over of the torturer’s values and beliefs; incapacity to trust in others and in oneself; tendency to become a victim again; tendency to victimize others. Victims of torture, as do patients with PTSD, frequently develop comorbidity, that is other severe symptoms like, depression, obsessive-compulsive behavior, suicidality, substance abuse, eating difficulties, and somatization. The final definition of the POST-TORTURE DISTRESS SYNDROME  is still not generally agreed upon. It is further complicated by the facts that it defines pathological suffering of a formerly reasonable sane individual and that it has to be considered as a result of extremely destructive social and political forces.
THE NATURE OF TRAUMA AND AVOIDANT BEHAVIOR
           It is not the traumatic act as such that is traumatic, but the feelings related to the traumatic acts which have to be fended off, because they are so painful. They also engrave their traces deep into the patient’s biochemical matrix. This results in various, at times extreme, “avoiding behavioral strategies”. Since the basic brain, the limbic system, was fiercely attacked, we can observe deeply engraved psychosomatic reactions as an evasive reaction to an aversive stimulus, which, however, is maladaptive in the sense that it perpetuates the basic disturbance, the trauma. Here the role of group psychotherapy becomes decisive, because it provides a safe container for the avoiding behavior as well as for the previously warded off traumatic feelings.
           Mary, a victim of torture, had recently joined the group. Another patient had his last session after three years of successful group analysis. The group engaged in an intensive exchange of feelings of affection, sadness, and separation. The patient had been an important group member, and all would miss him, though there was a common feeling that it was the right time to go his own way. After 30 minutes, Mary stood up and said that she would “wait outside and read a book.” She insisted that these feelings of loss had nothing to do with her. The group asked her back in only when they shared a glass of Champaign to celebrate the departure. Some months later Mary could verbalize how important it had been to avoid all these feelings of separation, abandonment, and rejection, evoked inside herself by the other patient’s departure. It had been equally important to be able to “wait” outside and to feel that she was not rejected, but could regulate and manage the situation to escape from her unbearable feelings of powerlessness in the face of feelings she could not have shared yet at that time.
DEFENSE MECHANISMS
           While under torture, the victim will have to develop special “defense mechanisms” to protect his ego from disintegrating, in order to make a desperate effort to “preserve” the good objects and to “save” the good, containing and holding “internal group,” both of which are attacked by the torture process.
Torture itself causes regression to the paranoid-schizoid position. This process is induced by the victim’s extreme dependent position, when submitted to a totally controlled environment. The first defensive step is to regress to splitting. The victim thinks that “We, the group of victims, e.g. the members of my political movement are all good, and they, the torturers are all bad.” If the torturer succeeds in breaking down this splitting defense, he succeeds in his aim, because he will be able to take the place of the holding group. Below, in the section on sexual torture I will discuss this point in more detail.
I feel that splitting, projection and projective identification  describe more accurately of what’s going on under torture than dissociation, because the point is emphasized that the victim patient was in an extremely regressed state and his more neurotic defenses had already broken down. Torture strives to tear down projective and splitting mechanism and to truly break the personality.
At times we can also observer hypnotic dissociative ego-states in victims of torture. I conceptu-alize these dissociative state as ones, where the victim has become the container of the negative feelings of her/his important reference figures, and the torturer may have taken their place. Processes of projective identification too play a role in this defensive maneuver.
However if the pressure rises and the dissociated good internal object is threatened even more, the victim of torture will react paranoically and regress to projective mechanisms and splitting in an desperate attempt to save the good internal object.
A prominent “defense mechanism,” even years after torture, is self harm. It manifests itself in physical violations and by the symptom that the soul [“ego”???] wants to flood itself with horrible pictures to protect itself from even more pain. Self-generated pain (and self-mutilation) can actually rescue the victim from other, seemingly unbearable feelings.
           The obsessive focus on bodily symptoms also serves the purpose of avoidance of the feelings connected with the trauma. Avoidance may be further reinforced by the insecure situation the patient lives in, e.g. his concern about a resident permit. This supports a “strategy” of warding off the unbearable feelings connected with the trauma, and at the same time to flee from the here and now.
In the group the patient often plays a withdrawn, ego-restricted role, he may feel persecuted or take over an attacking role, identified with the former aggressor.
THE FIRST THERAPEUTIC CONTACT
The first major task in the psychotherapy of survivors of torture is to “give the victim a hand” and to lead him in the here and now. Otherwise his symptomatology will become chronic and the avoidant personality structure will become petrified. A degree of “collusion” with and accep-tance of his view of the world, however distorted it may be, is necessary, to let the feeling grow that therapy is a safe space. By collusion in this context I do not mean to experience oneself as a victim but to take the victim’s side, and to emphatically attune to his/her state of mind.
           Before the therapist and the group can relate adequately to the victim, he or she has to overcome a gigantic wall of shame. These feelings represent not only shaming by the ego ideal, blaming a “fallen” ego, they are also an expression of the incapacity to link and to relate. Eternal isolation of the victim is what the torturer strived for. It is done by gruesome attacks on linking.
To destroy the links between ideas, between objects and among persons, etc. has been described by Bion ( 1959) as a primitive mechanism for coping with painful emotions.
In torture the victim is robbed of his familiar holding and containing links with beloved and valued others by denigrating his attachment to them, by trying to foster attachment to the world of the torturer during a state of absolute dependency. Feelings of absolute annihilation can be fended off this way as I will discuss in case no.1 below.
Shame and disgust of ones own body are devastating effects of torture: “What kind of a person am I, that this happened to me.” “My body is ugly and spoiled, I hate my body.” “My whole life is destroyed, I can’t tell anybody what I experienced.” “My psyche is sick, my head crazy.” These are feelings and thoughts, deeply engraved. I think of several victims of sexual abuse as well as torture who for decades “kept quiet” about their trauma, because the feelings of shame were so painful that it was impossible for them to communicate their suffering. In this phase it is especially valuable if these feelings of shame can be shared by other members with strong shame conflicts, because this will soften the Super-Ego conflict.          
           And yet, despite all our efforts, we can not help but become persecutors at some moments of history in our work with victims because in certain regressed ego states a question, a gesture, our mere presence might represent torture to them. Here, a group matrix in which a positive feeling for a fellow patient may survive gains paramount importance. The compassionate empathy of a fellow patient may at times bring back the soothing of the fellow inmate.
           At times, we must also follow this compassionate line and help the victim cope directly with his painful symptoms by recognizing their crippling extent and to assist him in finding alleviation by catharsis or at times via cognitive and behavioral techniques.
            Therapy has to open up a space for the patient to share his violations, his denigration, his abandonment. When the victim comes in touch with these unbearable feelings, there may be times when words cannot express his pain and grief adequately and sufficiently, and the group’s collective mourning and shedding of tears may be the most appropriate and sometimes the only possible way to express not only the victim’s, but also the group’s overwhelming feelings. At the same time, this process may in turn create a bond which can become an early step towards mutual consolation and recovery.
           Finally, therapy must work through the deficient self-esteem, the self-accusations, the dependent character, and the basic insecurity of the group members. Group therapy gives us opportunities beyond an individualistic model such as that of Melanie Klein, which is founded on the dynamics of libidinal and aggressive drives. Internalized, life-preserving and life-forbidding group dynamics become externalized in the group setting. We can conceptualize the group as a matrix of object relations, as a web that contains a certain amount of energy in its knots, cells, and links. The web can contain, hold, and generate positive social energy (Wallenberg and Griepenstroh, 1979) or it can strangulate, imprison and suffocate. The web can also lack cells and links, resulting in insecurity. The group can now, in a manner analogous to a heart transplant, become such a network of links and cells with whom the victim can link and bond. Gradually a holding web may be internalized, i.e. “transplanted” as healthy new psychic elements within the selves of the members.
           Consider, for example, a patient who again and again was flooded by anxieties, felt bodily paralyzed, panicked, and let himself be rushed to the hospital to get an injection of sedation. This habitual pattern in turn reinforced his conviction that he was unable to bear his feelings, and he felt increasingly dependent on his medication. After the group had explored and put into words the context of his “sudden” attacks of anxiety (whenever he felt deserted), and as he realized through the group’s interaction that he was able to take a stance against others, he felt less fearful and increasingly empowered. He became able to take a stance against his own anxiety. He could now tolerate such feelings and share them with the group.     
           The therapeutic group may provide the safe space within which it becomes possible for the victim to look once more at the feelings that are chronically numbed because they were initially experienced as so overwhelming. The fended-off traumatic feelings include especially extreme feelings of loneliness, isolation, abandonment, loss of trust in one’s own perception, total powerlessness and dissolution of self. Therapy can succeed when the traumatic feelings are accepted and contained. It offers a chance to restore some familiarity with our everyday, reasonably secure world, because group psychotherapy carries the power to support, sustain, and reinforce the good internal objects.
           Finally we can help the patient to discern between his premorbid personality and the life destroying group dynamics he internalized under torture. This will free him of crippling feelings of guilt. We can try to reconstruct what was destroyed, but what remains is a certain emptiness in face of the experienced loss of humanity.
TECHNICAL CONSIDERATIONS IN SETTING UP GROUPS
           When a victim of torture begins group therapy, several points have to be considered.
In the beginning a series of individual sessions usually are helpful, to open a space for the patient’s feelings of shame. Homogeneous groups may be of greater help for victims of ethnic cleansing then individual torture.  These groups, in my experience, have the quality of solidarity groups concerning the difficulties to live in a foreign country and/or to continue a political fight against the torturing system from abroad. To the degree they foster solidarity and holding they improve the chances for the endeavor of group-psychotherapy.
The use of drugs should of course be very time-limited and has to be carefully judged in relationship to the abuse of psychotropic drugs the victim was subjected to under torture.
Hospitalization usually is only appropriate in an emergency situation. Not only because the hospital frequently reminds the victim of the institution prison, but also because the treatment period will be too short. In my experience the therapy takes from 6 months to 4 years. It can not be completed in a few weeks.
           1. It is my experience that a certain degree of a healthy capacity for ego demarcation is necessary in order to enable the victim/patient to integrate into a heterogeneous therapy group.
           2. We should bear in mind the concept of critical acculturation, that is to say, that the patient’s cultural background is to be respected and that he is supported to keep it alive and to build bridges with the culture of his “guest country” (Barudi, 1989) and is not expected to discard or deny it. Otherwise there is the danger that the patient will perceive living in the host country as a repetition of the torture scene.
           3. Concerning group composition, it is my experience that there should always be at least one other severely traumatized patient in the same group. The easily possible identification with a fellow patient prevents early dropouts because it reduces the danger of scapegoating as well as of idealization by the group-members and reduces the victim patient’s fear of abandonment .
           4. I prefer to work with heterogeneous groups. They correspond to the reality of life, are much richer in their mutual therapeutic possibilities and offer also the less disturbed patients a chance to come in contact with deeper layers of their personality structure. The overwhelming, traumatic material, in my experience, can very well be contained and worked through in a heterogeneous group, provided that a space opens up for the non-traumatized members to communicate frankly and with as much respect and importance, about their emotional reactions. The therapist may utilize the fact that even non-trauma patients can understand trauma in some respects since, via television and other media, nearly everyone is vicariously familiar with such experiences! Trauma if understood as a result of a flooding of the self with excessive feelings can be explored on a gradual scale. This helps to build bridges with not-tortured, but traumatized fellow-patients.
           5. After an initial phase, where the whole group has to learn to tolerate and to address trauma and related feelings, it is my experience that the integration of severely traumatized patients furthers group cohesion.
          6. The communication with the victim’s large social system should start as soon as is possible, because frequently it is a pre-requirement for a successful realization of psychotherapy (See below the discussion of  “Large Social Systems Therapy”).
               7. Special attention has to be paid to the fact that the traumatized patients, with their special emotional sensitivity, are not exploited by more emotionally numbed patients to contain feelings that the latter are not yet able to experience.
TASKS FOR GROUP PSYCHOTHERAPY
           The following is an overview of some of the key issues, concerns, and difficulties which will be experienced in running a psychotherapy group for torture victims (homogeneous grouping) or which include victims of torture in the membership (heterogeneous groups). The group evolves from an aggregate of strangers with an unknown history, to establishment of personal histories and expressions of anxiety, to a recurrence of the fusion which took place between torture victim and victimizer, with mutual projections, to empathy and the reconstruction of trust and the capacity for closeness. The damaged personality must be restructured, and society must cooperate in the task of acknowledging the atrocities and helping these individuals:
           1. The psychotherapeutic work starts out in a foggy twilight, where the original personality structure, the experience of torture, and the resulting personality deformation (or even destruction) of the patient are very much interwoven. It becomes our task to get an understanding of a) who this person was before torture; b) why he or she experienced torture in this particular way and not in another way; c) how he or she was in fact abused, tortured, and maltreated; and d) what effect the torture had on his or her personality.
           2. Since we deal with a real pre-existing traumatic or cumulative traumatic event, and not merely a fantasy as such, we should never forget when working with these individuals that to encounter them should prevail over analyzing them. We can accompany them, when confronting the often unspeakable nightmares of torture once more, in their effort to free themselves from the ghosts of the past. But these ghosts were real humans and did real injustice, force, and violence to the patient. And worst of all, torture was the absolute inescapable experience that there exist humans and human institutions that leave humanness completely behind them, the real barbarian.
           3. Effectively tortured humans don’t trust their own perception any more. They incorporate the torturer’s view of the world and at the same time lose their own confidence in their view of other people. Here of course, the psychotherapeutic group can be of great help, as it represents a training field to check one’s perceptions. Moreover, the group can provide the experience that a humanity beyond torture continues to exist. The group may open a transitional space, where the life destroying group dynamics can be recognized and confronted with a life-giving and life protecting dynamic.
           4. The group is a place where the effects of torture can be explored. It can provide the empathic mirror to reconstruct the truth. The patient (and the other group members) can begin to see how his ego boundaries had been blurred, even the border between torturer and tortured; how, during the regressive ego states that go along with torture, anxieties of annihilation, of total abandonment, and of absolute rejection of a psychotic quality, a fusion of ego boundaries had occurred; and how, sometimes quite suddenly, the victim had become the perpetrator.
           5. In group psychotherapy, the notion of “fusion of ego boundaries” becomes especially important, because the fusion recurs with the entire group. It is as if, suddenly, triggered by perhaps a casual remark, facial expression, or gesture, the victim/patient feels victimized, persecuted, and tortured by the entire group. At times then in turn the victim/patient starts persecuting the entire group, becoming a “persecuting victim.” In my understanding, such dynamics occur in moments when the victim is overwhelmed by the terror of fusion, of becoming swallowed up, overwhelmed and extinguished:
           Peter kept complaining that the group members, and, in particular, the therapist, did not like him. The group noticed that at the same time he felt intense needs for closeness. He began to attack the group and the therapist vehemently, thus destroying any feelings of closeness. Several times he “seduced” the group to violently counter-attack him, accusing him of destroying any feelings of closeness and affection. Only after an understanding had been worked out by some group members that the very closeness he wanted so much must seem so threatening to him, could he recall and discuss several instances when a seemingly close emotional relationship had been established by his torturer with him. This closeness had been brutally abused and destroyed to make him even more dependent and “broken.”
           6. Thus, in the spur of the moment, projective mechanisms may prevail. The psychotherapy group is then challenged to demarcate itself against the life attacking forces exerted on it and to empathetically understand the extreme anxieties, agony, and feelings of abandonment which underlie the projections. The potential destruction of the life preserving, life-giving, sustaining, and holding internalized group must be recognized and if possible “confronted” with the life-protecting group dynamics of a well functioning psychotherapy group.
           7. The group becomes a container for unbearable feelings. At times the group will have to tolerate feelings of abandonment, isolation, agony. The members will need to just sit and attend, and not to run away.
           8. This is done by the members’ genuinely and authentically relating within the group. The matrix of mutual relations, the tolerance of the other, form the soil in which empathy, instead of pity, can grow. If the group members succeed in relating their genuine feelings, also “countertransference-feelings” about each other then this process will counteract the destruction of linking and alleviate the damaged feeling of belonging.
           I think of several torture victim patients, as well as of other severely traumatized patients, who, upon feeling rejected in the course of a group session vehemently attacked the group. Their own feelings were inaccessible to emotional correction through the shared perception of fellow patients. Only as each of these patients succeeded in creating a feeling of complete helplessness in all other patients and myself, and after we shared this feeling with the patient, did the patient himself feel relieved and no longer rejected, but understood and accepted.        
One could conceptualize the group in this process as a “digesting container”, in which, originally unbearable feelings are contained, digested and can be survived without a traumatizing  effect.
           9. The psychotherapeutic group as an empathic mirror can help the victim to find his post-torture personality, which must strive to integrate the experience of torture for the rest of the person’s life. In this process the limits are felt most painful. Therapy in many cases can only alleviate, not heal, least undo. The container, a deep rooted feeling of basic trust, is broken and can be repaired only partially. It is in this area of extreme traumatization where we can diagnose the “broken personality” of the torture victim.
           10. As I discussed above, in the process of reestablishing the borders, reality has to be reconstructed as far as possible, has to be acknowledged and has to be made public. The group thus becomes the first public space, where the capacity can grow to demarcate oneself from the world of torture. Pathological loyalty with a traumatizing system, which we find in many of our patients, can be resolved.
           11. In this context, the bonding with institutions like Amnesty International means that a reference group survives torture. In this way, good and bad are kept in their respective places and a complete blurring of borders can be prevented or at least borders can be restored. In my experience this is a phenomenon we find in many severely disturbed patients. Their chance to integrate into social life and to grow emotionally increases as they succeed in joining and creating groups that are important to them. (In another paper I discussed this as the group-dynamically understanding of the ego-function of social participation).
           12. It is my understanding that group psychotherapy alone, however, cannot accomplish this task. Society at large is challenged to support this process. I think of many raped women, e.g. between 30 - 100 thousands in the area around Berlin that were raped at the end of W.W.II by invading Soviet troops. It seems incredible that such a large scale crime was not recognized by society, could not be verbalized and was denied for decades. The children born out of these rapes were “turned into Germans” by their ashamed and traumatized mothers. These women had to cope with the task of loving their children and yet be allowed to hate their fathers.
           Today’s raped and pregnant women from Bosnia are confronted with the same impossible task. They are not only traumatized by the act of continuing rape, but continuously traumatized thereafter if they and their children are robbed of any protective ethnic tent to live under.
           The process of group psychotherapy for victims of persecution, torture and ethnic cleansing can be facilitated or hampered by social processes in society. For example, at present, for over 8 years, all the old files of the former East German secret state police are open. Now, every victim has the right to learn what information once was stored about him, how his life was destroyed, which destructive influences where exerted on him in what way. A whole administration has been created (called the Gauck-administration, after its chairman, a highly respected clergyman of former East-Germany) which scrutinizes, administrates and deciphers all available records of the former East German secret police. And every German citizen has the right to ask for a full record of everything that is available on any oppressive, destructive activities that were carried out against him and by whom. The South African truth commission serves the same purpose.
           13. Healthy superego development is dependent upon a sincere, loving parent-child relationship. The group dynamics of torture, however, “prove” to the victim that ideals may be lethal. Differing somewhat from ethnic cleansing, torture also attacks ideology, beliefs, and ideals. Through torture, the victim’s ideals proved disastrous. Ego ideals crumbled and treachery lead to a loss of morale.  A corrupt super-ego may results. The adult ego blames a corrupt superego, neglecting the fact that at times of torture there was no adult ego. From this a terrorist superego may develop and the feeling of total powerlessness. Guilt feelings, the feeling to have caused it all keeps away the feeling of total abandonment and absolute powerlessness.
At times the victim experiences himself as a cripple, as the offspring of rape, as a bastard, a devil. The psychotherapeutic group can develop the power to convey that he is yet a human being in his own right, despite the shame and guilt for all he betrayed, for all those that had to suffer, because of him. The group can help to put such things in a realistic perspective.
The frequent “seemingly irrational” feelings of guilt are the traces of absolute dependency and total impotence. If the victim feels guilty this allows him to feel active, not so completely powerless and overwhelmed by external powers any more. At least it was him, who caused everything. Leon Wurmser (1999) discussed similar ideas.
In the group process it becomes necessary to address this relationship: how the victim-patient feels himself totally overpowered and completely helpless in face of the group-perpetrator and how his guilt feelings are a reaction to these unbearable feelings.
           14. In a certain way the tortured individual is like a victim of rape. He too was raped, he frequently betrayed his fellows, and yet, that part of the self that survived torture is like the helpless “infant-self” stemming from the act of rape. Can the victim of torture still love himself or must he hate himself, since he is a product of the violence of torture? The task of the group is to take him back into the human family. This is a task which in my experience is valid for many of our severely disturbed patients.
15. Victims of ethnic cleansing where robbed of their homeland and a fierce attack was made on their ethnic tent. In my experience the rebuilding of this tent has to be supported and simultaneously the integration of the victims of torture, rape and mutilation back into the ethnic community has to be accomplished. Thus, the task of the newly installed coordinator for the reconstruction of Bosnia has also to achieve a very important psychological and group-dynamical task. The victims of rape and torture of ethnic cleansing, other than victims of political torture, where mostly chosen randomly and not because of their convictions. This made them often more vulnerable, because they had not the feeling that out there was a group that preserved solidarity with them. For these victims preliminary homogeneous solidarity-groups are often a necessary requirement to become able to enter group-therapy proper at all.
16. Victims of the holocaust, and their offspring are frequently immersed into a life-long silence. However, especially in their offspring we can see how a psychic trauma is transmitted from one generation to the next without being spoken about. The therapy-group might become the first psychological space where the patient , who belongs to the second generation becomes aware of his traumatizations. Initially he might have entered therapy because of symptoms he did not necessarily link with the traumatization of his parent. With these patients we can even observe the phenomenon of the denial of the traumatization.
THE BURDEN OF THE BARBARIAN WITHIN US: EXPLORING PROJECTIVE MECHANISMS AND COUNTERTRANSFERENCE FEELINGS
           The victim of torture in our therapy groups nearly always comes from another country, frequently from another culture. He often represents the alien/scapegoat upon which even we professionals and clinicians project all that is “evil” within us. Chattopadhyay and Biran (1998) reported on a meeting of group psychotherapists (International Group Relations and Scientific Conference: Exploring Global Social Dynamics), where this process could be studied. But, we need only look at our own professional group processes, considering for example, how rivaling psychotherapeutic schools frequently attack and shame each other.
           Projective mechanisms are relevant to the question of pity versus empathy. Pity allows us to keep distance and serves to reaffirm our prejudice towards the other as the inferior barbarian. When empathy grows, we become disturbingly confronted with the barbarian within us.
           Our initial countertransference feelings in response to the victim of torture, are shame and sadness in the presence of a broken man or woman. This frequently leads to countertransference feelings of wanting to repair and to revenge the atrocities. Consequently the danger of enmeshment for the therapist becomes a paramount challenge. The psychotherapy group members themselves too will be torn at first between doing repair work to the victim/fellow-group-member and fantasizing about the striving for revenge.
           The group’s countertransference responses to the somatic destruction of the patient (the awareness of the physical harm and somatic problems due to torture) often include rejection, avoidance and denial.
          George kept repeating his complains and descriptions of his somatic pains again and again. His stereotyped behavior usually resulted in a politely listening group that rather sooner than later ended up bored and without interest. Sometimes however, George not only reported his somatic pains, but unwillingly (it broke out of him, though he wanted to suppress it) conveyed the horror, agony, and fears of annihilation underneath the somatic pain: the psychic pain he had taken in under torture. In those moments the group reacted scared, sad, and silenced. For George it was not possible to experience this as a friendly reaction but as rejection. He stiffened up and withdrew himself into silence.
          The frozen pain of torture, frozen within the somatic symptom, could be melted by giving the group members a space to share their feelings in reaction to George’s somatic symptoms. This in turn  helped George to become able to tolerate, live through once more, and demarcate himself from the psychic pain that had been intolerable for him under torture.
As a reaction to the loss of trust in humans, and to the destruction of basic trust, the group itself may feel petrified and absolutely powerless.
                      David, who had been kidnapped from home, extensively tortured for some month, and had been at the verge of death several times had also been submitted to extensive brainwashing and indoctrination techniques. When he reported, how he had been shown indoctrinating films for hours and hours, his eyes fixed on the screen, in a completely powerless physical and mental position of absolute dependency the group realized that at times he obviously experienced the group too sometimes like a film. His hypnotic states, but also his lack of capacity to trust and to believe in the perceptions of the group made them in turn feel absolutely powerless and in the beginning petrified. Later they tried to “persuade” David of their view of the world, that they where trustworthy, and that he was valuable. In vain of course. Only as they could start to share their feelings of absolute powerlessness, of feeling paralyzed, and rejected, David in turn, could start sharing his feelings he had under this specific mind exterminating torture.  
As a defense against the extreme feelings of powerlessness and helplessness envy of and identification with the aggressor can be observed within the group.
Last not least I have observed from my case-examples, and from supervision work, if the traumatic feelings overwhelm the therapist he may regress himself and, at times, identify with the victim-patient’s projections, become the aggressor and verbally attack the patient.
THREE CASES
        In the following four sections I want to illustrate my understanding of the group dynamics of torture and how we can challenge them. For reasons of confidentiality, but also to protect the physical security of the one or other patient, still under threat even abroad (just think of Solman Rushdie), the case examples are heavily disguised and also several group and psychodynamically similar cases are condensed in one. I feel however they are still powerful enough to convey the underlying group dynamics at work.
           
Case 1: The Life-Attacking Group Dynamics of Torture - Inside and Outside Confinement
           This case demonstrates the group dynamic forces effective under torture, the influence of a torturing political system, and how such a system finds its downfall in the internalized life attacking, identity destroying group dynamic that prevents the individual from coming to terms with his own past, to link up, and bond with his fellow beings, and with himself, in the here and now. It demonstrates, what the core issues are that need to be addressed in group-psychotherapy, what we have to expect to become relived in the group-therapeutic setting.
           A very sophisticated, academically trained patient had come to my office because one of his children had become drug addicted and because of the increase of his own symptoms of sleeplessness, nervousness, depression, recurring nightmares, and a permanent restlessness. He had become acknowledged as a political refugee and his status in Germany was secure. The internalized isolation and life-forbidding relationship-cutting, link-attacking forces were however so strong, that therapy proper was not possible for him.
           The patient had been imprisoned for 2 years and regularly physically and psychologically tortured, among other forms of torture submitted to several mock executions. He had been confined into a cell of 15 fellow inmates, who all had been submitted to torture. He described the relationship with fellow prisoners as a source of intimacy that helped to endure the drag of torture, to contain the pain, and allowed for a closeness that was a clear contraweight to the loneliness experienced under torture. They represented humans who understood his suffering. Solidarity in the cell was a source for sharing, if not by words, then by looks in each others eyes, or touch. This closeness protected them from the isolation that most humans are not able to endure. It helped them to maintain the conviction of being on the right side and the importance of remaining truthful to oneself. Thus a minimal degree of containing could be preserved. Torturers know this and try to destroy this life preserving group system by enlisting spies within the group. This patient’s recollections give us a first hint how group psychotherapy might work as a holding, secure, reassuring container that allows life to be.
           After release from prison, he still was obliged to report to the “torturer’s state police” once a week, telling them with whom he had met, and what he had talked about. This meant that every person that he contacted now, automatically, became a suspect too. In a psychological sense, he was contiguously infected with a deadly disease, “torture”, that could be transmitted by the slightest social interaction. There remained no one he could talk to without running the danger of becoming a torturer himself. This lead to cruel isolation he experienced as greater mental pain than the physical and psychological torture to which he had been submitted in prison.
           We can assume that this period of continuing traumatization resulted finally in the destruction of the patient’s holding and containing internal group dynamics. Each time he felt close to a person, when he felt the need for warmth and closeness and the need to communicate, such nurturing was prohibited by the “social control” of his torturers.
           We can draw parallels to a child who is exposed within his caretaking environment to “torturing” abuse and attacks on his physical and psychological integrity and yet feels the need to approach his “torturer” for recognition, affection and holding, and once again is suddenly attacked. This dynamic stands for the torturing system’s ultimate attack on linking. Fragmentation of the self and the objects remains the last resort to preserve a rudimentary feeling of existence in face of this totalitarian annihilation. When reversing the process of fragmentation by reintegrating the self and the objects, the arising anxiety must be contained. The therapeutic group can offer a strong and reliable container.
           Finally, two years later, after having arranged the flight of his wife and his children the patient succeeded in escaping to Germany. However, he found out that he was not totally safe even here. He learned of some mysterious assassinations of fellow fugitives, who had become victims of the secret service of his home country operating abroad. This caused a deep conflict. On the one side he felt the urge to inform the world about the atrocities that were committed in his country, while on the other side, he felt threatened if he exposed himself too much. We can here observe how the prohibition to talk is brought to its extreme.
           Within a few therapy sessions several central points became very obvious which exemplify the group dynamic and psychological position of victims of torture:
1. My patient still lived in the past: his trauma still kept him prisoner.
2. His family’s present life was a mess, a condition for which he held himself responsible. His life-attacking group dynamics, introjected during the experiences of torture, become projected into the dynamics of his family.
3. Feelings of guilt and shame were central in our contact. The patient felt responsible for the emotional state of his family. He felt shame and guilt that he had not been able to tolerate the situation at home any further and believed he had “betrayed and abandoned” his countrymen.
4. The question of how he was before torture (“premorbid personality”) became increasingly highlighted
           5. Lurking beneath his doubts whether he should be allowed to benefit from psychotherapy was the question of whether he could become capable of confronting the horrible feelings, the unbearable solitude of isolation, the grief over the lost solidarity of his fellow inmates, the pain of torture.
           Unfortunately, for this patient the space of a therapeutic group did not open. He was unable to demarcate himself from the role of the perpetrator, opening a space for himself. He carried the life-forbidding, relationship-forbidding, linking-forbidding dynamics so strongly within himself that he was unable to free himself from this invisible bondage, which via the secret service of his native country had extended all over the world.
I was not strong enough to reach out and lead him into a group, providing a life-supporting, containing, holding and growth-enhancing group environment. One of the reasons was probably that I had been too fascinated and intrigued by the content of what he had recalled and had not addressed sufficiently, in the initial phase of our encounter, his feelings of shame in the relationship with me. There was some corner deep down in his psyche, where he felt guilty for everything he had suffered which made him to reenact the torturing scene again and again. I also should have addressed his feelings of vis-a-vis his family and the fact that to enter therapy for him in this moment paradoxically meant to abandon them. These topics should also be addressed in the initial phase of group-psychotherapy.
                       
Case 2: Isolation, Withdrawal and Inner Immigration[2] of a Former East German Dissident
           The second case illustrates how a life supporting, life affirming group dynamic can challenge the internalized life attacking, identity-destroying group dynamic forces by opening a space to share the extreme isolation, loneliness, and feelings of abandonment the victim suffered. The group can lead the victim of torture away from the pathological development of a chronic avoiding personality disorder.
           Sonja had been imprisoned 18 months in former East Germany, was bought to freedom from the then West German (for about $ 50 000), and finally released to former West-Germany. (At the time of the division of Germany into East and West many thousands of political prisoners have been bought to freedom by the then West German government. Today all the files of the former East-German secret police are open and everybody has the right to find out, and this is researched by the “Gauck-administration”, who spied on him and what subtle or overt pressure was put on him..).
In former East Germany she had been submitted to continuous observation and harassment, because she had engaged in non-violent activities, opposing the system. When she could not bear the pressure any more and it had became clear that there was no more professional future for her, she tried to escape, but was captured at the then heavily guarded border.
           During her stay in prison, she had been submitted to physical and psychological torture. She had entered therapy because of recurring depressions, free-floating anxiety, inability to focus her attention, prolonged difficulties at work, obsessive compulsive thinking, and eating difficulties. In the course of participating in a standard group analytic setting, twice a week, the patient decided to participate in a three week long time-limited psychoanalytic therapeutic community (v.Wallenberg, 1992). She had perceived how it offered the fellow patients in her group a chance to feel more secure. She would have the opportunity to be seen, perceived, and perhaps understood in her entire existence. This expectation became true to the degree to which in the community she re-enacted the internalized dynamics of persecution and isolation.
           She put her dynamics on stage within her work group of six members, whose task was to build a greenhouse. She managed to participate in the group’s work, but only in view of the others, fixing windows, yet working completely for herself. Her fellow patients tolerated her satellite existence, but felt hesitant to cross the imaginary border she drew around herself.
           Her suspiciousness and lack of trust in turn, of course, caused a countertransference feeling in fellow patients of wanting to keep their distance from her. They sensed how easily hurt she was, and that her social withdrawal, too, caused suspicion and hurts in others. At another phase of her therapy, this patient became prone to become a scapegoated outsider by avoiding involvement, and because she was identified with the resisters against a terrorist regime, thus representing a very strong ego ideal, which was at times experienced as a terroristic superego.
           It was only at the time of an excursion to an art exhibition that she could make visible how she really felt. That day she again appeared isolated and withdrawn. At the entrance to the exhibition, she was asked by a guard to leave her bag in a locker for security reasons. Suddenly, she looked utterly bewildered, paralyzed, as if her self had collapsed. A fellow patient, who shared the bedroom with her discreetly told me that inside the bag was her teddy bear. Out of what could be called “informed therapeutic intuition,” I firmly intervened and told the guard that inside the bag was a life saving medical apparatus, which this person needed to have with her all the time. The group spontaneously, too, insisted on not being able to enter the exhibition unless this person would be allowed to take the bag with her. The guard was so baffled that he allowed her to take the bag with her, without further questioning its content. The life saving apparatus was a transitional object, a little teddy bear that was most important to giving her a feeling of security and belonging!
           It was through this action that the group could understand the full extent of the lack of trust and the isolation from which the patient was suffering. At the moment she was asked to hand over the bag, she felt as overwhelmed and as impotent as when she had been imprisoned and tortured by a powerful state that tried to rob her of her innermost convictions, beliefs, perceptions, identity, and had destroyed her basic feelings of security towards the world in general.
           In the group session that evening, the patient could begin to share her feelings of total abandonment and absolute powerlessness under torture. That the group spontaneously had backed her, and that I had stood up for her, counteracted this devastating experience. Originally the relationship with her teddy bear represented a comforting relationship that gave her power.  Now the relationship with the group had instilled power and confidence into her.
           When the bag was about to be removed the patient had been flooded with feelings of unreliability, an absolute lack of power, and overwhelming anxieties. In the subsequent sessions it became possible for her to convey her feelings of absolute helplessness and to share them with the group and myself. These emotions were utterly painful and hard for the group to tolerate. But only through this group process, where pain really had been shared could she step out of her isolation and satellite position in the group.
           The destruction of basic trust, of dependability, and of reliability in relations is one of the basics of torture. The torturer’s destruction of the internalized  life sustaining, holding group can be understood as the essence of torture and explains why the reaction of the group to this patient so positively touched her and implanted the seed of healing within her.
Case 3: Seduced, Abducted and Sexually Tortured
           This next case involves the effects of sexual torture, which is indeed the most extreme form of torture, because here positive and negative stimuli are so intertwined that total dependency is provoked. Such torture resembles the situation of a child who is abused, maltreated, “tortured” and yet is totally dependent on his “torturer” for any positive affection. In the worst case scenario, the torturing situation represents the total and only available universe for the person.
           Sexual torture, according to Agger (1988), is defined as “a relationship between torturer and victim characterized by ambiguity, containing aggressive as well as libidinal elements.” Not only pain is inflicted, but, in addition, positive sexual stimulation is used to foster shame and dependency and the destruction of the personal and sexual identity.
           Central in sexual torture is the evoked fusion of good and bad self and object, the breakdown of splitting as an identity saving mechanism, and the fusion between self and object. By this, I do mean the fact that the victim internalizes not only by identifying with the aggressor, but introjects the torturer via this more primitive psychic process, wherein the boundaries between self and other are blurred and disappear. The tortured thus becomes the torturer.
This process is induced by the victim’s extreme dependent position when submitted to a totally controlled environment. The victim is totally dependent on the torturer for her bodily functions. Food and water are supplied when the torturer wants to or doesn’t want to, as much as light, sound and noise, hot and cold. Whether she may see at all or is blindfolded, may go to the toilet or wash depends entirely on when the torturer wants. Frequently she has to defecate or urinate her clothes. Every mutual reliable relationship is annihilated and the victim is thus driven into an extreme regressive psychic and physical state. In this state she becomes incapable of relating to her body, to the outside world and to other human beings, because the torturer attacks her private self (like a sadistic Superego), instills feelings of guilt, mocking and denigrating her.” (Amanti, 1983, p.119).
           The regression to splitting is a desperate adaptation attempt to save the good self, the ego-ideal and the good internalized objects. Clinical experience has shown that the traumatic consequences correlate in their devastating extent with the torturer’s capacity to stimulate the victim sexually (in a psycho-physiological sense). The reason is that, if in the paranoid-schizoid position the victim reacts to sexual torture with physical and psychological sexual arousal (consciously or unconsciously) then this results in her experiencing the relationship with the torturer as ambivalent. By sexually stimulating the victim at an ego state of extreme regression, early libidinal bonds with mother can be revived and projected on the torturer. The ambivalent reaction to the torturer makes it impossible for the victim to really fend off the “bad,” the torturer, as it generally still is possible in rape. This process is accomplished by using the bad and the good torturer, the latter of whom provides warmth, holding, friendly skin contact etc., and also positive sexual stimulation. The processes of splitting and projection break down, ego boundaries dissolve, and the victim regresses to a state of complete dependency. The victim incorporates the bad, and feels “finished”. She starts looking at the world through the eyes of the torturer and feels guilty, because she has been subversive and fought against the political system and its representatives. The personal and political identity of the victim are destroyed.
           After torture, shame and guilt feelings are generated as the predominant, overwhelming feelings and threaten to stay with the victim forever, because she submitted to the torturer. In treatment, talking about sexual torture is associated with extreme feelings of shame and social taboo. For example, it took Linda one year of therapy in the group until she could express the first hints that something like sexual torture could have happened to her. The group in turn “missed” her first two hints and first heard only plain physical torture and denied the sexual quality because it obviously seemed too painful and dangerous.
           In rape, the victim is usually more able to maintain a demarcation between herself and the perpetrator. Although the assault is also traumatizing, the fusion between good and bad, perpetrator and victim is not accomplished by the perpetrator, as it is done by the torturer. Male victims of torture usually are not confronted with this extreme dissolution of ego boundaries, but their sexual organs are destroyed more frequently. In sexual child abuse, quite obviously, the fusion we find in sexual torture can occur too. The results of course are as devastating.
           Clara, age 22 came to treatment via the recommendation of her lawyer, after she had made her fourth suicide attempt. Though not a political fugitive, she had a history of sexual torture. After a few individual sessions she joined one of my analytic groups.
           In her experience, rape, and sexual torture was combined with complete economic dependency on her torturers and the impossibility of leaving them behind. The torturer at the same time seemed to promise security from existential anxieties, starvation and abandonment. In her transference relation with the group, Clara felt completely ashamed and guilty, but also absolutely dependent upon the group. Her suicide attempt at an early period in therapy was a total effort to reestablish her ego boundaries, a rudimentary self-esteem, and dignity. She was striving to regain her capacity to split the world again into good and bad and to throw the bad inside her out, to rid herself of the bad introjects and simultaneously to establish borders between the self and the outside world.
           In the subsequent group sessions, it proved helpful that another foreign group member too, had a history of sexual abuse and the victim patient didn’t need to feel so “strange.” It became gradually evident that her seductive behavior had evolved more and more as desperate behavior, but the only option available to make and keep contact and to satisfy her dependency needs.
           Later, she could verbalize that the erotic approach, which she instinctively chose as a way of getting close to others, was her way of controlling the situation. Eventually, she became able to experience intimacy without sexualizing the relationship.
           Supporting the victim/patient’s efforts to regain sexuality as a satisfying way to relate is a therapeutic challenge with uncertain outcome. Frequently, the time necessary for such a process is not available for financial reasons and because the stay of the patient is sometimes permanently endangered by the impending exile of the patient by the state administration.
SOCIAL SYSTEMS THERAPY
           Victims of torture, fugitives of totalitarian, persecuting, or fascist systems, and coincidentally many other severely disturbed patients, frequently are caught in a network of “helpers” (social workers, lawyers, volunteers), legal authorities (police, court, prison administration), and administrative bureaucracy. This societal network of significant others may be conceptualized as a “large group system” (von Wallenberg, 1997), which represents the individual patient’s life space. This may include the patient’s residential group (family, partner, friends), the psychiatrist with medical responsibility for prescribing and monitoring medication, psychotherapists, coworkers or co-participants at a sheltered workplace, family, friends and, during times of acute crisis and subsequent hospitalization, the hospital staff, the representatives of the social welfare agency (which provides the financial support for the social work input), and representatives of other bureaucratic institutions. Such a “large group system” is not convened purposely and will never meet as a group. However, if, for the sake of argument, we conceptualize this network of significant others as a quasi-large-group, who consciously and unconsciously relate to the patient and each other, we can work with these interactive dynamics and understand disturbances in communication as a mirror of the psychic processes of the patient.
           Victims of torture (especially within the large group system setting of their unknown host country) may regress to psychic states first experienced under torture and re-experience the same traumatizing feelings. This is not only because small stimuli may trigger the memory of torture, but also because the “large group” effect that works within the large group system may cause identity diffusion and regression, because of the anonymity involved and the fact that barriers and misconceptions are harder to break down than in small groups.
           Since the large group system is characterized by the fact that face-to-face communication is no longer possible, it easily arouses persecutory anxieties and reinforces the defense mechanisms of projection, projective identification, splitting and fragmentation. This has been frequently discussed in the recent literature, for example Kernberg (1995). If we achieve to integrate our knowledge of large group system processes and of the psychic mechanisms working in an extremely regressed self, as we find it in victims of trauma, this may open new possibilities to make use of the large group system processes in a healing way.
It is my understanding that the large group system is a means of getting in touch with the psychotic nucleus of groups as well as of individuals. From a developmental, psychogenetic and group genetic point of view, feelings experienced in the large group system by a self in a regressed ego-state appear to date back to an early developmental period in the life of the infant, where the differentiation between I and you, self and other, the inner self and the external world is at best blurred but certainly not yet fully established. The establishment of a mature sense of identity is in statu nascendi, and feelings of omnipotence alternate with states of helplessness and impotence. Projective identification is a major means of maternal communication with the infant and persecutory anxieties alternate with feelings of oceanic well-being, complete containment and ecstatic fusion. Similar processes can occur in the large group system as well as in a large group proper and in social institutions, like a hospital, etc.).
           The following hypotheses are an attempt to challenge our conventional knowledge relating to large system group processes and to facilitate a dialogue which will explore the conditions under which they become constructive and healing. It is also a response to Kernberg’s (1993) discussion on the disruptive power of large group processes. The hypotheses I wish to propose are:
           1. The large group system dynamics are prone to be experienced as threatening and persecutory, thus evoking projection, projective identification, splitting, in the case of borderline personalities, and fragmentation[3] and fusion in the case of psychotically structured personalities.
           2. We can observe parallel processes occurring within the large group system’s dynamics and within the psychotic, pre-oedipal nucleus of the individual personality (Bleger, 1972). Agazarian (1994) discussed similar ideas on containment from a system centered approach.
           3. If, as influential members of the large group system, we succeed in fostering a change of the prevailing group dynamic towards one of a mutually holding relational matrix which fosters tolerance, respect, appreciation, communication, and containment, then, as a result, split off, fragmented feelings and aspects of personality become perceivable and discernible. They can then become contained, verbalized, worked through, and integrated. A sense of security and a feeling of becoming master of one’s own fate, of being able to survive and transcend the catastrophe experienced by the self, grows within the patient.
           4. This feeling, too, will grow in the other members of the large group system. They will become more able to tolerate feelings of impotence and helplessness in face of the “landscapes of death” (Benedetti, 1992) of the patient’s self. They will be less compelled to manage and control the patient, instead become a facilitator of emotional growth and accompany him on his therapeutic journey.
           As skilled group therapists of the large group system we may obtain the leadership of the group and cope with the destructive communicative disruptions from within it. These disruptions frequently mirror the predominant defensive organization of the patient, and can be understood as an expression of his or her deep seated conflicts arising from the traumatic feelings experienced under torture. Such an approach provides us with impressively forceful insights which enable a deeper understanding of the traumatic scenery the patient carries within himself and which he has not yet succeeded in leaving behind, to become able to fully live his own life.
CASE EXAMPLE OF THE THERAPEUTIC USE OF THE LARGE GROUP SYSTEM
           Said, pending trial, had sewed up his mouth because he faced deportation to his home country. He had been tortured brutally and, if returned, according to his judgment, would face instant execution. He had become imprisoned in Germany on charges of a drug offense, and German policy is to expel such persons. Large group system psychotherapy here meant specifically to build a network between the various individuals who where involved with Said and to foster a common understanding of his person. Beyond that, it meant to contain the anxieties of those persons involved who feared that Said was a liar, that he would fool them, that he was psychotic, that he was simply seductive, but also their own overwhelming feelings of anxiety, powerlessness, and almightiness in face of the traumatic feelings assiciated with the fact that Said really had been cruelly tortured.
           Working with victims of torture confronts the therapist as well as group members and members of the larger group system with questions like: What would I have done in such situations? What has really happened? To answer this question was the decisive point in Said’s therapy. As his therapist, I had to fight this out with him, but also with the significant societal figures in his life, such as his social worker in prison, his lawyer, the judge, and the minister of internal affairs. Eventually we all reached the same point: it became clear that there was only his testimony and nothing else. To believe or not to believe meant for him to be or not to be.
           Importantly, and in contradistinction to the traditionally more passive role of the psychoanalytic psychotherapist, we can be therapeutically effective with victims of torture and severe trauma only if we are willing and able to take a stance. Otherwise therapy will merely result in another in the series of traumatic destruction of their personality. Only our recognition of the suffered injustice and our clear-cut stance will make reconstruction, mourning, and “healing” of the wounds possible. At a certain point, we become empathetically the fellow human being who must accompany the victim of torture and persecution through his mourning for his lost faith in man, his lost dignity, his psychic and physical pain, the destruction of his psychic structure, and his existential fears.
           Psychotherapy with Said addressed his superego pathology by working through his hatred of authority and the institutions he identified with his torturers and simultaneously empowering him to demarcate: to say “no” not only by sewing up his lips, as in anorectic behavior, but to become able to say “yes” without fearing the destruction and annihilation of his self. The final goal was to revive a containing internalized group. For Said this became possible because the large system group evolved in such a way as to contain his and its own anxieties. He could return to the society of the here and now and he did not have to rely any longer on “psychotic” behavior nor to live on in his world of torturers of the there and then. Eventually he received the relatively mild punishment of probation, and a permanent resident permit.
In my experience, in our daily clinical work with severely disturbed, regressed patients, who frequently too are caught up in a large social system this knowledge about large group and large system processes and how to cope with them makes group therapy proper only possible. The managed care approach to psychotherapy too can be analyzed from this perspective and discussed under the rational, weather e.g. processes of fragmentation are to be understood as a projective identification with the patients internal mechanisms, or weather a destructive large social system prevents the patient’s emotional growth and tries to abuse him/her for its purposes.
           
SUMMARY
As Malcom Pines ( 1994) illustrates, group analysts today do not only treat more disturbed patients then ever before (borderline personality disorder, severe narcissistic personality disorders, psychotic, and even schizophrenic patients), they are also more aware of the fact that their patients suffered real traumas and that beyond confrontation, interpretation, containing, and setting limits an empathic approach is necessary that provides holding and soothing. Informed empathic mirroring, holding, and emotional sharing go beyond pity and mere supportive psychotherapy in the following ways.
           1. Such empathetically attuned therapy challenges the therapist’s capacity to share, to let himself get involved and “used” as a container and as a partial object by the patient and yet to demarcate himself again and to survive as therapist. The group, as well, is challenged to survive and not to fall prone to pity or to become a revolutionary revenge committee.
           2. Feelings of shame combined with feelings of guilt are in many respects the patient’s  largest initial obstacle to recovery. In the therapy group this means sharing these feelings, acknowledging “rational” guilt, and demarcating irrational feelings of guilt.
           3. The working through of re-traumatizing situations, living them through in the group, containing them, and learning the difference from the there and then and the here and now becomes the first opportunity to live life in the present. A generalized avoiding personality disorder may be reversed. This applies to all kinds of traumatized patients!
           4. Psychosomatic reactions can be integrated into the group psychotherapeutic process. We can translate them into dialogue. They are prominent, not only because the pain is unspeakable, but also because torture attacks the personality at such an early, regressed stage that the entire being is attacked. The memory of torture is conserved on the body level too. To the clinician a certain hypochondriacal impression may arise, or hysterical, dissociated ego states may be perceived. This means that the victim/patient is as yet incapable of integrating the feelings connected with the traumatic experience in his psyche.
           John, a victim of torture, was very much worried about cancer of the skin. He dreaded the possibility of melanoma. At first the anxiety he expressed to the group seemed very realistic, so the members eagerly sought to give him recommendations for a good doctor, etc. Gradually, a strange feeling grew in the group, as his fears of skin cancer, after another biopsy did not subside. He appeared increasingly obsessive despite the negative diagnosis. Even as some members of the group started to insist that this fear of skin cancer might be related to his existential anxieties and his fears of dissolving, he kept insisting on his skin cancer. Though he suffered very much from these hypochondriacal anxieties, they helped him to avoid his much more traumatic feelings. The group first reacted rather angry and confronted John with his avoidance. Only one fellow patient who himself had been very traumatized could understand the fear and shared his own suffering before he had been able to confront himself with the cruel feelings that went along with his trauma. This opened the group up for John’s fears of the traumatic memories and overwhelming feelings. His fears of skin cancer became a metaphor for his existential anxieties.
           5. The dissociation between the use of civilized speech and the destruction of civilization and humanness is what strikes us in these cases. Within the group context dissociated feelings can be recovered. The traumatic emotional impact of torture associated with expressions like “telefono,” i.e. strokes on the ears, “submarino,” submerging in a stinking liquid up to near-drowning, “papagai,” tying legs and hands together and suspending, is recovered. The overwhelming feelings that went along with the traumatic interactions can be integrated and eventually put to rest.
           6. Eventually we can learn, how the group psychotherapeutic process can help to integrate the traumatizing process by recalling, narrating, and sharing the overwhelming emotions and strengthening the mature post-torture personality.
           7. Primitive, early defensive psychic processes like splitting, projection, dissociation, numbing can be recognized, recovered, and even worked through. The ego regains the strength to survive and to live on.
           8. There accumulates a heightened recognition and consciousness of the children of these victims of torture, children who, as we know, carry the unspoken within themselves. The victim of torture undergoes group psychotherapy not only for himself, but for his offspring and for subsequent generations.
           9. Victims of torture teach us that it is our pain that gets in the way between them and us.
           The treatment of victims of torture represents significant progress in the evolution of a therapeutic group culture. It acknowledges the reality of traumatogenic social conditions and takes full psychotherapeutic, social, and political responsibility for the patients. It is yet another application of the “group dynamical understanding of structural violence” (Wallenberg, 95)[4].
           The psychotherapy group explores truth. What really happened with this person, where did his own responsibility end, where did he become a victim, how did he react, how was he able to survive? What did the torturer and the life-attacking small and large group dynamics do to him? The therapy group is also a quest to understand what torture did to the patient’s inner world of internal objects, group dynamics, and his capacity to relate to and bond with himself and others.
           To be confronted with a victim of torture and man-made trauma confronts us with questions like, would I too have behaved like this, what are my ideals? The group psychotherapy of victims of torture opposes any ideology of  “there is no absolute truth.” To put it simply, man-made physical and psychological death is absolute truth. The treatment of victims of torture calls for a global perspective and demonstrates how much we need common symbols that unite mankind, and common laws that set standards for humane behavior.
           The treatment of victims of torture makes us aware of the fact that everyone of us can be destroyed physically, mentally, and emotionally so easily, and that only a holding, containing group can assure our survival. It gives us hope for the future. When the traumatic wounds of torture are challenged they will not have to be transmitted to the next generation with their destructive, revenge-seeking, life-attacking impact.
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[1]              Pseudonyms are used throughout this chapter, and to further assure confidentiality, the case examples are syntheses of a many actual patients, so that no single patient is discussed, and any resemblance to any patient is purely coincidental.
[2] “Inner immigration” is the process of secluding one’s true convictions, one’s true self, one’s identity, shut it off from the outside don’t make it public any longer, because otherwise one would run the risk of becoming destroyed, even physically. May be it’s too much of a German translation, because in German this is a commonly used expression for the people who did not emigrate from Nazi-Germany like Thomas Mann etc. but kept their, the regime opposing convictions with themselves.
[3] I consider fragmentation as a primitive psychotic defense mechanism that saves the patient from total annihilation and dissolution in face of an object that otherwise would be experienced as totally overpowering, overwhelming.
[4] At the end of the sixties the Oslo social scientist and peace researcher Johan Galtung (1975) defined structural violence as the cause of the difference between, or of the failure to reduce the difference between actual and potential achievement of an individual , as well as a whole group.
Taking his ideas further I (Wallenberg, 95) consider all group-dynamical conditions which encourage the isolation of the individual and whole groups and hinder their ability to enter into lively contact with others and to undergo further development as manifestations of structural violence. On the other hand, I do understand all conditions, which encourage differentiation of individuals and the differentiation of group-structures (internal differentiation, as well as differentiated relationships to a variety of other groups) as a factor, standing up against structural violence. Structural violence wants to keep the balance of power as it is, it wants to control the needs and wishes of the individual and whole population groups, the group’s capacity to sense own needs, to live an own identity is a permanent threat to the yielders of structural violence.
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