The only way "out" is "through".

On the influence of war on life and psychoanalytic practice

Iryna Malyshko

The article is based on the paper presented at the IPSO Days in Ukraine conference, November 30 – December 1, 2024, “The Fate of Symbolic Thinking During Traumatic Events.”

Iryna Malyshko  is a Psychiatrist, Ph.D., IPA member from the Ukrainian Psychoanalytic Society

© People in Need, 2024 (photographer: Alberto Lores) from the website: European Civil Protection and Humanitarian Aid Operations

“I see the dead bodies of my fellow fighters; they are mutilated and

scattered everywhere,

their eyes are open.

I try to close my eyes so as not to see them.

But my eyelids are damaged. My horror grows even more.

I understand that I have lost the opportunity

to close my eyes and not to see”

(From the patient’s dream)

“There are no words yet. There is already poetry…”

Lina Kostenko

 

Introduction.

Referring to the ancient idea attributed to Aeschylus that the first casualty of war is truth, John Steiner adds that the second casualty of war is the capacity for symbolic thinking (from the paper presented at the IPSO conference in Ukraine, November 30–December 1, 2024). He emphasizes: “When symbolism is blocked, we are limited to the concrete thinking that is characteristic of war” (Steiner, 2024). The epigraphs selected for the article, in my opinion, reproduce the limits of the psychoanalytic optics setting: from the astonishment of the shocking experiences of patients and my own, the concreteness and sense of the infinity of traumatic experience, unbearable pain through the endurance and search for words that contain, the restoration and preservation of mental life and the psychoanalytic process, to healing creativity. In this article I will try to bring together impressions, thoughts and questions regarding the state and vicissitudes of symbolic thinking in wartime. Concern about this has persisted since the early days: for many of us, psychoanalysis as a field of human knowledge and psychoanalytic practice have become an important resource for mental survival, self-help and help for our patients, people who were forced to face the challenges of wartime. The working condition of the personal mental apparatus, its containing capacity, productivity, and flexibility were and are still critically important.

Working on this text was quite difficult. Different aspects of my own personality (the one that experiences, the one that helps others experience, the one that reflects), like musicians in a jazz band, were coordinated – from the cacophony of sounds to a common leitmotif – strenuously and painfully. I encountered difficulties that can be considered typical of the state of the psyche in wartime: emotional and event overload; defocusing on individual impressions and thoughts, with the difficulty of building a hierarchy and homogenizing into a coherent narrative; the difficulty of maintaining an appropriate but truthful tone due to the constant risk of breaking into excessive emotionality, subjectivity, flinging still undigested images and elements of patients’ or my own experience into a large audience or, conversely, packing myself into the psychoanalytic theory of trauma and quotes, using it as a mechanical container. So the only way “out” is “through.” Therefore, the text itself can be considered an additional clinical vignette to those given below, using the example of which I try to illustrate the interaction in an analytic pair, the state of mind of the analyst and the patient, who are in both a traditional therapeutic setting and in the format of short-term crisis intervention in wartime.

 

 

About the war.

The war in Ukraine began in 2014, but it took time for both Ukraine and the world to comprehend the scale of the destructive force that was gaining momentum. The export of destructiveness from totalitarian Russia was embodied in a full-scale invasion. And it stunned. Despite all the obviousness of the intentions, until the morning of February 24, 2022, most of us did not believe in the possibility of a conventional war with street fighting, a huge front line, Bucha, the Mariupol Drama Theater and the explosion of the Kakhovka dam, a missile destroying the childrens’ hospital in Kiev.

With cinematic precision (which is in itself a sign of traumatic memory\recollections), I recall the morning of February 24, when, filled with anxious anticipation of war, we are awakened by missile strikes on the city. I run up the steps to my 83-year-old father. “Dad, it’s a war,” I hear my voice from the outside, everything happens as if in slow motion. While rereading this text, I deliberately left the mention of the events of that morning in the present tense – as it was spontaneously written. I think this can serve as an illustration of what H. Weiss expressed about trauma: “Because trauma knows neither time nor place, it is everywhere and nowhere. It overwhelms the present with a past that never ended and fails to have a future because it is an endless repetition of the same”. My father is glued to the TV screen, hoping to reconstruct the picture of the world. I feel myself and the world around me drawn into Lars von Trier’s thriller The House That Jack Built, about a psychopathic architect who builds his dream house from the bodies of the people he has killed: futile attempts at architectural designs are resolved by sadistic murders; mortified flesh serves as the building material for the realization of his mad idea, which has become a patch for the failed creativity. Putin’s policy of Russia looks like a remake of von Trier’s film adaptation in reality. The lethality (deadliness) of the dictator’s narcissistic rage seemed predetermined.

My first impressions and anticipations were then associated with several theses from the fundamental psychoanalytic authors Ron Britton and R. Money-Kyrle. Putin’s revanchist imperial policy seemed to be an externalized version of the intrapsychic situation of greed and genocide described by R. Britton. He writes about “an impulse to annihilate otherness. In the biological sphere, this expresses itself in the vagaries of the immune system; in the psychological, in the form of a xenocidal impulse; in the social, in the form of genocide”. He emphasizes the rage of an envious, cruel self-destructive Super-Ego (as a result of failure of early mother’s containment) in response to an independent choice – an irresistible impulse to annihilate the manifested otherness and independence. “The desire to possess the attributes of the object is combined with the urge to destroy the object as the source of such disturbing feelings… a hostile Super-Ego internally menaces “particularly when (they) show signs of independent personal development, sexual maturity, or creativity. It is as if the superego is modelled on a parent whose loving care can encompass the very earliest stages of infancy but whose continuing love is complicated by envy of the child’s personal capacities and, when there is separate development, creativity”. All this promised a war to exhaustion, according to R. Money-Kyrle. In his paper “A Psychological Analysis of the Causes of War” he wrote: “war releases immense quantities of normally unconscious aggression in many forms. The resulting mania does not subside until all the countries involved are utterly exhausted”. One wanted to believe in a quick end, but common sense indicated that one must be patient.

The war was gaining momentum. Mass destruction, genocide and ecocide (the legal legitimacy of using these concepts is still open). The war invaded the lives of all Ukrainians with an unthinkable experience (in the Bion’s sense), changing people and their destinies, the landscape of the country, stuffing thousands of square kilometers of land with explosives (which piercingly painful like a mother’s damaged body). The war is still going on. Autumn 2024 is more than 2.5 years of heavy military action at the front and mass terror of the civilian population with combined missile and suicide drone attacks, psychological impact of misinformation, destroyed infrastructure. The world is getting used to the war in Ukraine, shaken by other wars and outbreaks of terror, its own political and economic crises and natural disasters. The manic-omnipotent defenses against helplessness, chaos, fear of death and uncertainty, so necessary for maintaining the fighting spirit of the military and civilians, are exhausted by this point. “Heroes do not die. But Sons do.” The “invincibility” of Ukrainians is being tested for their strength not only by the power of destructive influence, but also by exposure — to time — to exhaustion, revealing new depths of the meaning of the word “to endure.” The new law on mobilization has caused a feeling of persecution in many people, intensifying the dangerous and painful split in the society between civilians and military men. The fragility of the balance between despair and hope is hanging in the air. Nuclear blackmail activates annihilation anxieties on a larger geographical scale, influencing political choices and attitudes toward Russia’s war in Ukraine. All the manifestations of the death instinct/human destructiveness described by psychoanalysis are in use. And what about the image of the future? We ask ourselves: is the scenario of the future realistic or pessimistic, expressed by the identity statement “Ukraine and war are synonyms”? What might exhaustion look like in this war? How the bottom of the civilizational failure looks like this time? For many people in Ukraine this war is not only for national identity, it is a war for the opportunity to freely choose the path of development. But for many in the world, Ukraine’s subjectivity (agency) on a macro-geopolitical scale remains questionable. This is a special type of pain and anxiety, with the pressure to play out an assigned role. The distant postwar period worries us with the post-traumatic scenario of our society’s development.

 

On the mental state in wartime.

War pierces all levels of mental organization like a treacherous stake, simultaneously activating the anxieties of the schizo-paranoid and depressive positions. External reality loses its previous structure and quality, resonates with the primitive and powerful anxieties of annihilation and persecution, hidden in the depths of the psyche. The necessity to simultaneously process anxieties related to different levels of mental organization is a huge challenge: both primitive anxieties of survival of the self with the loss of faith in good internal objects (anxieties of the SP position), and anxieties of the depressive position (DP) related to the state of its objects (relatives, loved ones, community, country, activity) and internal objects, associated with the actual or probable loss, mental pain, grief. Sometimes the shocking cruelty of external events threatens with dehumanization: the desire for a fair trial and retribution, punishment of the guilty seem unrealistic, triggering a thirst for revenge according to the law of Talion. It becomes “normal” to become abnormal in order to survive in an abnormal reality – for the military at the front, and for the civilian population – in conditions of missile terror, hours-long sirens, to adapt one’s life to the absence of light/water/communication, school lessons – in bomb shelters. But is it possible to imagine years of life in a concrete shelter? “To have a life worth the name will inevitably involve some risk” – writes C. Garland about life as such. A life worthy of its name for civilians in war means an order of magnitude greater risk and can continue “not thanks to, but in spite of”  the  signal anxiety  (which informs the approach of helplessness), but often even in spite of the automatic anxiety of actual danger. (Although, when destruction and annihilation occur side by side, it becomes increasingly difficult for the traumatized Ego to distinguish between automatic and signal anxieties). Is this due to what Britton says “tempting to view as an example of containment” of automatic anxiety, the “domestication of nameless dread”? He writes: “When as a child in the Second World War I asked my father what it was like to be shelled, he said: “well, you know if it has your name on it, you will get it; if it hasn’t, you won’t”. It did occur to me even then that some might think every shell has their name on it and others that it probably has not. I have spent a lot of time with soldiers since then and found this narrative, “if it has your name on it”, is often repeated. I am tempted to think that this is an example of containment, that the general threat is circumscribed by the idea that the fatal missile might have your name and address on it or not; it makes it rather like winning the lottery in reverse; we could call it the domestication of nameless dread”. Some of my patients said that they felt as if being forced to play “Russian roulette” during massive missile attacks by Russia, sometimes with the same taste of unhealthy excitement in the aftertaste – the missile could be signed with your name. Many patients repeated the words of Viktor Frankl about the survivors of the concentration camps: “The first to break were those who believed that it would soon be over. Then – those who did not believe that it would ever end. Those who survived were those who focused on their own affairs, without waiting for what else might happen.” For many people, these words became a route sheet in enduring the circumstances of war. But Frankl’s “focus on your own affairs” is often not “domestication the nameless dread” \ containment (which R. Britton writes about), but means a defensive maintenance of detachment from external and internal reality in order to hold at arm’s length the threat of overwhelming anxieties, deluge of overexcitement and shock. Direct contact with destruction causes consequences that C. Garland considers critical for symbolic thinking: “the injured ego can no longer afford to believe in the alarm signal in any situation that resembles a life-threatening trauma: it behaves as if overwhelmed by automatic anxiety. This is a key factor that causes the loss of symbolic thinking” (Garland, 1998, p. 17). This is well illustrated by the example described by I. Romanov (Romanov, 2023, p. 109-110), a mother covers with her own body a child who has been frightened by an airplane and has fallen to the ground in terror in the middle of a relatively calm city in Western Ukraine.

The impact of the high intrusiveness of modern means of communication requires reflection, when the person appears to be under bombardment of unprocessed photo-video material – raw elements of experience, expelled by eyewitnesses, participants of traumatic events. Telegram channels are becoming not so much channels of information, communication, but as evacuation, chronically flooding and retraumatizing.

 

On the fate of the word in the context of symbol formation.

The inevitable Ukrainization for the Russian-speaking part of the people of Ukraine, which completely coincides with a conscious civil choice, is experienced in this case with difficulty. We know that the Word, when it is born, is in itself an expression of the process of symbol formation. We also know that symbolic thinking in wartime is under threat due to the traumatic external reality, which, confirming and activating the most primitive unconscious fantasies, strives to stick together with them, binding them forever (Z. Freud), plunging the subject into the claustrum of concreteness and timelessness of trauma. In my opinion, for those who thought with the Russian word, the deep conflict is that the Russian word, naturally born of one of its own identities, is felt as hostile to another own identity. The verbal Rhesus conflict threatens the abortion of thought. And as with the biological Rhesus conflict, in each specific case the outcome depends on a combination of factors. Such a situation of rejection of the mother tongue in which thinking occurs differs significantly from the transition to another language under other circumstances. In the first situation, an internal paranoid atmosphere of the type “stranger among his own, his own among strangers” arises during word formation, unlike others, when there is no verbal Rhesus conflict, when words safely coexist and are interchangeable. Linguistic disidentification causes mourning, but this mourning is politically incorrect, and it confronts the individual with the Super-Ego for thinking in the language of executioners-killers.

Reflecting on the “language” issue, I try to separate (as far as possible in times of war) the political and propaganda context and adhere to the vector of development of national identity, as well as morality, conscience, values and ethics. Separating the propaganda context is not so easy, because as I. Romanov emphasizes: “propaganda refers not only to external forms of statements by political leaders or the discourse of mass media, but also to certain internal propaganda “voices”, which a person quite often cannot resist or is inclined to perceive with varying degrees of readiness” (I. Romanov, 2023, p. 24). When this finally becomes possible, I observe a wider and polyphonic range of feelings of guilt – from persecutory to depressive – in relation to both languages. So I mentally turn again to R. Money-Kyrle and his reflections on feelings of guilt, morality and ethics in the famous article “Psychoanalysis and Ethics” (Money-Kyrle, 1955). When he writes about conscience and morality in people who are capable of feeling guilt, he distinguishes them by the type of feeling of guilt and divides them into people with authoritarian and humanistic conscience. People with authoritarian conscience mainly feel persecutory guilt, and submit to the demands of the Super-Ego or its external representatives (so it is quite possible that the containing language of the mother becomes the language of the executioners in the plane of authoritarian conscience, and submitting to the demands of the Super-Ego becomes a virtue). People with a humanistic type of conscience mostly feel depressive guilt, they feel grief if they damage or leave something they still love, they try to protect the object of their care and value. “It is most difficult for people with a dual identity during the war,” recalls Igor Romanov (in private communication), referring to conversations with Gilbert Diatkine during a seminar in Georgia back in 2015-2016. The humanistic conscience cannot remain on the sidelines, and tries to protect the inner home and family of good inner objects, once consecrated by the language of the (Russian-speaking) mother. An identity built “from the reverse” is always fragile, because it has a built-in psycho-genome of revenge and persecutory guilt, the explication of which inevitably leads to destructive consequences. Therefore, the fate of the word in times of war turns out to be just as painful and full of contradictions, losses and sorrow. Language can be used as a weapon, but there is a risk of reducing it to a specific weapon. Of course, this process has many individual and geographical differences.

In such external and mental realities, the helping specialists – psychotherapists, psychoanalysts, psychologists – find themselves directly experiencing war. At the same time, there is a request from the outside for help from their side. And also their own need to preserve their good objects and identifications – to survive mentally, to preserve their professional identity, and therefore, the ability to feel, perceive, empathize and think, to process their own and their patients’ experience.

 

 

On the state of the main psychoanalytic instruments in wartime.

Continuing practice in the described realities, we try to make “the best of a bad job” (W. Bion) with our own psychic apparatus and setting attacked by war. We often asked ourselves: is psychoanalysis what we practice? How does the attacked setting and the war macro-situation affect the unfolding analytic process? What exactly do patients report, getting stuck in the external reality of war? Or how do they defend themselves from the unbearable caused by war, focusing on the analysis of intra-psychic processes and current personal circumstances? How does the actual anxiety change in the session? Have I domesticated my own “nameless dread” for a state of free-floating attention, and what is the impact of my interpretations – do they contribute to understanding and living through, or is there a ping-pong of unbearable mental content between us? (I will illustrate this with clinical vignettes below).

 Clinical vignette 1. Patient V., a borderline patient, closer to the psychotic level of organization with manic-narcissistic defenses against primitive anxieties, who was able to leave the territory of Ukraine on the first day of the war, will later say that if he had stayed in Ukraine, he would have gone completely crazy (implying his states of disorganization, fragmentation, “white noise” of the disintegration of thinking), since he would have experienced every Russian missile launched at Ukraine, flying towards his balcony and he would have exploded before they reached their destination. His nameless dread seemed undomesticated, – in his reality every missile was signed with his name. It is noteworthy that, being in another country at a considerable distance from the war, he only once at the very beginning expressed concern about me and my decision to stay in Ukraine and spoke of envy for my ability to withstand (bear) the fear of shelling. By the end of that session, he masterfully dealt with envy, evoking it in me, showing me a beautiful sunset, the splashing ocean and the peaceful promenade where he had secluded himself for the session (before session with him I had just escaped from the cold underground parking where we had hidden during the shelling, and had grieved acutely during the first months of the war). From then on, he almost never mentioned the war, as if it did not exist.

However, this winter, at the height of his despair, when his manic defenses failed and he found himself on the verge of disintegration, internally haunted by primitive anxieties and narcissistic depression  connected with external failures and the collapse of codependent relationships, he spoke with empathy and insight about the difficult situation in Ukraine, about the external crushing threat, about the internal atmosphere of persecution in connection with the law on mobilization, about the impossibility of victory in the form that everyone in Ukraine wants, about the split in the society and the desperate state of affairs, about the lack of resources for recovery. I was impressed by his scope of perception of the external situation of the war and the emotional resonance that I hadn’t expected from him. I hesitated whether to regard this change as a greater contact with reality, as approaching the threshold of a depressive position? Or as D. Tuckett put it, should I consider his associations as a day-dream, as an eloquent image taken from outside the session’s window?  Later it became obvious that the patient had chosen an extremely penetrating image of war to represent and communicate to me the state of affairs in his inner world – a definitely piercing me image of his despair and threat, the lack of his own resources and the need for help from outside. It was easy for me, being inside the situation he described in Ukraine, to sense the full depth of despair and to resonate with the experiences in his inner world. The image of the war in Ukraine became a caesura for our psyches, through which despair, pain and anxiety flowed, which we had to cope with in our pair.

The cases I described concern psychoanalytic work with the patients affected by war in the sense of the so-called everyday war traumatization. Here we are talking about, in essence, ordinary psychoanalytic work in the unusual circumstances of war, when the impact of reality tends to deafen the analytical ear, dissipate vision, flatten or overwhelm the analyst’s container.

On the setting.

The war distorts the framework of the analytical process with the various attacks on it mentioned above. Some of us were able to maintain practice in our consulting rooms; others had their homes and offices destroyed or were at a high risk of destruction, so colleagues were forced to leave them. The possibility of maintaining the analytical connection through on-line sessions, the wide geography of migration of patients and analysts created multiple and changing configurations of the setting. I will list some of them:

– the analyst and patient share a similar external reality: in person or on-line, remaining in Ukraine under military threat of missile attacks, with interruptions in electricity and communication;

– the analyst and patient are both in a relatively safe space, sharing the experience of refugee life;

– the analyst and patient are in different conditions regarding the external threat (the analyst is safe, the patient is in danger and vice versa);

– an analytically trained specialist provides crisis assistance “in the field” (hospitals, social assistance centers, etc.).

The impact of the asymmetry of the situation related to external danger on the relationship in the analytic pair requires understanding; the importance of patients’ awareness of the analyst’s location (the patient’s anxiety about the analyst, about the analyst’s state of mind, the patient’s reactions to the analyst’s departure from Ukraine, the fantasies of patients who have fled about the fate and motives of the analyst who remains in danger in Ukraine). Or, on the contrary, how does the symmetry of experience (becoming a refugee or being under a missile threat) affect the development of the transference situation, what kind of figure the analyst will become in the patient’s inner world.

We tried to develop an algorithm of actions (or to understand its absence) in moments of a missile threat during face-to-face work in the consulting room. The struggle to maintain connection during blackouts, lack of internet, connection failures during a session (both on the part of the therapist and patients) had their own peculiarities; questions arose about payment for sessions in an attacked setting, and many other nuances. Much of this was both external factors influencing the analytical process and became an expression of its unfolding, intertwined with the transference-countertransference language of messages. It was necessary to distinguish the first from the second. Technical difficulties arose: would the attacked setting remain an event of external reality or could it become part of the analytical process; how should the analyst interpret to the patient his\her defensive use of the influences of external military reality on the setting? These and many other questions were often resolved on the go, with inevitable enacting, and difficulties for retrospective understanding and working through.

 

 

On “domestication the nameless dread” in an analytical pair. Difficulties of the analytical process.

Face-to-face work with patients in a consulting room during missile attacks was particularly difficult. Patients’ reactions to the possibility of resorting to precautionary measures (two walls, shelter, interruption or continuation of the session) varied depending on their character structure, the depth of disturbance of their personality and the type of defenses used. Being an analyst responsible for the setting and physical safety of the patient, it was not easy for me to develop a single algorithm of actions in such a case. In one of the groups in the “Helping the Helpers” project we had a discussion with the colleagues based on their experience in such situations (Should there be a possibility of using a shelter? Should we interrupt or continue the session? Should we extend the session if it was interrupted and there is a possibility? What about the payment issues?) I received recommendations from the supervisor, the correctness of which was obvious, but… unrealistic: “Using a shelter should be a directive. And it is better to conduct the session in a shelter.” It did not seem realistic to implement either the first or the second in practice. The overwhelming majority of patients did not have the opportunity to use shelters in most other situations (home, work, shops, banks). I understood, that for the civilian population part of the general setting is the inevitable risk of mortal danger exists as a fact of external reality, with the only difference being to what extent a  patient is in contact with this anxiety, how does he or she cope with it? What role do I have in the patient’s picture during the session? Quite typical experiences were “it’s not so anxious here/with you, it’s safe here”, which often reflected the idealization of the omnipotence of the parental figure attributed to me, or the image of the mother-environment, absorbing all the anxieties and dangers. Or there was the opposite reaction – “I’ll cover you with myself” or “let’s go down to the shelter if you’re scared”, when the anxiety and fear were projected entirely into me. There was a challenging technical question: how to support the patient’s ability to be in contact with external danger and their anxiety, without pushing into them the unbearable – fragmenting annihilation anxieties.

 

Clinical Vignette 2. Patient A. is in repeated analytical therapy with me since the beginning of the war in a setting of two weekly meetings face to face. He is a reasonable and successful man of middle age in social and business terms. The main complaint when he came to me was a feeling of emptiness and futility of efforts despite the formal success of many undertakings and useful initiatives, problems in relationships with women, which, started with exciting infatuation, but often ended in mutual disappointment. The problem and peculiarity of our contact most of the time was and still remains that I am given the role of an important spectator (audience), in whose presence self-analysis unfolds with many conclusions and what at first glance could be considered deep insights, but which do not affect either him or me. The patient is very disciplined in the setting, he treats his therapy with an emphatic seriousness, as an important process. He always treated my attention to alarm signals and suggestions to go down to the shelter with condescension, parrying “if it flies here, nothing will help us”, discussing the ineffectiveness of alarm notifications that appear later than the “arrival” (explosion) of ballistic missiles, which corresponds to reality. Even in the first months of the war, he deleted all information applications reporting the missile threat, they “prevented him from living and working”. Of course, he would not want to be distracted by them during sessions either. He spoke about this with the confidence of a person who has accepted inevitability (“domesticated the nameless dread“?) He illustrated his solution with an elegant story (of which he is a master) about a Japanese scientist who hardly knew about the events of the Second World War and the atomic bombing of Hiroshima and Nagasaki, because, locked in his laboratory, he was developing a perfect snowflake; his discoveries formed the basis of technologies that prevented the icing of airplane bodies and helped develop aviation. Creating a perfect snowflake became a working (eloquent)  image in our therapy, but the depth of meaning eluded him under the brilliance of the metaphor itself. One day, when he used it again, he doubted whether it was a real story or an imaginary one.

 

A fragment of a session. Patient A. is talking about his latest project, is carried away by his self-analysis, confides in me contradictory and even unsightly aspects, establishes parallels in relationships – at work and with women. He views external events in his life through the lens of his knowledge of his mental structure. A distant explosion is heard; a siren howls outside the window, I see a notification about a red danger level for the city pop up on the phone screen. After a fleeting “Wow”, the patient remains captivated by the process and does not react to the situation outside the window. Another explosion is heard. I essentially interrupt him and suggest going down to the basement. He is disappointed that he has to get distracted “at the most interesting part”. I get up from the chair. He is still sitting: “if that will make you feel better”. I am alarmed and already irritated, I retort that “inventing the perfect snowflake is becoming increasingly unsafe… in every sense”. Another explosion follows. We go down to the basement, the patient comments that he is “interested in the new space after all”. Down in the basement, equipped for work if necessary, he looks around and comments “Not bad. But I don’t feel comfortable here”. We sit down. After a short pause, he returns to the previous topic, to the place where the first explosion interrupted him, but it is felt that he is speaking defensively, coping with mounting anxiety. I pay attention to the physical manifestations of anxiety, the hoarseness of his voice and the obvious dissonance of nonverbal signs with what he is saying. And I try to cope with mine anxiety. The patient continues to speak. I point out to him that he is trying to behave as if nothing has happened or is happening, and that the factual and emotional context has not changed.

Patient: It has changed. And I don’t like it. And you are anxious. Has it become difficult for you to work?

Analyst: I think that what is happening now is really worrying and cannot but affect us, our feelings and thoughts … we both have to cope …

Patient: I could cope upstairs, even better. The fact that we came down interrupted me and made me anxious. I don’t like closed spaces. You are infecting me with your anxiety.

Analyst: It seems that all the anxiety is in me now. Both mine and yours. (After a short pause) When I react to anxiety by acknowledging the threat and insisting on doing the little that is in our power, you feel that I am forcing into you something that is difficult to bear – the fear of death.

Patient: Isn’t it better to “work on the perfect snowflake” so enthusiastically that you are not touched by useless anxiety… We cannot change anything… If we listen to it, then we must never leave the shelter…

Analyst: Unfortunately, these experiences are now part of our life (we remain silent and his anxiety is obviously growing. I feel that I am insisting too much and confronting him with anxiety, which he resists even more actively. As well as many other feelings that he considers “useless”. I am not sure whether it is worth voicing this thought. I wonder to what extent he and I are capable to work, will I be able to contain my and his anxieties? And under the pressure of anxieties and his growing discontent, I am tempted to return to his reasoning and earlier material in the session. We remain silent).

Patient: I think it depends on each of us what our life will be like at this time (some more rhetoric) It seems that everything that was supposed to impact has already arrived, or has been shot down… (I perceived this as a reproach for excessive anxiety and futile actions)

Analyst: I think that the fear of death is so great at such moments that the only way to cope is to ignore the danger, as if it does not exist at all. Perhaps you manage to get rid of other difficult feelings in a similar way. (Pause) Last week, debris from a rocket fell on a school, if the teacher had not taken the children down to the shelter, there would have been many victims (I want to rely on the fact of reality).

Patient: This is my school, I went to it (he wipes his eyes and forehead with his hand, as if brushing  something off). Yes, I know. I drove past on purpose afterwards, wanting to see what was going on with the school. I didn’t want to talk about it. And yet I’m more afraid here than up there…

Analyst: Here you found yourself in greater contact with your anxiety… Up there you managed to ignore it, self-analysis became sort of a refuge (Pause). It’s dangerous. Fearless soldiers die more often. (The last phrase was definitely a mistake. He seized on it to continue his speculations, I myself opened the door to them for him again).

The above serves as an example of the transformation of the analytical process into a refuge from external and internal anxieties. I tried to use a specific situation and the anxiety it caused at the point of urgency as a caesura/access to the patient’s difficult-to-bear states and defenses against them. Later we were able to return to this episode. A number of difficulties are evident in the above: how to facilitate the patient’s contact with the intense anxieties of fragmentation and disintegration revealed by the war? How to cope without forcibly returning to the patient what he projected onto me? Where is the limit of what is bearable for each of us in the analytical pair? How to use the access to primitive anxieties and defenses against them in the patient’s inner world, provided by the war and often explained by it, without turning the analysis of intrapsychic reality into an escape from the external one?

 

Clinical vignette 3. Patient B, middle-aged, physician, mother of two children. Often feels exhausted by contact with people and as if locked into her profession, in which she has invested much effort and succeeded as a result. At the same time, she often dreams of mastering something else, as if to break out of the claustrum of her medical practice. Since the beginning of the war, she has experienced intense anxiety in connection with missile attacks and a feeling of guilt for not daring to leave and take her children away. After more destruction in the city, she asks herself: “What else must happen for me to decide to leave home?” My recent departure from Ukraine increased her anxiety about staying home and caused envy to my capability of leaving a dangerous home. She was able to talk about it, but associated it mainly with the opportunity to work online in my job. I suppose that for her professional activity and identification are akin to a second skin (E. Bick), providing pseudo-integration. Before the war, her family had an unsuccessful experience of moving to another country, which caused a crisis at the time and remained as a memory of failed separation. The patient is caught between two intense anxieties that are almost identical for her – being under missiles is experienced as mortally dangerous, but more bearable than the anticipation of repeated disintegration due to the loss of professional identity and separation in a foreign country (fragmenting anxieties on both sides). At the moment of discussing this hopelessness and her despair in the session, the patient suddenly responds with a story that shows (in my opinion) a defensive distortion of her thinking. The story of how she ends up in a hospital in a dangerous condition, where one of her patients – an official in this hospital “mobilized” the entire staff to provide her with timely and high-quality care. She conveys to me in person the conversation with the attending physician, who irritably asked her then: “Who are you that all this fuss is about you?” – “I’m just a person,” she answers with a sense of moral righteousness. With this story she seems to refute the understanding reached the day before about the defensive function  of her professional identification, raising the phrase about “being just a person” as a slogan. I interpreted it to her saying that she would rather like to be able to feel as she said, but in fact for her to be “just a person” without the protective covering of professional status means almost a mortally dangerous state. I see how her agora-claustrophobic dilemma is exacerbated to the point of despair, I am unsure of the fate of words at the moment when I give the interpretation. My patient pseudo-resolves her conflict by distorting her thinking in the session, when a new portion of anxiety, provoked by knowledge about herself,  becomes unbearable. Her severe super-ego, sort of, takes the microphone, switching off other voices from the audience and propagandistically broadcasts how she, being “just a person”, should feel confident and calm. In the countertransference I feel like the one, who pushes her to salvation, in which in her unconscious there is a catastrophe.

This vignette illustrates a frequent situation when military events shake and destroy psychic retreats as a system of defenses and relationships in the inner world of patients. For some of them it means disintegration, which is more frightening than a real military threat; for others, it becomes a zone of growth and development; for still others, it is a re-creation of their retreat in new context (decoration).

 

Psychoanalysis leaves the couch. To bear the unbearable in a short-term crisis counseling setting.

A new experience for many of us, to which we were able to devote ourselves to (or I would say “subject ourselves to) to varying degrees, was crisis counseling in a short-term setting (2-4-6 meetings) for people with the consequences of acute war trauma: refugees, internally displaced persons, family members of the deceased, military personnel wounded in hospitals. It is impossible to cover everything in one report, but I cannot help but mention the main thing. As never before, the truth of the saying “psychoanalysis is not what we say, but who we are” was felt; all the accumulated personal and professional experience became a resource for self-help and assistance to people going through acute grief and trauma. With the support of British analysts and facilitation from Melanie Klein Trust (MKT), the project “Help for Helpers” was created to support fellow frontliners working with acute trauma, based on psychoanalytic theory and practice; the project united 58 specialists and has been running for almost 3 years. Such practice imposed special requirements on the receptivity and container capacity of the psychic apparatus of the helping specialists. Following the task of domestication of the nameless dread, life and practice set the challenge of enduring the unbearable, caused by trauma, for the consultant-patient pair.

What exactly was of much help to us? After some time, I can say that it was all possible thanks to psychoanalysis as such, which became an internal good object, sometimes more stable than other aspects of the self and internal objects. I believe that PA became a common collective identification that integrated various features and was woven from many connections, theory, teachers, supervisors, colleagues and patients’ stories; everything that was reliably introjected thanks to PA training, personal analysis and participation in educational programs. I recollect how at one of the regular seminars of the educational program on Klein analysis, held with the support of the MKT in Ukraine for more than 20 years, we gathered in the first months of the war. At a time when our homes, offices and psyches were being bombarded by war, the online space of our seminar felt like a mental home, reliable, stable, protective and so necessary at the height of chaos and the threat of homelessness.

It is impossible to cover everything in one report. I had to exclude the vivid examples of short-term counseling – acute trauma recovery in the work of my colleagues from the H4H project in order not to overwhelm the audience with pain, despair and grief. However, a sense of reality and respect for the horrific experiences of patients and reparative efforts in the therapeutic couple have motivated me to share those experiences. But I would just like to mention a dream of a traumatized in every sense soldier, the dream that became a symbol of war trauma for me. He dreamed that he saw horrific pictures of the dead bodies of his comrades; their eyes were open; he wanted to close his eyes and not to see; but his eyelids were cut off, and an inner voice told him: “You will never be able to close your eyes again.” The open eyes of his murdered comrades, his own damaged eyelids, the impossibility of not seeing, the impossibility of forgetting, of remembering rather than living in endless terror – images of gaping holes in the protective shield of his psyche, images of the irreversibility and endlessness of trauma and its consequences. I would like to use this dream to illustrate the power of the challenge that psychotherapists face now, not after the war, to find and restore a reparative resource.

 

On the restoration of the reparative resource.

The current ongoing war traumatization limits the possibilities of working through, stimulates splitting, prevents the sorting of the external and internal, the past and the present, complicates the work of grief (since the traumatic impact does not cease), without which it is impossible to restore the symbolic functioning of the psyche and the internal space in which the traumatic event can be experienced as a “memory with emotion and meaning”, to “historicize” the trauma, transferring it to the register of subjective experience, and to mobilize the internal reparative resource.

Methodologically and technically, the question arises as to what we can rely on now in confronting internal destructive forces – circles of revenge and paranoid guilt, revealed and catalyzed by prolonged exposure to war trauma in the absence of external prerequisites for productive work on grief, forgiveness and reparation (mental mechanisms that are closely interconnected). There is still no end to the infliction, no repentance, no just judgment. This context of external reality makes it difficult (sometimes impossible) to access the unconscious destructive attacks of patients, but without processing them it is impossible to help traumatized patients to restore favorable internal object relations. How can one get through to the guilt for fantasized attacks on objects and the consequences of this in the internal world of object relations through the real ongoing traumatic experience (being a victim of attacks from outside)?

In this respect, the following example of one of my patients, who many years ago emigrated to a country far from Ukraine, is illustrative.

 

Clinical vignette 4. Addressing me, the patient was experiencing chronic anxiety and near-psychotic states with agitation, fragmentary hallucinations and overvalued idea . Her thin-skinned narcissism covers destructive states of intense envy, competitiveness, anger – deflected inward, they lead to impaired thinking and depersonalization; manifested outward, they cause persecutory guilt and attacks of her harsh Super-Ego. Since the beginning of the war, her condition has improved significantly, and during the sessions she constantly talks about the war, gets angry and wants revenge; she experiences the war, it seems, more acutely than those in Ukraine. She develops volunteer activities to collect funds and help Ukraine. At the same time, quoting her husband’s words about herself, she conveyed to me something that coincides with my impression: she is “somehow strangely and strongly involved in the war.” I saw it as if the internal Putin/(internal Hitler) (M. Klein) has externalized, strengthening the split between the external and the internal reality; attempts of concrete manic reparation through volunteer activities and the righteousness of anger,  legitimization of her own destructive attacks – all this brought her temporary significant relief. The ongoing war makes it difficult to sort out destructive attacks, external and internal, flattens the internal space, making it very concrete and changes my words into verdicts, when I tried to interpret these observations. I felt as if we were walking through a minefield.  Over time, the balance she maintained collapses and the state decompensates again to the point of unexplainable experiencing herself of being a monster. In the material the events of the war are pushed back and disappear, but the feeling of “monstrosity” of the internal world and the readiness to cooperate analytically more deeply enter the arena with pain, shame and self-persecuting.

I am reminded of «Shantaram» by Gregory David Roberts: “It took me many years and many trips around the world to learn all that I know about love and destiny and the choices we make in life, but I learned the most important thing when I was chained to a wall and beaten. My mind screamed, but through the scream I knew that even in that crucified, helpless state I was free – I could hate my tormentors or forgive them. Freedom seems relative, but when you feel only the inflow and outflow of pain, it opens up a universe of possibilities. And the choice you make between hatred and forgiveness can become the story of your life.” Can this “very relative freedom” be found, the source of which is in one’s own reparative mental resources to forgive the unforgivable? I. Romanov quotes from memory the words of Caroline Garland at Melanie Klein Trust’s recent webinar on trauma: “A traumatized person will never become the same as he was before the trauma. But the trauma can become only a part of his life story, and not something that defines one.” Great potential for this is seen in the idea of «difficult forgiveness» and the hypothesis of H. Weiss, that “in psychic processes it is not so much the particular traumatic experiences which lead to long term damage, but those experiences which interfere with the natural integrity of the processes of reparation”.

He draws a parallel between biological and mental processes, comparing the reparative mental resource that prevents the growth of destructive internal mental processes triggered by trauma, with the work of the immune system to recognize and eliminate malignant processes at the intracellular and cellular levels. He concluded: “Such a view has ramifications for treatment in that its task is not only seen as reconstructing particular experiences, but to regain a capacity for reparation”. He introduces the concept of psychic resilience. Literally according to H. Weiss, it is not so much the object itself – external or internal – that must undergo reparation, but the very capacity for reparation of the traumatized person. The abilities to forgive, love, hope, trust are seriously damaged as a result of traumatic experience and the need to fight for physical and/or mental survival. To what extent they can be restored is an open question for each specific analysis. The solution to this problem lies through the restoration of one’s own reparative resource recognizing, like the immune system, destructive vicious persecutory cycles of hatred and revenge and guilt, thereby opening the way to the further development of the individual. Restoration of the processes of reparation and symbolization, building things and using your creativity, reclaiming the containing power of good internal objects and a more favorable internal mental situation become an important part of the itinerary in our work of accompanying our patients.

I decided to conclude my reflections with my own poem, which is illustrative in the context of the conference theme and became for me an intuitive poetic description of the processes of containment, restoration of the reparative resource, the revival of the creative word, which I lost after the crisis circumstances.

You’ve returned.

Welcome back.

It is you awoken.

Your gentle touch puts me at rest,

Calms the heartbeat of my words unspoken

In my forever aching chest.

Seek out and name with an all-seeing line
A faded memory from a fleeting dream
Stuck in swamps and silted by the melancholy of mine
Longing in the anguish of the verbal stream
Name it.
Let your voice
Grow inside me
Stanza by stanza like my vertebrae.
In the dark and the cold of the night
Find familiar shapes, hear my plea.
Don’t abandon me in my grief or delight.
Without you I go totally blind and numb,
Without you around me I get lost inside,
I get speechless, wordless and dumb.
It’s you again.
Welcome back.
Be the midwife of my miraculous new birth
In the sadness of my midnight, in the joy of dawn.
See my every move, feel my real worth
In my fleshly passion
At the peaks and down below
Help my thoughts fly high above the earth
Strengthen my two wings and let them grow.
The wings of humbleness and hope – I need them both.

In the words of H. Segal, “the need to create is irresistible.” She expresses it best here: Only when the loss has been acknowledged and mourned re-creation can take place… all creation is really a re-creation of a once loved and once whole, but now lost and ruined object, a ruined internal world and self. It is when the world within us is destroyed, when it is dead and loveless, when our loved ones are in fragments, and we ourselves in helpless despair—it is then that we must re-create our world anew, re-assemble the pieces, infuse life into dead fragments, re-create life”.

Working on this text is my personal reparative act, and our discussions today are attempts to support symbolic thinking in the containing space of the analytic house.

 

 

Conclusion.

War falls on a person with a multitude of destructive and irresistible events, disrupts the usual course of life and creates chaos. Psychoanalysis has always considered the consequences of traumatic external events through the lense of their interaction with the subject’s internal reality. We observe how the psyche is flooded as a result of an “explosion” (Britton, 2005) of unconscious fantasies of a terrifying and persecutory nature. The actualization of these fantasies by the insurmountable reality of war flattens and destroys the internal psychic container, the processes of splitting and projection are intensified, which leads to the concreteness of thinking, loss of the ability to symbolize and the subject’s getting stuck in a paranoid-schizoid state with a loss of faith in good internal objects (which intensifies disintegration). Under such circumstances, the subject is at risk of getting stuck between the chaos of disintegration and fragmentation and the cycles of hatred-revenge-persecutory guilt.

We believe that if the impact of external reality is not so overwhelming, a psychoanalyst who directly experiences war is able to “tame the nameless horror”, sort out the external and internal, restore or preserve the ability to distinguish between the past and the present, the self and the object, the internal and the external, and assist the patient in this too. In such a case, despite the war’s attack on his or her own mental apparatus and setting, the analyst repeatedly proves capable of overcoming the anxieties of the paranoid-schizoid position and seeking within oneself and the patient a resource for reparation of the inner world and integration into the new, war-changed reality. This becomes possible due to the painful recognition of the irreversibility of losses and grief. Psychoanalytic theory serves as a reliable internal container for the analyst, and psychoanalysis as such partly turns out to be the only most stable internal good figure in the midst of the chaos and devastation of war. It is difficult to overestimate the influence of psychoanalytic training and integration into the professional community in shaping psychoanalysis as a good, stable internal object. The vulnerabilities of symbolic thinking and the analyst’s internal container are obvious.

I propose a working classification of variants of the analytic setting in the current conditions of the Russian war in Ukraine, I consider it useful for understanding the nuances of the transference-countertransference situation in the psychoanalytic process in wartime. Close attention to the consequences of the influence of the external reality of war and the mental state, the transference of the patient to the state of mind of the analyst were and still are critically important in our daily work in the conditions of the traditional analytic setting, as well as short-term crisis counseling. Using clinical examples, I tried to show how this happened and how much the analytic pair managed to do the best they could.

I emphasize the containing role of language, trying to distinguish between mind creative and mind destructive processes in the transition from one language to another and the impact of this phenomenon on symbolization and thinking. In my article, I address the importance of finding and restoring a reparative resource in traumatized patients (Weiss, 2020), which, both at the individual and social levels, lays the groundwork for the “historization” of trauma, translating traumatic events into experience, rather than something that will determine the subject and society in the future.

 

References:

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  19. Романов, І. (2023) Сучасна пропаганда та пропагандистські стани души: психоаналітична перспектива. Українській Психоаналітичний Журнал, т. 1 №3, с. 24 – 29.

Iryna Malyshko, Dnipro, Ukraine

Ukrainian Psychoanalytic Society

malyshko.irina@gmail.com

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