War and Peace: Psychotherapy With a Holocaust Survivor

“Ms. A” was a 68-year-old Jewish woman of European origin who was referred to our outpatient geriatric psychiatry clinic by her internist. She had a long history of depression and anxiety, currently exacerbated by concerns over her husband’s health and her own medical problems. She reported a depressed mood, fatigue, initial insomnia, and poor-quality sleep interrupted by recurrent nightmares. She reported intrusive thoughts, such as ruminating over news of someone’s death or suicide. She had a history of panic attacks that included tremors, tachycardia, profuse sweating, and anxiety, attacks that had resolved spontaneously 30 years previously. Although she reported no current suicidal ideation, Ms. A had contemplated suicide when she was younger. Her first major depressive episode was at age 17. Two others followed, with the longer one lasting 8–10 months and occurring approximately 15 years before our meeting. She had felt sad most of the time, even when her depression had lifted, but she had been able to enjoy her life with her family to some extent. She also exercised regularly and had an active social life.

Ms. A has never been hospitalized nor had she attempted to harm herself. The mainstay of her past treatment was psychotherapy, and she was taking a low dose of a selective serotonin reuptake inhibitor the time I first saw her. Her medical history included mild hypertension, hyperlipidemia, and questionable fibromyalgia. Ms. A had several years of college education and a marriage of 50 years. Besides raising her two children—now successful adults—she had worked outside of her home. One of her jobs involved being a counselor to children and teenagers who abused drugs. She also helped her own children process some aspects of the trauma she had suffered in her early years, and they all developed, as a result, a sophisticated understanding of psychological phenomena. Her family history was relevant for her father’s severe depression, although he had never been diagnosed or treated. Her daughters and one grandchild had different degrees of depression or anxiety. Ms. A had a difficult childhood during the war years in Europe, which continued to haunt her.

Ms. A had survived the Holocaust by hiding for 2 years with her family, beginning when she was only age 4. Her parents, two siblings, and 10 other family members were concealed in a neighbor’s barn to escape the Nazis. During those 2 years, her mother and younger brother had died. No one ever explained to her why or how they had died. She could only recall that her mother was ill and then one day disappeared. Having been unable to grieve for her, she felt an irreparable loss. Especially painful was the fact that there were no photographs left of her brother. She remembered him well but felt she needed time to mourn him, too.

During the time they had spent in hiding, soldiers would periodically come to the neighbor’s barn to get food. The patient and her family lived in terror; they could not move or make a sound for fear that they would be discovered. They were afraid to even breathe because their warm breath might melt the snow on the roof and lead to discovery by the Nazis. She felt that their lives had stopped, and she was not allowed to go on living.

After 2 years of hiding, the neighbors asked Ms. A and her family to leave because they feared that their lives were in danger for concealing a Jewish family in their barn. All of the belongings they had possessed before the war—if not looted or destroyed—remained in the farmer’s possession. Ms. A and her family crossed the Alps on foot and found refuge in a “displaced persons” camp in Italy, where they spent several more years waiting for the country to accept them after the war was over. Ms. A recalled these years as good times, when they were respected and could observe their religion. They did not return to their country of origin because they felt unwelcome there. At age 8, Ms. A became ill with rickets and tuberculosis but received proper care and recovered. Her father was thoroughly demoralized after the war. He never talked with her about her mother’s death or what happened in their hideout.

Ms. A came to the United States at age 12 and eventually adjusted to school and the new culture but only with considerable difficulty. Her father remarried another Holocaust survivor, who was harsh and unkind to Ms. A and her older sister. However, Ms. A’s sister appeared better equipped to deal with these changes. Ms. A adjusted to the new family over time and became less of a target for the stepmother’s wrath. Two half-brothers were born, and the minimal attention that Ms. A was receiving from her father and stepmother deteriorated into nothing. She was expected to take care of herself, to never complain, and to avoid mistakes. She often heard statements such as, “No one wants you; you are lucky you have a home,” or, “Who do you think you are? You are nobody.” She became increasingly despondent. When she was 17 years old, after graduating early from high school, she suffered her first major depressive episode. She started working so she could pay for her psychotherapy. Soon thereafter, she met a young man, married him, and moved away from her parents. Her husband was very supportive and helped her fight her intense depression.

Ms. A first stepped into my small windowless office on a wintry afternoon. She appeared poised and elegantly dressed but timid. Her expression, under the vivid gaze and slight smile, was a mixture of pain and dignity. Articulate and eloquent, she described her difficulties by telling her story through a veil of tears. Upon an initial mental status examination, she reported a depressed mood. Her thoughts were coherent and well organized, and she was fully alert and oriented. At the end of her appointment, Ms. A asked if I could be her therapist. It was a direct word-sparing question. Because she correctly discerned that I was originally from Europe like her, she may have requested me because she felt some form of kinship with me. I knew that I had less than 6 months of training left, and I would move to another town after graduation. I did not think that it would be a good idea to commit to an in-depth exploratory treatment that would soon be over. After sharing this dilemma with Ms. A, she still felt that she wanted to work with me, and I accepted. I liked her, and I pictured her as a famished little girl in a dark barn, paralyzed with fear—a still life, surrounded by grown-ups as terrified as she was. This image seized my imagination, and it has stayed with me ever since. I was also moved by the fact that one of her daughters is actually my age. This daughter’s children, in an almost uncanny way, are actually my children’s ages. Ms. A was even a counselor at one point. She and her daughter were working on a book about her Holocaust experience.

We began weekly psychotherapy, haunted by the shadow of termination from the start. I was hoping to see transference emerge that would place me in a maternal role, where we could more easily explore her feelings related to her mother’s death. Knowing that I would soon have to part from her, I realized that our upcoming termination might precipitate acute feelings of loss. On the other hand, my departure was a palpable reality, a concrete deadline, which we knew about from the beginning, unlike the mystery of her mother’s disappearance. I was fascinated with her psychological complexity and intrigued by the resilience that allowed her to overcome the terrible trauma of wartime and the early loss of her mother.

To better prepare for my work with her, I started reading a book by Viktor Frankl (5) and asked for consultation from supervisors on aspects of Holocaust-related trauma. I felt I did not know enough about that time period.

Although Ms. A could tell from my accent that I was from a similar area of Europe, she never asked me where I was from.

We would assume that there will be some topics that she will be afraid to reveal in therapy.

This is a very good point. She did talk about her guilt and feared that she would lose me if she said the wrong thing. She was always careful to be pleasant and to compliment me on how I dressed. I even noticed myself dressing differently on the days I saw her because I knew she would be commenting on what I was wearing.

Ms. A asked me to be her therapist, and I actually offered to refer her to a psychologist for therapy. She said, “No. I want you.” This is part of the kinship that I felt was developing. I think she felt that I would be able to understand her better. She even said that she did not think that she would find somebody like me. She was already seeing me as the idealized mother that she longed to have. And, as Dr. Gabbard said, I think she was repeating the experience of the frozen 4-year-old. I was a little intimidated by her. Could I work with her as well as others had? I was a beginner, but she seemed to be comfortable, and I certainly liked her. She clearly wanted to talk about what had happened during the 2 years in hiding and about her mother’s death. Later on, she brought out some experiences that she said she hadn’t been able to share with previous therapists because of their male gender. Some of these had to do with sexual abuse. She also reported a dream early in the therapy in which she was partly an adult and partly a baby who needed help. The dream took place in a barn like the one in which she had hidden and her mother had died.

I was already worried that I would be retraumatizing her by ending the therapy at 5 months.

I think processing termination right from the beginning is important. I told Ms. A in the first session that we had 5 months and that we ought to keep that in mind. It placed a good deal of pressure on me, and I also was thinking I wanted to write a case report.

By talking about how her mother disappeared one day, I felt that Ms. A was also talking about the uncertainty connected to herself. She was plagued with tormenting questions: “Who am I really? Do I really exist?” Hence, at some level, she wondered if she herself had actually disappeared when her mother vanished. She reflected on this fantasy and connected certain memories to it: when she was a bad girl and had done something that her stepmother would punish or criticize her for, she would sit in a corner punishing herself until she made herself small and invisible.

I carefully orchestrated my interventions to avoid being too aggressive. I was concerned that this very thing might happen—that I would say something that would traumatize her and cause her to retreat into her invisible defensive posture. I also noted that she would idealize me as a nonjudgmental caretaker. She made such comments as, “You are so young, but you have so much experience.” She would also say, “You are wise beyond your years.”

One manifestation of the negative transference came up when termination approached. Ms. A actually took vacation at the time that we were originally supposed to terminate as a way of taking over the control of who left whom. Thus, it shortened our work by 2 weeks.

Ms. A expressed a wish to be friends and wanted to take me out to lunch. I politely said, “No,” but it sounded like a previous therapist had done that with her at the time of their termination. She had a precedent, so it seemed reasonable to her. I wondered if she wanted to feed me or to simply give me something in exchange for my services. She came with a small gift to the last session, and I began by saying, “I cannot accept this gift because we’re not allowed to accept gifts from this clinic.” She brought a big bag of small gifts and said, “Come on, I have to take care of you.” I accepted the gift after we explored what this meant to her.

I pointed out to Ms. A how much work she had done and how much she had accomplished.

That is my style. It was important for her to receive that validation.