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Extreme Traumatisation: Strategies for Mental Survival

Disruption and loss characterise the life of the person who has undergone extreme traumatisation (torture, concentration camp, etc.), especially when he/she lives in exile. This presents new challenges both in understanding trauma and massive traumatisation and in treating it. When planning and conducting treatment, it is of special importance to take into consideration the mental survival strategies that the person has developed. These are mental capacities that aim both at developing methods of avoiding the pain of re-experiencing and at achieving solutions to the dilemmas posed by the posttraumatic phase. The latter often consists of aborted attempts at mentalisation and integration of traumatic experiences. The traumatised person will often experience the therapeutic encounter as threatening because of fear of re-experiencing and re-traumatisation, and also because having experienced atrocities disturbs or damages the capacity for developing a trusting relationship. This paper discusses the complexities of the consequences of this situation and describes a model for a psychoanalytic approach to the treatment of these patients, focusing on the disturbance of symbolisation and mentalisation caused by trauma. Treatment must address this and provide a setting where experiences that have been insufficiently symbolised (expressed in somatisation, acting, non-verbal characteristics of speech, procedural aspects of transference, etc.) can be placed in context through a process of historisation.