One recipient this year of the Mary S. Sigourney Award, the highest international honor for contributions to psychoanalysis, is Sverre Varvin. Varvin, a Norwegian psychiatrist and psychoanalyst, has been busy building a bridge between psychoanalysis and human rights. Along with chairing the International Psychoanalytical Association (IPA) Working Group on Terror and Terrorism, Varvin has been active with the Norwegian Medical Association Committee on Human Rights since 1997, and has chaired it since 2000.
In cooperation with the World Health Organization, the committee has done extensive work in the Balkans re-establishing contacts broken during the wars between medical associations and setting up programs for psychosocial rehabilitation of war-traumatized patients who had been tortured and degraded. Varvin and his committee have extended this kind of work, creating treatment centers for tortured and severely traumatized patients in Turkey, where there are human rights violations; and in China, as non-governmental organization (NGO) experts, leading human rights dialogues on prison health, the education of prison doctors and health staff, and the rights of prisoners. The committee developed the work in Turkey into an online course on detainee health and human rights, which was launched by the World Medical Association in September 2004.
In the process of bringing a psychoanalytic understanding to the negotiating table with government officials, diplomats, and the like, Varvin has integrated his experience with human rights activities into psychoanalysis. His numerous writings on psychoanalytically-informed treatment of trauma patients and on terrorism and genocide have broadened our understanding of the dynamics and effects of the most disturbing—what is often referred to as evil—aspects of human behavior.
Christine Ury, D.Ps., is international editor of TAP.
I conducted the following e-mail interview with Varvin.
CU: What does psychoanalytic knowledge contribute to the work of severely traumatized patients that other bodies of knowledge cannot? Can you say something about teaching methods and strategies for transmitting this specialized knowledge and expertise?
SV: Psychoanalytic knowledge and psychoanalytically-oriented therapy differ from other contemporary approaches to the treatment of severely traumatized patients in several respects. The most obvious difference is the comprehensive understanding of the patient: How one's problems and suffering are interwoven with one's personality and life history. Having a developmental perspective and an understanding of the significance of loss and grief deepens the understanding of the traumatized patient who has been a victim of atrocities, as both an emotionally developing person where important aspects of development have been hindered or arrested because of trauma or exile, and a person who has suffered severe losses which need to be grieved. These perspectives have important advantages over more focused and specialized techniques dealing only with parts of the problem, for example, cognitive therapy and eye movement desensitization and reprocessing.
Having a developmental perspective and an understanding of the significance of loss and grief deepens the understanding of the traumatized patient who has been a victim of atrocities…
When I teach, I always start with a broad perspective on trauma and traumatization, which includes the history of the concept of trauma within psychiatry and psychoanalysis; the social history of trauma (which also includes how traumatized persons have been neglected and even misused); the recent revitalization of the trauma concept; and, when it concerns the exiled and refugees, how trauma and the context of exile make overcoming the aftereffects difficult. An important aspect of this history is society's difficulties accepting trauma victims. This may then lead to a discussion of countertransference problems both on a societal level and individually, especially in therapy.
I emphasize that the past traumas for many are only a part of the problem; that the traumatized patient may have a wide range of problems, such as losses and complicated grief work, problems with being accepted, and a wide variety of social problems.
CU: In your work with the victims and perpetrators of trauma and political terror, issues of countertransference must inevitably arise. Can you tell us a little about the nature of that countertransference and how you work with it?
SV: As I've already mentioned, countertransference is important to understand both at the individual and group/societal level. The individual resistance in the therapist/analyst as well as in the patient may gain support from denial at a social level.
In my experience, countertransference with these patients does not in principle differ from work with other patients. What differs is often intensity of emotional reactions and the different defenses that may be involved. Anxiety about “going into the traumatized part of the patient's personality” is common: “Can I do harm by asking about past traumatic experiences?” The patients often perceive this anxiety and then feel there really is something bad that cannot be touched. Therapists (including myself) may have a wish to deny the severity of the problem, and repress or dissociate gruesome parts of the patient's history. Strong feelings of helplessness, anger, cynicism, and sarcasm are seen as expression of identification with the victim or the aggressor.
It is important to have colleagues to speak with, but also to have regular supervision from time to time. The more difficult part may not be listening to terrible histories, but bearing emotionally the emptiness, hopelessness, and serious depressions we meet in these patients. The hopelessness may pervade therapies and words may seem to be of little help. This lack of vitality may accompany the therapist outside work, which underscores the need to regulate caseload and also establish proper self-care.
CU: In the kind of work that you are doing, the traditional psychoanalytic concern with trauma seems to be brought to a new and more complex level (sociopolitical as well as psychological). How do you think this new kind of encounter will affect psychoanalytic thinking?
SV: The encounter with patients who have been exposed to human-made traumas and violation of their human rights and who have also been socially uprooted and have to live in exile necessitates the development of the psychoanalyst's mental representation of the social context. This link between the internal world and the social and cultural context has generally been conceptually problematic within psychoanalysis. More than in other therapies, there is a need to understand the subject's relation to others and the social context in several dimensions: bodily-emotional, relations on a group level and on a cultural level. It is, for example, obvious that difficulties in accessing cultural narratives may hamper the meaning-making function of the mind when living in exile. The violation of human rights, such as in the cases of torture and being exiled, makes clear how basic trust also is grounded in a stable social structure.
I think psychoanalysis in the work with these patients and also with social problems related to social traumas may widen the scope not only in the understanding of the relation between the individual and his/her social context, but also in understanding complex societal processes, for example, traumatized societies (as Vamik Volkan has done).
CU: In your work at the sociopolitical level (medical associations, human rights organizations, NGOs, governments), do you encounter resistance as we do in ordinary psychoanalytic
work, and, if so, what forms does it take and how do you work with it?
SV: We have been working in situations with lots of stress and with organizations under pressure. Resistance and various forms of defense both on a group level and individually are ubiquitous. The feeling of being right, fighting a just cause, for example, may make it difficult to realize that one also may do other people harm. This was obvious during a hunger strike in a prison. Here doctors and their human rights organization supported the fight, but denied that they, by doing this, also had some responsibility for many deaths and also that several prisoners were chronically impaired because of malnutrition.
The need to maintain a picture of the other as enemy was an important resistance when we worked with medical associations in the Balkans. Representatives from one part of the former Yugoslavia would only participate if the medical association of another part would apologize for what their army had done during the war. A whole day's visit with a recalcitrant medical association proved unsuccessful, even when trying to approach the resistance in an empathic and understanding way. Returning with a lot of propaganda in our luggage made us realize that the resistance was deeply rooted in actual and historical problems.
CU: You are in the process of building a bridge between psychoanalysis and human rights. How did you get into work like this, what is its personal significance for you?
SV: It was the meetings with people who had been victims of violations of their integrity and human rights that brought me into this work. I found that my psychoanalytic knowledge was important not only in working with these patients but also in human rights work abroad. The ethics of psychoanalysis has something to bring to human rights, and psychoanalysis may gain from knowledge of problems that are rooted in social contexts of violence.
I feel I can combine my professional knowledge with work for social justice in this way. I must also say that this is an interesting field of work. I have met extraordinary people who have done far more than I have done, and I must underscore that what I have done has always been in teams with excellent people.