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Ethically Treating PTSD Resulting from Terroism and other Traumas

Section 4
Interventions for Victims of Violent Crimes

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Psychodynamics of Victims
To further explain PTSD resulting from terrorism and other traumas, let’s now discuss the behavioral psychodynamics of a victim held captive. Understanding these dynamics is essential for the effective treatment of hostages, perhaps in a skyjack situation. A task I am sure you hope that you will never have to undertake. Here’s a case study where a question of ethical self-determination became involved for a therapist when his client, a detective, was sympathizing with his captors and pathological transference occurred.

An off-duty detective, James, was captured when he interrupted a robbery. When the robbers learned he was a detective, two of the gunmen shouted they were going to kill him. Then they placed a bag over his head and made him kneel down. The detective later stated, “I was glad it was going to be in the head, because I thought it would be quick.” Instead, he heard the robbers discuss him and then leave. He wasn’t shot.

Regarding pathological transference, months later, one of the robbers was caught. James visited the man many times. A close relationship developed and the detective told the robber, “If you need me, I’m there for you, because you were there for me at the time.” When the second robber was caught, the detective told his superior, “Chief, this guy has really changed,” and went out and bought lunch for the second robber. The third robber is still at large. The detective fantasizes, in therapy sessions, conversations he has with the third robber: James will say, “Listen Otis, what went down, went down; turn yourself in. Believe me I’ll work with you. I’m not looking for revenge.”

Ask yourself if James... were your client, ethically, would you define this as pathological transference or not. Or, is this a case of ethical patient self-determination and autonomy? Studies indicate that pathological transference only occurs when someone threatens a person’s life, deliberates, and then does not harm him. The victim, as in the case of James, doesn’t dwell on the threat, but rather the feeling that the criminal let him live.

Pathological transference usually does not occur when the criminal harms the victim. What are your feelings on this point of ethics: pathological transference, patient self-determination, or both?

Psychological Transference
Pathological transference is consistently found in individuals held hostage by criminal terrorists. As you know, hostage victims are essentially instrumental victims. That is, they are used and exploited by their captors as leverage to force a third party (the family, police, or the government) to accede to the captors’ demands. The captors threaten extreme violence to the victim, primarily in their communications to the third party, if their demands are not met. This suggests to the victim that the terrorists will not harm him, if the third party gives in to the captors’ demands.

The key to transference... here is the terrorists’ use of the victim as leverage. This leverage sets the groundwork for intense pathological transference. The transference is both accelerated and heightened when the hostage has already been psychologically traumatized by terror.

When treating victims of violent crime, my colleagues and I have found the following four intervention techniques to be most effective. See how these compare with your current practice. As you listen to these four you might think about how they relate to the Ethical Principles of respecting your client’s self-determination and autonomy.

4 Intervention Techniques for Victims of Violent Crime

♦ Intervention #1. Restoring power to victims early on by asking permission to interview them: For example, to restore a feeling of power to the victim of violent crime, I ask, “Is this a good time to talk to you?” or “Do you mind if I ask you some questions?” Have you found, like I have, that asking permission like this diminishes the one-up position held by the therapist...similar to the one-up power position of the client’s former captor or assailant.

♦ Intervention #2. Reducing isolation by providing nurturing behavior, thus diminishing the experience of the hostile environment to which the victim was subjected. Of course, a nurturing environment is key in a therapeutic relationship, but I find I need to increase my self-awareness of my body language and voice tone, especially so as to provide a positive open space but not infringe on the traumatized client’s space.

♦ Intervention #3. When treating a victim of violent crime, diminishing the helpless, hopeless feelings of the client by giving him or her the experience of determining his present and future behavior in terms of space and time. I foster this by asking permission, for example, to cross the room to get my note pad by saying, “Is it okay if I go to my desk to get a pad for you to write this information down?”

♦ Intervention #4. Reducing the feelings of being subjected to the dominant behavior of the captor by identifying yourself to the client’s satisfaction. As you know, fully identify yourself, especially at your first meeting, and explaining to your client’s satisfaction, for example, the agency you represent can be a key in building trust.

Psychological Infantilism
The preceding four interventions are based on undoing and reversing the factors that can bring about traumatic psychological infantilism. By psychological infantilism, I mean the rescuers must remember that the sudden release of the victims usually causes an acute phase of crying, clinging, and submissive behavior. The victims still are in the grips of traumatic infantilism.

Using methods like those interventions described above to help nurture and restore power are crucial to prevent the rescuers from causing even more injury to the survivor. Also, you may have found it is important to allow the survivor privacy without isolation. The basic ethical principles of genuineness, honesty, and sincerity are, of course, applied here.

Thus, the two components of pathological transference and traumatic psychological infantilism form the crucial elements in this transference to the captor.
Reviewed 2023

Peer-Reviewed Journal Article References:
Carsky, M. (2020). How treatment arrangements enhance transference analysis in transference-focused psychotherapy. Psychoanalytic Psychology. Advance online publication. 

DeTore, N. R., Gottlieb, J. D., & Mueser, K. T. (2021). Prevalence and correlates of PTSD in first episode psychosis: Findings from the RAISE-ETP study. Psychological Services, 18(2), 147–153.

Eagle, G., Benn, M., Fletcher, T., & Sibisi, H. (2013). Engaging with intergroup prejudice in victims of violent crime/attack. Peace and Conflict: Journal of Peace Psychology, 19(3), 240–252. 

Hasselle, A. J., Howell, K. H., Bottomley, J., Sheddan, H. C., Capers, J. M., & Miller-Graff, L. E. (2020). Barriers to intervention engagement among women experiencing intimate partner violence proximal to pregnancy. Psychology of Violence, 10(3), 290–299. 

Krahé, B., & Busching, R. (2015). Breaking the vicious cycle of media violence use and aggression: A test of intervention effects over 30 months. Psychology of Violence, 5(2), 217–226.

Shubs, C. H. (2008). Transference issues concerning victims of violent crime and other traumatic incidents of adulthood. Psychoanalytic Psychology, 25(1), 122–141.

Stuart, G. L., McGeary, J., Shorey, R. C., & Knopik, V. S. (2016). Genetics moderate alcohol and intimate partner violence treatment outcomes in a randomized controlled trial of hazardous drinking men in batterer intervention programs: A preliminary investigation. Journal of Consulting and Clinical Psychology, 84(7), 592–598.

What are the two crucial elements of transference to the captor for individuals held hostage by criminal terrorists? To select and enter your answer go to Test.

Section 5
Table of Contents